**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 5 residents reviewed for notification of changes. The facility failed to establish contact with the NP after Resident#1 had an unwitnessed fall where he was found lying face down on the floor on 8/13/25 at 11am. LVN A sent the NP a text at 11:40 am but she was not aware until she received a second text notification at 12:44 pm. Resident #1 was transported to the hospital at 1:30 pm, after an induration formed above his left brow. An IJ was identified on 8/15/25 at 6:05 pm. The IJ template was provided to the facility on 8/15/25 at 7:10 pm. While the IJ was removed on 8/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. Finding included:Record review of Resident#1's face sheet revealed a fifty-six-year-old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side (paralysis and weakness on one side of the body), paraplegia, cerebral aneurysm (blood vessel in the brain), a cerebral infraction (stroke), and the use of a tracheostomy. Record review of Resident #1's care plan disclosed that he utilized a feeding tube for meals and required supplemental oxygen. Record review of Resident #1's progress note dated 8/13/25 at 1:30 pm by LVN A documented unwitnessed fall, resident on floor next to bed in prone position with head turned to the left side. Bilateral arms straight and bilateral legs straight. Small swelling to left upper temporal noted upon assessment. Resident assisted back to bed x4. Vital signs obtained BP: 123/87 pulse: 89 respiratory: 20 temperature: 96.8. Neurological checks initiated per protocol. Physician and family notified. Resident mother stated resident tends to move a lot and he will try to get out of bed and this is not a new action for him. Precautions have been put in place. Two bedside mats or placed next to resident bed. Bed will continue to be lowered to ground call light within reach. In an interview with LVN A on 08/14/25 at 3:38 pm, she stated that Resident #1's mother alerted her that he was on the floor around 11am. She stated that she found him laying with his arms to his side and he did not have any signs of pain. The NP was notified, and she began neuro checks. After a few checks, she noticed a raised area forming above his brow and she alerted the NP who was also in the building at that time. The NP ordered Resident #1 to be sent out for further evaluation. LVN A explained that no fall protocols were put into place because he had not moved much since his admission, and they were not aware that he was able to move on his own. In an interview with Resident #1's family member on 08/15/25 at 10:50 am, she stated that when she entered his room at 11am, he was laying on the floor facedown with his trach still connected to his throat. LVN A was immediately alerted, and staff came inside the room and began assessments. She stated that she informed that staff amongst admission that Resident #1 could move and prior to him coming to the facility, he had done physical therapy at other facilities. EMS was called and he was transported to the hospital at 1:30 pm due to swelling above his left eyebrow. In an interview with CNA A on 8/15/25 at 11:53 am, she explained that she had worked with Resident #1 on 8/13/25 around 9:30 am to shower him. She stated that day, he was moving a lot. He would constantly move his legs up and down and he moved his head a lot. Resident #1 slept on an air mattress and before she left his room after his shower, she lowered his bed to the lowest position. She recalled that there was not a fall mat next to his bed because he was a new admit and she guessed nursing staff did not see a need for it at the time. In an interview with the Unit Manager on 8/15/25 at 12:16 pm, she stated that Resident #1 was nonverbal, but he could follow people with his eyes. She explained that he was able to move his arms and legs and described them as jerk like reactions. She stated that since Resident #1 was admitted , he had begun to move a lot more and his mother had also noticed his increase in movement. On that day of the fall, she was called to his room (time unknown) by LVN A and noticed that he was face down on the ground. There was no blood, and he was able to move his head. Initially there was no swelling, but after a few hours swelling began to appear on his left side. The Unit Manager recalled that the NP was in the building, but she could not recall if she assessed him immediately after the fall. The Unit Manager stated that the protocol after an unwitnessed depended on if it was a fall with an injury; then they would be sent out immediately. If there was an unwitnessed fall without injury, the facility's fall protocol was to notify the physician of NP and get an order to send them out. The surveyor asked that since Resident #1 had a history of head injuries, previously suffered from a stroke, and was found face down from an unwitnessed fall, would he be qualified to be sent out? Unit Manager took a long pause and said she was thinking and stated that he had no visible injuries, but he was a special situation and if the NP was in the building, she would have grabbed her to come see. In an interview with the DON on 8/15/25 at 12:35 pm, she stated that she did not know when the NP assessed Resident #1, but she was informed by LVN A when he fell, and she was informed when the swelling appeared. She stated that when LVN A noticed the swelling around 1-1:30 pm during neuro-checks and he was sent out afterwards. When the DON and Surveyor reviewed his orders, the DON confirmed that Resident #1 was on Aspirin, which was a blood thinner and the harm in not seeking emergency medical services post fall could be hemorrhaging or bleeding. She stated that no fall preventions were in place because Resident #1 was not able to move, and she believed he may have fell on the floor due to increased alertness. In an interview with the NP on 8/15/25 at 1:30 pm, she stated that LVN A sent her a text message on 8/13/25 at 11:40 am but she did not see the message. She could not give a definite time, but she stated that she entered the facility sometime between 12 pm and 2 pm to complete rounds. While she was there, LVN A sent her a second text message at 12:44 pm and informed her that Resident #1 had some swelling on his head post fall, and she went in to assess him. The NP found a little induration on the left side of his temple and stated that because he was on blood thinners, she ordered him to be sent out because she was concerned about internal bleeding. She stated that if someone had a fall where they hit their head, whether witnessed or unwitnessed, it would be best practice to send them out for a CT scan. This was especially significant for Resident #1 because he had a suspected head injury and was on blood thinners at the time. NP also noted that when she assessed Resident #1 that day, he was notably more alert, was able to shake his head, and seemed to understand her in conversation. Observation on 8/15/25 at 2:57 pm in the hospital, Resident #1 was sitting in bed at a 90-degree angle and his eyes were bright and alert. He seemed to have a smile on his face and followed the surveyor around the room as she spoke to him. He was nonverbal but attempted to make grunts and groans in response to conversation. In an interview with the HSW (Hospital Social Worker) on 8/15/25 at 2:59 pm, she explained that Resident #1 was admitted for a fall on 8/13/25. She stated that his admitting diagnoses were interval acute bleeding to the left side of the head, and he had new chronic appearing left frontal sub [NAME] hematoma Internal bleeding to the side. HSW stated that in addition to that, he was currently being treated for sepsis and pneumonia, which was present upon admittance. Record review of the facility's policy titled Fall Management revised July 2024 displayed that:1. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated.2. If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the Physician/Physician Extender. The ADM and DON were notified on 8/15/25 at 7:10 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 8/16/25 at 12:30 pm: Plan of Removal: F580 - Notification of ChangesAugust 16, 2025Immediate action:The facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or conditions or clinical conditions. Resident #1 was transferred on 8/13/2025 to the ER and remains in the hospital. Action: LVN A was immediately re-educated by the DON on 8/15/25 on the facility's fall protocol and notification procedures, including the requirement to make direct verbal communication with the provider NP/physician for all significant changes, and event escalation if the NP/Physician does not respond.Responsible: Director of Nursing Completion: August 16, 2025 The Administrator and Director of Nursing notified the Medical Director of the IJ F-0580.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: Ad Hoc QAPI conducted on 8/15/25 with Medical Director, Administrator, DON, & Unit Managers regarding IJ F0580 and F684.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: All license staff will be re-educated by the DON/Designee on the following: facility fall protocol to include immediate provider notification following all unwitnessed falls, regardless of visible injury. All license staff will be educated prior to the start of their next shift. Staff will not provide direct resident care until training/education has been completed. Staff should follow facility protocol and provide verbal communication to the provider.Escalation Protocol for Provider Notification:In the event of an unwitnessed fall and any other changes of condition from resident's baseline:1. Notify the Nurse Practitioner (NP) immediately.2. If the NP does not respond, contact the attending physician.3. If the attending physician does not respond, contact the Medical Director.4. If the Medical Director does not respond, contact the Administrator.Responsible: Director of Nursing/DesigneeCompletion: August 16,2025 Action: Administrator reviewed on 8/15/25 the facility falls policy and changes of conditions notification policy and no changes were needed. Responsible: AdministratorCompletion: August 16, 2025 The Surveyor monitored the POR on 8/16/25 as followed: Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to contact 911 after Resident#1 was found laying face down on the floor after an unwitnessed fall on 8/13/25 at 11am. Resident was transported to hospital at 1:30pm, after an induration began to form above his left brow. An IJ was identified on 8/15/25 at 6:05 pm. The IJ template was provided to the facility on 8/15/25 at 7:10 pm. While the IJ was removed on 8/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death.Findings included:Record review of Resident#1's face sheet revealed a fifty-six-year-old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side (paralysis and weakness on one side of the body), paraplegia, cerebral aneurysm (blood vessel in the brain), a cerebral infraction (stroke), and the use of a tracheostomy. Record review of Resident #1's care plan disclosed that he utilized a feeding tube for meals and required supplemental oxygen. Record review of progress note dated 8/13/25 at 1:30 pm by LVN A documented unwitnessed fall, resident on floor next to bed in prone position with head turned to the left side. Bilateral arms straight and bilateral legs straight. Small swelling to left upper temporal noted upon assessment. Resident assisted back to bed x4. Vital signs obtained BP:123/87 pulse:89 res:20 temp:96.8. Neurological checks initiated per protocol. Physician and family notified. Resident mother stated resident tends to move a lot and he will try to get out of bed and this is not a new action for him. Precautions have been put in place. Two bedside mats or placed next to resident bed. Bed will continue to be lowered to ground call light within reach. In an interview with LVN A on 08/14/25 at 3:38 pm, she stated that Resident #1's mother alerted her that he was on the floor around 11am. She stated that she found him laying with his arms to his side and he did not have any signs of pain. The NP was notified and she began neuro checks. After a few checks, she noticed a raised area forming above his brow and she alerted the NP who was also in the building at that time. The NP ordered Resident #1 to be sent out for further evaluation. LVN A explained that no fall protocols were put into place because he had not moved much since his admission, and they were not aware that he was able to move on his own. In an interview with Resident #1's family member on 08/15/25 at 10:50 am, she stated that when she entered his room at 11am, he was laying on the floor facedown with his trach still connected to his throat. LVN A was immediately alerted and staff came inside the room and began assessments. She stated that she informed that staff amongst admission that Resident #1 could move and prior to him coming to the facility, he had done physical therapy at other facilities. EMS was called and he was transported to the hospital at 1:30 pm due to swelling above his left eyebrow. In an interview with CNA A on 8/15/25 at 11:53 am, she explained that she had worked with Resident #1 on 8/13/25 around 9:30 am to shower him. She stated that day, he was moving a lot. He would constantly move his legs up and down and he moved his head a lot. Resident #1 slept on an air mattress and before she left his room after his shower, she lowered his bed to the lowest position. She recalled that there was not a fall mat next to his bed because he was a new admit and she guessed nursing staff did not see a need for it at the time. In an interview with the Unit Manager on 8/15/25 at 12:16 pm, she stated that Resident #1 was nonverbal but he could follow people with his eyes. She explained that he was able to move his arms and legs and described them as jerk like reactions. She stated that since Resident #1 was admitted , he had begun to move a lot more and his mother had also noticed his increase in movement. On that day of the fall, she was called to his room (time unknown) by LVN A and noticed that he was face down on the ground. There was no blood and he was able to move his head. Initially there was no swelling, but after a few hours swelling began to appear on his left side. The Unit Manager recalled that the NP was in the building, but she could not recall if she assessed him immediately after the fall. The Unit Manager stated that the protocol after an unwitnessed depended on if it was a fall with an injury; then they would be sent out immediately. If there was an unwitnessed fall without injury, the facility's fall protocol was to notify the physician of NP and get an order to send them out. The surveyor asked that since Resident #1 had a history of head injuries, previously suffered from a stroke, and was found face down from an unwitnessed fall, would he be qualified to be sent out? Unit Manager took a long pause and said she was thinking and stated that he had no visible injuries but he was a special situation and if the NP was in the building, she would have grabbed her to come see. In an interview with the DON on 8/15/25 at 12:35 pm, she stated that she did not know when the NP assessed Resident #1, but she was informed by LVN A when he fell and she was informed when the swelling appeared. She stated that when LVN A noticed the swelling around 1-1:30 pm during neuro-checks and he was sent out afterwards. When the DON and Surveyor reviewed his orders, the DON confirmed that Resident #1 was on Aspirin, which was a blood thinner and the harm in not seeking emergency medical services post fall could be hemorrhaging or bleeding. She stated that no fall preventions were in place because Resident #1 was not able to move and she believed he may have fell on the floor due to increased alertness. In an interview with the NP on 8/15/25 at 1:30 pm, she stated that LVN A sent her a text message on 8/13/25 at 11:40 am but she did not see the message. She could not give a definite time but she stated that she entered the facility sometime between 12 pm and 2 pm to complete rounds. While she was there, LVN A sent her a second text message at 12:44 pm and informed her that Resident #1 had some swelling on his head post fall and she went in to assess him. The NP found a little induration on the left side of his temple and stated that because he was on blood thinners, she ordered him to be sent out because she was concerned about internal bleeding. She stated that if someone had a fall where they hit their head, whether witnessed or unwitnessed, it would be best practice to send them out for a CT scan. This was especially significant for Resident #1 because he had a suspected head injury and was on blood thinners at the time. NP also noted that when she assessed Resident #1 that day, he was notably more alert, was able to shake his head, and seemed to understand her in conversation. Observation on 8/15/25 at 2:57 pm in the hospital, Resident #1 was sitting in bed at a 90-degree angle and his eyes were bright and alert. He seemed to have a smile on his face and followed the surveyor around the room as she spoke to him. He was nonverbal but attempted to make grunts and groans in response to conversation. In an interview with the HSW (Hospital Social Worker) on 8/15/25 at 2:59 pm, she explained that Resident #1 was admitted for a fall on 8/13/25. She stated that his admitting diagnoses were interval acute bleeding to the left side of the head, and he had new chronic appearing left frontal sub [NAME] hematoma Internal bleeding to the side. HSW stated that in addition to that, he was currently being treated for sepsis and pneumonia, which was present upon admittance. Record review of the facility's policy titled Fall Management revised July 2024 displayed that:1. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated.2. If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the Physician/Physician Extender. The ADM and DON were notified on 8/15/25 at 7:10 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 8/16/25 at 12:30 pm:Plan of Removal: F684 Quality of CareDate: August 16, 2025 Immediate Action:According to the IJ Template, F684 Quality of Care, The facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-center care plan, and the residents' choices, in that: The facility failed to contact 911 after Resident#1 was found face down on the floor after an unwitnessed fall on 8/13/2025. Resident #1 was transferred on 8/13/2025 to the ER and remains in the hospital. Action: LVN A Was immediately re-educated by the DON on 8/15/25 on the facility's fall protocol and notification procedures, including the requirement to make direct verbal communication with the provider NP/physician for all significant changes.Responsible: Director of Nursing Completion: August 16, 2025 Action: August 15, 2025 Regional MDS Nurse and Director of Nursing audited all falls within the past 30 days to determine all care plans have appropriate interventions were in place. All care plans were confirmed to be up to date.Responsible: Regional MDS Nurse and Director of Nursing Completion Date: August 16, 2025 August 15, 2025 - All licensed nursing staffAction: Director of Nursing will educate all nursing staff on Fall Management, and Changes of Condition Policies and Procedures before the start of their next shift. The DON will educate all licensed nursing staff to ensure all residents receive appropriate and immediate care after an unwitnessed fall. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated. The Director of Nursing to train on the proper protocols to take once a resident has a fall and if there is a delay in physician response. In the event of a witnessed or unwitnessed fall of a resident anticoagulants staff will immediately send out to ER 911. No staff will be able to work until they are educated and trained. Responsible: Director of Nursing Completion Date: August 16, 2025 Action: Ad Hoc QAPI conducted on 8/15/25 with Medical Director, Administrator, DON, & Unit Managers regarding IJ F0580 and F684.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 August 15, 2025 - Facility Medical Director NotifiedAction Taken: The Medical Director was notified and provided the following protocol for unwitnessed falls:If the resident is not coherent and cannot reliably state whether they hit their head: Send to ER via 911 immediately.If the resident is coherent and reliably states, they did not hit their head:Proceed with: Appropriate assessments Neurological checks Vital signs monitoringIf any change in condition occurs later: Send to ER via 911.Head Injury Protocol for Residents on AnticoagulantsIn the event of a witness or unwitnessed fall, if the resident: Strikes their head, and Is currently on anticoagulant therapyStaff must: Call 911 immediately and send the resident to the emergency room (ER) for evaluation.The staff have received education on witnessed/unwitnessed falls of residents on anticoagulants that strike their head. The medical director protocol was not added to the policy instead we will keep the information included in our current fall management policy that states The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review including anticoagulants, and receive orders as indicated.Responsible: Administrator/Director of NursingCompletion Date: August 16, 2025 August 15, 2025 - Daily Fall Review and Care Plan UpdatingAction: The IDT Team will review all falls daily during the clinical morning meeting. The MDS Coordinator/Designee will update the care plan as needed. Designee/DON will monitor falls during weekends and after hours electronically in Point Click Care system and communicate with present licensed nursing staff.Responsible: DON/DesigneeCompletion Date: August 16, 2025 The Surveyor monitored the POR on 8/16/25 as followed: Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall Management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 (CR#1) residents reviewed for accidents and supervision. 1. The facility failed to ensure CR#1 received adequate supervision and assistance devices to prevent accidents resulting in CR#1 sliding out of bed to the floor sustaining a cut to the right eye and left thalamic bleed (a type of intracerebral hemorrhage) without intraventricular (inside the brain's ventricles) involvement. 2. CNA A failed to ensure two-person assistance was used to provide care to CR #1, who required total assistance with all ADLs, and resulted in CR#1 sliding out of bed to the floor. The noncompliance was identified as PNC. The IJ began on 08/11/2025 and ended on 08/12/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing serious injury, pain, hospitalization and death. Findings include: Record review of CR#1's face sheet, dated 08/08/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia (difficulty swallowing), respiratory failure (when the lungs cant properly exchange gases causing abnormal level of carbon dioxide or oxygen in the blood), cerebral infarction (brain tissue dies due to lack of blood supply), unspecified hypoxia (low oxygen in the blood), and hypertension (high blood pressure), Constipation (difficultly passing stool) vitamin deficiency (too little of one or more of the essential vitamins in the body), gastroesophageal reflux disease (a digestive disease in which the stomach acid or bile irritates the food pipe lining), feeding tube (a device that delivers liquid nutrition directly to the stomach or small intestine through a tube), anticoagulant therapy (treatment that prevents or reduces blood clotting), tracheostomy (a surgical procedure that creates an opening in the wind pipe to help with breathing) and need assistance with personal care. Record review of CR#1's baseline care plan, dated 8/5/2024, revealed he was assessed as dependent on staff for all areas of ADL's. Record review of CR#1's revised care plan, dated 8/5/2025, revealed the following areas of concern: Focus: ADL Self Care Deficits: CR#1's has ADL selfcare deficits and is at risk for further decline in ADL functioning and injury AEB decline physical function.Goal: CR#1 will be well dressed, groomed, clean, dignity will be maintained and will have no further decline in ADL functioning or injury the next 90 daysIntervention: Anticipate needs - provide prompt assistance. Encourage independent function as able Encourage resident to ask for assistance for ADL care as neededEnsure call light is within reach and answer in a timely mannerKeep daily preferred routine unchangedProvide (Total) assistance of (2 of support persons) for transfersProvide (Total) assistance of (1 of support persons) for bathingProvide (Total) assistance of (1 of support persons) for bed mobilityProvide (Total) assistance of (1 of support persons) for eating via peg tubeProvide (Total) assistance of (1 of support persons) for personal hygiene/groomingProvide (Total) assistance of (1 of support persons) for toileting/incontinent careProvide (Total) assistance of (1 of support persons) for upper/lower body dressingFocus: Bowel Incontinence: CR#1 has bowel incontinence related to:Goal: CR#1 will have no alterations in skin integrity related to incontinence or brief use through the review dateIntervention: Monitor for signs of discomfort or agitation that may indicate the need for toiletingPerform routine rounding to include incontinence care and brief changes. Record review of CR#1's nurses notes, dated 8/6/2025, revealed CR#1 had a change in condition: - Fall 8/06/2025 at 5:00 AMLocation of the Fall: Resident's room classification of the Fall: witnessed with Head Injury:What was the resident doing prior to the Fall:Resident AAOx1, nonverbal. Vital Signs Post Fall Event: Blood Pressure-122/68, Pulse-72.Resident was sent to the hospital. Record review of CR#1's, undated, hospital records revealed he was admitted to a local hospital on [DATE] with a cut to the right eye, swollen shoulder and was later diagnosed with left thalamic bleed without intraventricular involvement. Observation on 8/08/2025 at 12:00 PM of CR#1 at the hospital revealed CR#1 was in bed. He appeared to be asleep, he did not respond when his name was called. He was clean and without odor, he was observed with a raise to the right-side front of his head, he had swelling to the right shoulder. There were no other visible injuries. In an interview on 8/8/2025 at 12:05 PM, the hospital RN said the resident was admitted to the facility on [DATE] from the nursing home due to a fall. She said he had swelling to the right shoulder, a cut to the right eye and a raise to the right front of the head but she did not know if the raise to the front of the head was because of the fall or an old injury. She said the family mentioned an injury to the left hand, but she did not see any injury to the left hand on her assessment. In an interview on 8/8/2025 at 12:45 PM, the DON said LVN B called and told her CR#1 slid off the bed to the ground when CNA A provided care to him, 911 was called and they sent him to the hospital. She said during the investigation CNA A told her she provided care to CR#1 and did not ask for help and the resident slid out of bed to the floor and sustained a cut to the right eye. Further interview revealed the resident was new and the staff were not sure of his mobility status. The DON revealed if a resident had a tracheostomy, sacral pressure sore or total care, they needed 2 persons for transfers and incontinent care. She said CNA A's decision to provide care to CR#1 by herself instead of asking for help resulted in CR#1 having a fall with injuries and was hospitalized . She said CNA A was in-serviced on getting assistance when providing care for residents who were total care. She said in-service began the same day with Nursing staff, ensuring them, there should be two persons assist when providing care to residents who were new and mobility not known, tracheostomy, sacral pressure sore and total care with ADLs. In an interview on 08/08/2025 at 1:17 PM with CNA A, she stated she was providing her last incontinent care to CR#1 at around 5:00 AM and everyone was busy, and she decided to do it by herself. She said she turned CR#1 to his side, and he slid off the bed to the floor. She said she did not ask for help. She said when the resident fell to the floor, she called the nurse for help and he came immediately and assessed the resident, called 911 and the doctor, the DON and the family, and the resident was sent to the hospital. She said she worked with CR#1 earlier in her shift and she knew the resident was two-person assist because she was assisted by the nurse. She said she knew CR#1 was total care with ADLs, but she thought she could do it by herself since everyone was busy. She said she did not know he would slide off the mattress. She said she was immediately trained on transfer and two-person assistance with bed mobility and incontinent care. She said she would never attempt to transfer or provide incontinent care to any resident who was total care. In an interview with CNA T on 8/8/2025 at 2:05 PM, she said she worked the 6-2 AM shift. She said she was in-serviced on abuse neglect, transferring and having two staff assisting when providing incontinent care to residents who were total care with ADL and could not assist the staff, infection control and dignity. In an interview with CNA F on 8/8/2025 at 3:39 PM, she said she worked at the facility for 4 years. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care with residents who were total care with ADL and could not assist the staff. In an interview with LVN A on 8/8/2025 at 3:58 PM, she said she worked at the facility for 4 years. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care to residents who were total care with ADL and could not assist the staff for repositioning. In an interview with LVN C on 8/8/2025 at 4:37 PM, she said she worked the 2-10 shift. She said she was in-serviced on turning and reposition of residents, abuse neglect, transferring and have two staff to provide care to residents who were total care with ADL and could not assist the staff In an interview with MA/CNA J on 8/8/2025 at 4:47 PM, she said she worked at the facility for the last 2 months and she worked the 6 -2 PM shifts. She said she was in-serviced on abuse neglect, privacy, transferring with 2 persons when using the Hoyer lift and have two staff to provide incontinent care with residents who were total care with ADL and could not assist the staff. In a telephone interview on 08/08/2025 at 4:57 PM with LVN B, he said he worked the 10:00 PM - 6:00 AM shift on 8/6/2025 when the incident with CR#1 took place. He said he worked with CNA A that night and assisted her in changing CR#1 during the night. He said the CNA did not call him to assist her during her 5:00 AM rounds. He said when the CNA called for him the resident was on the floor. He said he immediately called 911, the doctor, the DON and the family and the resident was sent to the hospital. He said the resident had a cut to the right eye and he did not see any other visible injury. In an interview with MA B on 8/8/2025 at 5:00 PM, she said she worked at the facility for 2 years. She said she was in-serviced on abuse neglect, fall precaution, two staff with transferring and have two staff to provide care with residents who were total care with ADL and could not assist the staff with repositioning, and infection control. In an interview with LVN E on 8/8/2025 at 5:08 PM, she said she worked the 2:00 PM-10:00 PM shift. She said she was in-serviced on abuse neglect, two persons assist with transferring and providing care to residents who were total care with ADLs. She said she also was in-serviced on infection control and dignity. In a follow-up interview with the DON on 08/11/2025 at 11:41 AM, she stated CR #1's care plan should have been updated to reflect two staff were required for bed mobility/incontinent care. She stated CR #1 was very new to the facility and they were still assessing him, so the revision was missed. She said the MDS was going to do an audit and all persons who were total care they should be two person assist for bed mobility and they were going to update the MDS and care plans. In an interview with CNA N on 8/11/2025 at 4:17 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff, resident rights, infection control and falls. She said if she was not sure if the resident was a two person assist, she would ask the nurse, look at the computer or call for help. In an interview with CNA O on 8/11/2025 at 4:20 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff, infection control, and resident rights. In an interview with CNA P on 8/11/2025 at 4:25 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview with LVN G on 8/11/2025 at 4:45 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview with MA K on 8/11/2025 at 4:49 PM, she said she worked the 2-10 PM shift. She said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff. In an interview on 8/11/2025 at 4:55 PM with the Administrator regarding the PNC IJ she said it came about because the CNA did not ask for help to provide care to CR#1 and he fell and sustained injuries to his face and head. She said the aide was in-service and all staff were in-service on transfers and using two people when providing incontinent care and transferring residents. In a follow-up interview with the DON on 08/12/2025 at 11:30 AM, she said CR #1's care plan should have been updated to reflect two staff were required for bed mobility/incontinent care. She stated CR #1 was very new to the facility and they were still assessing him, so the revision was missed. In an interview with LVN K on 8/12/2025 at 2:43 PM, he said he worked the 10:00 PM-6:00 AM shift. He said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff and infection control. In an interview with LVN D on 8/12/2025 at 3:14 PM, she said she worked the 2:00 PM-10:00 PM shift. She said she was in-serviced on abuse neglect, two persons assist with transferring and providing care to residents who were total care with ADLs. She said she also was in-serviced on infection control and dignity. In an interview with LVN H on 8/12/2025 at 3:45 PM, she said she worked the 2 PM-10 PM shift. She said she was in-serviced on abuse neglect, transferring and always to have two staff to provide care for residents who were total care with ADLs and could not assist the staff. Record review of staff training record revealed they were trained on incontinent, transfer and ensure two staff assisted when incontinent care was being done. Record review of the facility's, undated, policy and procedure on Incident and Accident read in part .Introduction:Ensuring resident safety management, incident response, in a nursing facility requires a structured approach to risk management, incident response and regulatory compliance. Incident vs Accident* Incident: Unexpected or unusual event within the facility that potentially affects resident safety, well-being, or quality of care.* Accident: An unplanned and unforeseen event resulting in harm, injury, or damage to a resident, staff member, visitor or property.Types of incidents and Accidents:Falls: Any unintentional descent to the floor, including assisted falls.Fractures or bodily injury: Any incident resulting in injury requiring medical attention. Record review of the facility's in-services revealed CNA A (received written disciplinary warning and 1:1 education) and nursing staff were educated on 08/06/2025, 08/07/2025 and 8/8/2025 regarding two-person assistance for residents who were total care or if staff were unsure of their mobility status related to incontinent care. Record review of In-Service, dated 08/06/2025, revealed CNA A (CNA A received 1:1 education) and all other nursing staff were educated by the DON regarding demonstrating accessing and utilizing the Kardex on PCC (the facility's computer system). Record review of in-Service, dated 08/06/2025, 08/07/2025 and 08/08/2025 revealed all staff were educated by the DON and Administrator regarding Abuse and Neglect, transferring of resident and 2 person to provide incontinent care for resident. Record review of the facility's Ad hoc Qapi dated 8/7/2025 revealed:Findings: Certified Nursing Assistant performed incontinent care on a resident that required a two-person bed mobility.1.The resident does not currently reside at the facility. He is currently at the local hospital.2. Certified Nursing Assistance was provided one and one education of the Kardex and before providing care to review the Kardex and use appropriate supervision and assistance.3. 100 percent audit was completed by nurse management to ensure all resident Kardex had the mobility and transfer status present.4. Administrator provided educational in-service on incident accident/accident policies and procedures and abuse/neglect and exploitation.5. DON/designee provided education on the Kardex. Kardex Competency skills training check off completed for Certified Nursing Assistant, and nurses. 6. All training and education will be provided before the next shift including PRN staff. All information was reviewed with the Administrator, DON, Unit Manager, Medical Director, during the Ad hoc QAPI meeting on 8/7/2025 to review all findings.7. During the morning clinical meeting, accidents and incident will be review daily and at-risk meetings for trends with IDT team members brought to monthly QAPI. The noncompliance was identified as PNC. The IJ began on 08/11/2025 and ended on 08/12/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. 1. RN A failed to call a code blue and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately 1-2 minutes before CPR was started on CR #1. 2. RN A initiated CPR with improper chest compressions and depth during CPR on CR #1 on [DATE]. 3. LVN A failed to place the mask over the resident's nose and mouth, ensuring a good seal. 4. Staff failed to ensure the crash cart had AED pads and was ready for use during CPR on CR #1. This led to a delay of approximately 1-2 minutes before CPR was started on CR #1. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:45 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of actual harm that was not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings included: Record review of CR #1's face sheet dated [DATE] revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included respiratory failure, Crohn's disease (swelling and irritation of the tissues in the digestive tract), Asperger's syndrome (neurodevelopment disability that affects the ability to effectively interact and communicate with people), cirrhosis of the liver (liver damage from conditions such as hepatitis B or C, or chronic alcohol use), gastroesophageal reflux (condition in which stomach acid moves up into the esophagus, causing heartburn), pneumonia, and malnutrition. She was discharged to a medical examiner after she died on [DATE]. Record review of CR #1's 5-day MDS dated [DATE] revealed she had a BIMS score of 00 (severe cognitive impairment); CR #1 ambulated via wheelchair; and CR #1 was dependent for ADL's (eating, toileting, shower, oral hygiene, and dressing). Record review of CR #1's care plan meeting, dated [DATE] revealed the following in part: .[ CR#1] will remain full code. [CR #1] does not have a POA . Record review of progress notes dated [DATE] at 10:50 a.m. by MA A revealed the following: cant [can't] swallow notified nurse [RN A] Record review of progress notes dated [DATE] at 12:34 p.m. by RN A revealed the following in part: .Change of Condition Identified: leukocytosis (above the normal range of white blood cells) . [PCP] present and visited resident [CR #1] . What do you think is going on with the resident: Resident lab results show WBC 22.1. [PCP] present and visited resident. New orders received as follows: 1) CXR 1-V & UA w/ C&S 2) Ceftriazone (antibiotic that is used to treat many kinds of bacterial infections, including severe or life-threatening )1gm IV QD x7 days 3) May place midline for ABX therapy 4) Levothyroxine (used to treat hypothyroidism - underactive thyroid) 50mg PO QD (RP ) notified of new orders and gave verbal consent for midline placement. Physician Notified: [PCP], [DATE] 12:00 PM Record review of CR #1's progress notes dated [DATE] by RN A revealed the follow in part: [CR #1] was observed unresponsive sitting in wheelchair. [CR #1] was confirmed full code, transferred to bed, and CPR was called. 911 was called @1321 [1:21 p.m.] which EMS arrived to room shortly after. EMS continued life saving measures. [Family member] was notified of resident's condition [CR #1] was pronounced deceased @1351 [1:51 p.m.] per EMS personnel. Resident was last seen alive between 12-12:30 [12:00 p.m. - 12:30 p.m.] during lunchtime sitting in wheelchair . Record review of CR #1's EMS Report dated [DATE] revealed: . Primary Impression: Cardiac - Cardiac Arrest . Call Received - 1:22 p.m. Dispatched - 1:23 p.m. On Scene - 1:24 p.m. At Patient - 1:42 p.m. Narrative: History - Nursing home staff stated they walked into the patient's room and found her unresponsive. The last time they saw . Assessment - On arrival, The pt was in bed in her room and nursing staff was doing very poor, slow CPR, and ventilating the pt on high flow oxygen via BVM . She was not conscious, not breathing, and without a pulse. There were no signs of rigor mortis. Her alive was one hour prior. The nursing home nurse states she has not been sick and does not know what could have caused it . Her airway appeared clear. Eyes appeared fixed, dilated, and non-reactive. Breath sounds: absent bi laterally. ABD: soft/nondistended. Skin: cool/dry. Rx/Treatment - Nursing home staff started CPR prior to arrival. 303 [EMS] arrived prior to 409 [FD ] and started ALS resuscitation. Upon contact, the nursing staff was doing low quality compressions and was corrected on proper rate and depth . After 20 minutes of high quality ALS resuscitation the family and POA called back and stated they wanted resuscitation terminated. Transport - The patient was not transported as resuscitation was terminated at 13:51 pm. Call complete. In service. Record review of RN A's cell phone call history dated [DATE] revealed 911 was called at 1:21 p.m. Record review of crash cart check list dated [DATE]st -18th 2024 revealed AED - function and ready. Observation and interview of the facility's crash carts, with the DON and LVN E, on [DATE] at 4:11 p.m. revealed it was located at the front 300 hall, approximately 1-2 yards away from the nurse's station. The AED was in a case on the outside of the crash cart, after unlocking case mild pitch siren and blue light. The code status binder was on the cart. There were no pads located in the AED machine, but pads were in a zipped side pocket of the bag the AED was in. No extra pads were observed in the drawers of the crash cart. A second crash cart on 100 hall was observed and had a pad in the AED machine and extra pad in the bottom drawer of the crash cart. The DON said LVN E was responsible for checking the crash carts daily. The DON said if a resident was found unresponsive, the staff should call out code blue, direct another staff to call 911, and verify code status to start CPR as soon as possible. She said she was not at the facility on [DATE]. She said she would have preferred for the AED to be used because it would instruct the staff what to do if there was no pulse or heartbeat. She said RN A was not able to locate the AED pads. The DON said RN A should have stayed with CR #1. She said he could have directed CNAs and Nurses to call 911, get the crash cart, which she thought he had done. She said this was a part of the delegation process during a code blue. LVN E said she checked the carts daily and remembered seeing AED pads. Interview on [DATE] at 9:11 a.m., with RN A said he worked the 6:00 a.m. - 2:00 p.m. on [DATE] when CR #1 expired. He said he was notified by CNA B who came and told him, CR #1 was unresponsive. He said he went to CR #1's room (on 500 hall) and checked her pulse and she did not have one. He said he left the room, went to get the crash cart (on 300 hall adjacent to the 500 hall). He said CNA B was left in the room with CR #1. RN A said on his way back with the crash cart, he looked at CR #1's code status in the binder on the crash cart and called 911. RN A said he left CNA B in the room with CR #1. RN A said when he returned to the room, CNA B assisted and placed CR #1 in the bed from her wheelchair. He said he did not yell out for help or code blue after CR#1's pulse was taken or instruct CNA B to get the crash cart. RN A said he told, CR #1's assigned CNA B, to get help. RN A said he placed the backboard under the resident. He said he attempted to use the AED and could not locate the pads. RN A said he started chest compressions. RN A said RT A and LVN A came in and assisted with the bag valve mask. He said he was not sure of the time when they both came in, but it was within a minute. RN A said he continued chest compressions until EMS arrived. He said he did not recall if EMS or the FD gave him direction on his CPR technique. He said he was CPR certified and was trained by the facility on the Code Blue protocol. He said code blue was called when a resident was unresponsive, without a pulse, and needed CPR . Interview on [DATE] at 9:55 a.m. with CNA B said she worked 6:00 a.m. - 2:00 p.m. on [DATE]. She said she had not worked with CR #1 before. She said she saw therapy worked with CR #1 in the morning when they took her for a swallow test at approximately 7:00 a.m. CNA B said she was working on the hall next to CR #1's room, when HK A came to tell her CR #1 was not okay. CNA B went to CR #1's room, saw her sitting in her wheelchair. CNA B said she touched CR #1's leg, and CR #1 did not move. CNA B said CR #1's eyes were open, and her head faced toward the hallway. She said she left immediately and notified RN A. CNA B said RN A went to CR #1's room, checked for CR #1's pulse, and left to get the crash cart. CNA B said she waited with CR #1 until RN A came back with the crash cart. CNA B said she could not remember how much time past, but she said it was approximately a few minutes when RN A returned to the room. She said RN A opened the AED and a siren started. She said, less than a minute RT A and LVN A came in to assist and she left out of the room. She said she did not see if RN A used the AED and did not see CPR performed on CR #1. She said EMS arrived quickly but could not remember how long it took. He said he was CPR certified . He said his CPR trained him to complete 30 chest compression and two breaths. In an interview on [DATE] at 12:58 p.m. CNA A said she had not worked with CR #1 prior to [DATE]. She said she recalled CR #1 had a swallow test around 7:00 a.m. on [DATE]. She said therapy assisted CR #1 with her meal. She said she saw CR #1 around 11:45 a.m. and assisted her with her lunch. She said CR #1 did not eat much. CNA A said she brought CR #1's roommate back to the room at approximately 12:30 p.m. CNA A said CR #1 was in her wheelchair looking out into the hallway. She said she saw staff running to CR #1's room and she stood at CR #1's door but left shortly after RN A and CNA A started to assist CR #1. She said EMS arrived approximately 5 minutes after the staff went in to assist CR #1. In a telephone interview on [DATE] at 1:47 p.m. PCP A said she saw CR #1 on [DATE] at approximately 10:00 a.m. She said CR #1's vitals were within normal limits. PCP A described CR #1 as chronically ill, lungs were clear, sounds reduced, heart was regular, very pale, and malnourished. She said there were no acute care issues. She said the b/p was on the low side but no interventions were needed. In a further interview, PCP A said when a code blue was called the staff should response as a team. She said the staff who found the unresponsive resident should yell out for help from the other staff by asking them the resident code status, get the crash cart, call 911, and immediately start CPR. She said if one staff completed all of the task, a delay in CPR could happen. In a telephone interview on [DATE] at 3:41 p.m. RT A said she was on another hall when she and LVN A were asked by (unknown CNA) to assist with CR #1. She said she could hear the AED siren as she ran down the hall. She said she did not hear anyone yell out code blue. She said she grabbed the O2 tank as she entered CR #1's room, LVN A grabbed the Ambu bag (manual resuscitator). She said LVN A placed the bag over CR #1's mouth without securing a tight seal. She said without a tight seal around the mouth and nose the resident would not get the full benefit of the manual breaths. RT A said she took over bagging CR #1 while RN A continued chest compressions until EMS took over. She said she did not remember if RN A said there were no pads for the AED or if she saw him search for them at some point and could not locate them. She said she saw a pulse oximeter on CR #1's finger but did not remember what the reading was. She said she did not remember if the paramedics educated RN A on the depth of his compressions. She said the facility had provided mock code blue trainings where the staff had to act out the code. She said she was CPR certified . She said a delay in CPR and use of the AED could negatively affect the resident. In a telephone interview on [DATE] at 3:48 p.m. LVN A said he rushed down with RT A to assist with CR #1. He was asked how he assisted, and he continued to repeat I did what needed to be done as a team. He later said he initially placed the Ambu bag on CR #1 and then RT A took over. He said RT A connected the bag to the oxygen, he said he did not know why, and he left before EMS arrived, to get the paperwork ready for EMS. He said he was CPR certified . In a second telephone interview at [DATE] at 8:59 a.m. PCP A said it should be a team effort when a code blue was called. She said the staff that found an unresponsive resident should have called out for help from several staff to bring the crash cart (which had the code status binder on it), get oxygen, call 911, and begin CPR. He should not have left the resident . In a telephone interview on [DATE] at 1:42 p.m. the EMS Supervisor said the verbiage low quality chest compression and depth indicated in the EMS Run sheet indicated the CPR provided for CR #1 did not get the full effect or benefit of the chest compression to aid in life sustaining efforts He said the chest compressions should be 1-2 inches as referenced by the American Heart Association. He said he would have to get permission for this state surveyor to interview the paramedics that responded to CR #1. Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part: Automated External Defibrillators (AED) AEDs can greatly increase a cardiac arrest victim's chances of survival . For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches . Hands-Only CPR consists of two easy steps: Call 9-1-1 (or send someone to do that) Push hard and fast in the center of the chest . About High-Quality CPR High-quality CPR should be performed by anyone - including bystanders. There are five critical components: Minimize interruptions in chest compressions, Provide compressions of adequate rate and depth . Record review of the facility's Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE] revealed, Policy The Facility will administer CPR per American Heart Association Guidelines and regulatory expectations for residents with a Full Code status, Procedure, In the event of a medical emergency 2. Check the resident for responsiveness. 3. Validate the resident's code status. a. If the resident is a Full Code, proceed with step #4. 4. Activate the Emergency Response System Code Blue and staff call 911. 5. Assess respirations/pulse simultaneously (within 10 seconds). a. If NO respirations (or only gasping) and NO pulse i. Start CPR. ii. Apply AED as soon as available and follow the prompts. iii. Perform cycles of 30 compressions and 2 breaths via ambu-bag. iv. Continue until EMS providers take over, the resident regains pulse, or receives a Physician Order to cease rescue efforts. 6. Document .Progress Notes . AED Considerations The Facility has an AED available for emergency use, is kept in a location easily accessible by staff, and is rescue-ready. Crash Cart Considerations Ensure the crash cart is ready for immediate use during a code situation . Conduct daily checks to ensure all items are present and in working order and document these checks on a log attached to the cart and regularly check . Ambu Bag Considerations Place the mask over the resident's nose and mouth, ensuring a good seal. Hold the mask with your thumb and index finger forming a C around the mask, while the other three fingers lift the jaw. An IJ was identified on [DATE]. The IJ template was provided to the Administrator and the DON on [DATE] at 10:10 a.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:57 p.m.: Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. F678 CPR IJ Plan of Removal for F678 [DATE] According to the IJ Template: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. The Administrator and DON notified the Medical Director of the IJ on [DATE] and held an ADHOC QAPI meeting to review the IJ template and POR . On [DATE], the Director of Nursing conducted a 1:1 education with RN A. Topic: CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. The DON initiated education on [DATE] with Nurses, and Respiratory Therapist on the CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. All Nurses and Respiratory Therapists will not be allowed to work their assigned shift until training is completed. Staff will verbalize understanding at of end of training session and further training will be provided as needed. Education will be provided in orientation for new hires. Completion date of [DATE]. The DON initiated education on [DATE] with CNA role and code blue situation. CNA will immediately report unresponsive residents to the charge nurse, can assist in announcing code blue and can respond with crash cart and AED to the CODE Blue site. CNA will not be allowed to worked their assigned shift until training is completed. Education will be provided in orientation for new hires. Completion date of [DATE]. The Regional RT and Clinical Team conducted a Mock Code on [DATE] with return demonstration with all staff on site during the 2nd shift. The RT and Clinical Team will conduct a Mock Code with return demonstration for the next 3 shifts with return demonstration to ensure understanding. The Regional RT and Clinical Team will conduct routine Mock Codes to ensure education compliance. Findings will be brought to QAPI and the facilities plan to maintain compliance will be updated as indicated. The facility will maintain compliance with professional standards by treating residents who are Full Code and unresponsive (no pulse) by: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED. The Facility will update the code status binder with OOH DNRs as DNRs are implemented. Residents without OOH DNR forms will be considered Full Code. The facility inspects and replenish crash cart daily and after code events by DON/designee to ensure crash cart is rescue ready. The Administrator reviewed the facility policy on [DATE] and no changes were required. The plan of completion is [DATE]. Monitoring of the plan of removal included the following: Record review of Education In-Service Attendance Record dated [DATE] - [DATE] revealed all nurses, CNAs (including RN A, LVN A) were provided education by LVN B - unit manager regarding nurses are responsible to ensure crash carts are restocked after code and CPR protocol. Record review of Education In-Service Attendance Record - Mock Code dated [DATE] -[DATE] (2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., and 6:00 a.m. - 2:00 p.m.) revealed all staff (nurses, CNAs, therapy staff, hk, were provided demonstration and return demonstration education by the Resp. Therapy Manager regarding Resident found unresponsive - What are our duties? (attachment: Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE]) Mock Code o Initiator: discovered resident, check vitals, called for help, started chest compressions. o Announcer: was code announced overhead o Leader: was control taken and directives given o Recorder: was documentation initiated o PPW (paperwork): was direction given to start paperwork for transfer? (copy of face sheet, etc.) o AED: was the AED initiated when bought [brought] to the scene? o Compressions: was compressions started at discovery and continued until arrival of AED? o Ventilations: was oxygen delivery via Ambu setup and started when emergency cart arrived Observation on [DATE] at 1:30 p.m. of Mock Code Blue - regarding the CPR procedure, checking code status before initiating CPR, assessing resident's pulse before initiating CPR, initiating CPR on residents who are full code and are without pulse, not initiating CPR on residents with a faint pulse, and administering oxygen via Ambu bag . No concerns with the mock code. Record review of Mock Code Blue inservice dated [DATE] at 9:30 a.m. revealed all facility staff were educated by a Regional Respiratory Manager regarding checking the crash cart, stocking the crash cart, AED use/location, steps of CPR, crash cart key location, clean up after and restocking, roles of staff during an emergency situation (all staff), and a mock code blue. Record review of the facility's document Ad Hoc QAPI dated [DATE] revealed the interdisciplinary team met to discuss CPR, the crash cart, code statuses, staff roles, and the AED. Observation of the two facility crash carts on [DATE] at 1:54 p.m. revealed both were fully stocked and code blue ready, including new AED chest pads visible in the AED and extras in the drawers. Interviews were conducted on [DATE] - [DATE] with staff on all shifts (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m. CNAs and Nurses) including the Administrator, the DON, RN A (morning shift), LVN A (morning shift), (morning shift), CNA A (morning shift), CNA B (morning shift), LVN C (evening shift), OT A (evening), Shower Tech A (morning shift), CNA C (night shift), CNA E (night shift) LVN F (night shift), LVN D (secure unit morning shift), RT A (morning shift) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related to code blue, restock crash cart and CPR protocol. The Administrator, the DON, were able to explain the importance of calling codes and using proper terminology when requesting assistance in the event of an emergency, prompt response to an emergency, retrieving the crash cart/AED, and appropriate implementation of the entire CPR process. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:01 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and 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 observation, interview, and record review, the facility failed to provide routine and emergency drugs and biologicals and pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. -The facility failed to send Resident #1's insulin medications with him when he went out on pass/leave for two days. Resident returned back to the facility with a blood sugar level of 457.0 mg/dL. -The facility failed to complete the Medication/Release Receipt form for Resident #1 when he went out on pass/leave for two days. On 02/13/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/14/24, the facility remained out of compliance at no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This deficient practice could place residents at risk of not receiving the desired therapeutic effect of their medications, result in worsening or exacerbation of chronic medical conditions due to missed doses, and/or death. The findings included: Record review of Resident #1's admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked as an active diagnosis. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections . Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 . Record review of Resident #1's Medication Administration Record, dated 02/13/24, revealed he missed 4 doses of his Lantus SoloStar and 6 doses of his Insulin Lispro when he was out on pass. Further review revealed he received 1 of 2 doses of his Lantus SoloStar and 2 of 3 doses of his Insulin Lispro before he went out on leave on 02/10/24. Record review of Resident #1's Blood Sugar Value, dated 2/12/24 at 16:57 (4:57 p.m.), revealed it was 457.0 mg/dL. In an interview on 2/13/24 at 12:45 p.m., Nurse A said she had been working at the facility for approximately one year. She said Resident #1 was a diabetic and had an order for insulin. She said she did not pull and send the resident's insulin with him before he went out on pass on 02/10/24. She said she did not think about it and said the resident was in a hurry to leave. She said she worked Friday, 02/09/24, Saturday, 02/10/24, and Sunday, 02/11/24 and did not receive a telephone call or any messages about his insulin not being sent with him. She said a medication list was not sent with the resident. She said if a resident was not sent home with their insulin medications, they could become hyperglycemic (high blood sugar in the bloodstream) or hypoglycemic (condition in which your blood sugar is lower than the standard range). In a telephone interview on 02/13/24 at 1:37 p.m., the DON said the Medication Release/Receipt form should have been completed by facility staff based on their policy . Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said a staff member (name unknown) packaged up his medications and put them inside his bag. He said he did not see what medications they put inside his bag. He said the facility's van driver dropped him off at his family member's home which was an hour and a half away from the facility. He said when his family member and he noticed his insulin medications were not sent, his family member called the facility and was told (name unknown) that his nurse was on lunch, and someone would call back. He said no one ever called them back. In a follow-up interview on 02/14/24 at 2:13 p.m., Resident #1 said not having and taking his insulin medications while he was out on pass made him feel light-headed and said it made his stomach hurt. He said he thought about going to the hospital because of the way he was feeling but decided not to because he thought it was just him overreacting. He said when he returned to the facility on Monday, 02/12/24, he was feeling light-headed . On 02/14/24 at 2:26 p.m., an attempted telephone interview was made with Resident #1's family member but there was no answer, and the voicemail box was full. On 02/14/24 at 3:03 p.m., an attempted telephone interview was made with the facility's NP but there was no answer. A voicemail was left requesting a return phone call. Record review of the facility's Day Outings/Therapeutic Leave of Absence policy, revised 6/2019, read in part .4) Facility staff will complete the Medication Release/Receipt if appropriate for resident/legal representative signature . This was determined to be an Immediate Jeopardy (IJ). The Unit Managers were notified on 02/13/24 at 5:55 p.m. that an IJ was identified due to the above failures and the IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 02/14/24 at 9:42 a.m. and included: [Facility Name] - IJ Plan of Removal for F755 2/13/2024 Allegation F755: Pharmacy Services The facility staff failed to follow their nursing policy and procedure Day Outings/Therapeutic Leave of Absence when Resident #1 went out on pass/leave for two days. The facility failed to provide Resident #1 his insulin medications when he went out on pass/leave for two days. Resident #1 returned from a leave of absence with family on 2/12/24 at 2:00pm. Resident's blood sugar was assessed by charge nurse on 2/12/24 @ 16:47 and was noted to be 457 and resident #1 received 20 units of Insulin Lispro for coverage. Resident #1's Nurse Practitioner was notified on 2/12/24 by the Unit Manager of 457 blood sugar and missed insulin doses while out on pass and no new orders were received. Resident #1's concern that he was not provided with his insulin while out on pass was brought through the grievance process and investigated by nursing leadership on 2/12/24. Counseling was provided to the charge nurse who was over Resident #1's care at the time he was given his medication and left the faciity on 2/10/24. The investigation was completed on 2/13/24. Resident #1 was assessed by the Nurse Practitioner on 2/13/24 with no adverse effects noted and no new orders received. The Administrator notified the Medical Director of the IJ on 2/13/24. The Unit Manager initiated education with Charge Nurses on 2/13/24. Topics included: Leave of Absence Policies and Procedure and Leave of Absence Medication Release form. The Charge Nurse will ensure that residents going out on pass are provided scheduled medications for the time frame they're predicted to be out on pass (including insulin) and that the quantities of medications provided, and medications received back are documented on the release form. The Charge Nurse should provide education on medication instructions, side effects, and signs or symptoms of missed doses. Charge nurses will be educated before starting their next shift. New Hires (Charge Nurses) will receive education in orientation. Completion date 2/14/24. The IDT clinical leadership team will review residents who or on leave in the morning meeting for compliance with the leave of absence policies and procedures. Started on 2/13/14 and will be an ongoing practice. On 2/13/24 The Unit Manager reviewed all residents who went on a leave of absence for the past 7 days with no adverse findings noted. Review was completed on 2/13/24. The Administrator reviewed the Leave of Absence Policy and Procedure on 2/13/24 with no changes required. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 02/14/24 through 02/14/24. Monitoring of the POR included: During interviews on 02/14/24 between 10:53 a.m. and 3:10 p.m. with staff from all shifts, the following Nurses were able to verbalize an understanding of the Day Outings/Therapeutic Leave of Absence policy and procedures and steps to follow when a resident goes out on pass and requires their medications to be released: Unit Managers A and B and Nurses A, B, C, D, E, and F. During an interview on 02/14/24 at 10:53 a.m., the DON said in-service trainings were started on 02/13/24 and completed in-person and over the telephone. She said the staff who completed the in-service trainings over the telephone would sign the in-service sheet when they returned for assignment. During an interview on 02/14/24 at 1:26 p.m., Unit Manager B said during their morning meetings they would review which resident(s) who were on leave, their leave status, and if there were any changes. During interviews on 02/14/24 at 1:48 p.m., Unit Manager A said she completed a review on all residents who went out on pass in the past 7 days. She said there was 1 resident who went on a leave of absence and took her medications with them. Record review of Resident #2 who went out on leave of absence in the past 7 days was completed. The resident was not a diabetic and no concerns were found during review. Record review of Resident #1's progress notes, dated 02/13/24, revealed he was assessed, the NP was notified, and no new orders were given. His blood sugar was noted to be 457 upon return. NP went to the facility on [DATE] and rounded on the resident. Record review of Resident #1's grievance Concern Report, dated 02/12/24, revealed resident reported that his insulin medication was not sent home with him when he went out on pass. The investigation details revealed Nurse A said she did not provide the insulin medications to him. The findings on the facility's investigation included the following: Nurse A was educated, in-serviced, received 1:1 counseling, and the facility would provide his insulin when he goes out on pass. Record review of Resident #1's NP's progress note, dated 02/13/24, revealed resident was seen and assessed by the NP. The NP assessed Resident #1 for a follow-up on elevated blood sugars reported upon return to facility from therapeutic pass. NP obtained permission from the resident to send in an order for a new medication since he had a change in insurance and resident agreed. Record review of Education In-Service Attendance Records, topic OOP [out on pass] Medications, dated 02/12/24, revealed 6 nurse staff signatures. Record review of Education In-Service Attendance Records titled Medications Released, dated 02/13/24, revealed 11 nurse staff signatures. Record review of Education In-Service Attendance Record, topic Policy & Procedures, dated 02/13/24, revealed 15 nurse staff signatures. Record review of Education In-Service Attendance Record, topic Request for Pass Medication/Leave of absence, dated 02/13/24, revealed 11 nurse staff signatures. The Administrator was notified the Immediate Jeopardy (IJ) was removed on 02/14/24 at 3:23 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.