**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 13 of 28 residents (Resident #1, #2, #3, #4, #5, #6, #8, #9, # 10, #11 #12, #13, and #14) reviewed for infection control. The facility failed to ensure residents (Resident #1, #2, #3, #4, #6, #7 #8, #9, # 10, #11, #12, #13, #14) did not acquire Candida auris (Candida auris is a fungal infection that can cause serious illness) infection at the facility. The facility failed to ensure staff (CNA B and LVN M) wash or sanitize hands after providing care to Residents (Resident #2, #3, #4, #5, #6 and #7) rooms. The facility failed to ensure that staff (CNA B and LVN M) implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting residents' (Resident #2, #3, #4, #5, #6 and #7) rooms. The facility failed to ensure that staff (CNA B) clean and disinfect equipment (pulse ox and thermometer) used to obtain residents' (Resident #2, #3, #4, #5, and #6) vitals before and after use. The facility failed to show proof that the facility had established and implemented a surveillance plan for mitigating the spread of Candida auris infection. An Immediate Jeopardy (IJ) situation was identified on 02/15/25. While the IJ was removed on 02/18/25 at 1:30p.m, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: Record review of Resident #1's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 02/02/2025. Record review of Resident #2's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 02/23/2025. Record review of Resident #3's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/13/2024. Record review of Resident #4's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/11/2024. Record review of Resident #5's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris present on admission. Record review of Resident #6's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/18/2024. Record review of Resident #7's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/06/2024. Record review of Resident #8's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 01/30/2025. Record review of Resident #9's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], 41 age years old; Resident tested positive for Candida auris dated 07/31/2024. Record review of Resident #10's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 04/08/2024. Record review of Resident #11's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 12/11/2024. Record review of Resident #12's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident tested positive for Candida auris dated 12/04/2024. Record review of Resident #13's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 11/06/2024. Record review of Resident #14's face sheet dated 02/18/2025 revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of Candida auris dated 05/21/2024. Record review of infection control binder provided by IP B revealed the facility was not able to show evidence the facility established/implemented a surveillance plan, for identifying, tracking, monitoring and/or reporting of infections, communicable diseases, and outbreaks. Record review of the facility furnished list, indicating positive Candida Auris results for 28 residents. List reflected there was 12 facility acquired candida auris positive residents and 28 total positive residents on the 3 of 4 hallways. Observation on 02/14/2025 at 11:40 AM, LVN M was observed entering contact precaution room [ROOM NUMBER]. without the appropriate Personal Protective Equipment, which included gloves and gowns while administering medication to Resident #7. Upon exiting Resident #7 room, proper hand hygiene measures were not implemented. Observation on 02/14/2025 at 11:50 AM, CNA B was observed inside contact precaution room [ROOM NUMBER] with Personal Protective Equipment obtaining Resident #2 vitals while wearing gloves and a gown. After obtaining vitals, CNA B did not remove the gloves, sanitize or wash her hands or clean equipment prior to exiting Resident #2's room. CNA B proceeded to enter room [ROOM NUMBER] and did not remove the gloves, gown, sanitize or wash her hands, and clean equipment before attending to Resident #3. CNA B obtained Resident #3 and Resident #4 omitting proper hand hygiene, cleaning equipment, and changing PPE between obtaining Resident #3 and Resident #4 vitals. Using the same contaminated gloves and gown, CNA B entered room [ROOM NUMBER] and proceeded to obtain Resident #5 and Resident #6 vitals without washing and sanitizing hands, cleaning equipment, and changing PPE between obtaining Resident #5 and Resident #6. Interview conducted on 02/14/2025 at 11:13 AM, IP B stated the presence of active C. auris cases within the facility, initially detected in April 2024. IP B expressed uncertainty regarding the number of residents who tested positive for C. auris and was also unsure about the total number of residents tested for the infection. She stated she recently was hired as the facility's IP. She stated the pervious IP was terminated approximately a week prior. She stated the DON and pervious IP (IP A) worked with the health department in testing residents monthly. She stated she was made aware of the Candida auris outbreak when she onboarded approximately a week ago. She stated she was not sure of the health department's recommendations. She stated the DON received the health department's recommendations and reports after each. She stated she was not provided with the plan of correction and recommendation from the health department. She could not articulate a plan to mitigate the risk at the time of the interview. She could not provide proof the facility established and implemented a surveillance plan. She stated when she stepped into the role, she was informed by the DON there were many gaps in the tracking and monitoring of infection within the facility. She did not explain the gaps when asked. She could not explain what actions she had taken to close the gaps. She stated she would follow up with the DON regarding the health departments recommendations. Interview on 02/14/2023 at 11:55am, LVN M verablized the error of failing to don PPE and wash hands. LVN M stated that Resident #7 was on Contact Precautions due to testing positive for Candida auris. She verbalized an understanding that the transmission of infection can occur when PPE and hand hygiene protocols were not followed. She stated that such error put residents and staff at risk for infection. LVN M mentioned receiving infection control training, some time ago. She stated that contact precaution required her to put wear a glow and gloves and wash or sanitize her hands before and after enter contact isolated rooms. She stated that the facility supplied adequate PPE. She stated that that the facility had not provided training on Candida auris, but she had knowledge of the infection. She did not identify why she failed to implement proper transmission precautions. She stated by failing to don PPE and wash hands she placed residents at risk for being exposed to the infection and the infection could rapidly spread. Interview on 02/14/2025 at 12:10, CNA B expressed uncertainty regarding why proper PPE measures was not utilized, hand hygiene practices were neglected, and disinfectant measures were not implemented. CNA B stated Residents #1, #2, #3, #4, #5, and #6 were on Contact Precautions due to testing positive for Candida auris. CNA B also acknowledged the risk of infection transmission in the absence of proper PPE, hand hygiene and disinfectant measures. CNA B mentioned undergoing training previously but was unable to articulate the specifics or content of the training provided. CNA B stated that she had not received training on caring for Residents with Candida auris. Interview on 02/14/2025 at 12:20 PM, Local Health Department Epidemiologist A stated the health department began working with the facility in April 2024. Epidemiologist A stated the facility initially (April 2024) had approximately 4 residents who tested positive for Candida auris. Epidemiologist A stated she was not aware of the current number of residents who were positive at the facility. She stated a plan of correction along with recommendations was provided by the local health department to the facility in April 2024, in the effort to mitigate the spread of the infection. She stated when visiting the facility monthly, the Local Health Department tested residents who had not been previously tested and identified as positive residents. She stated results were then provided the facility. She stated the facility continued to have positive test results during each visit and there was a continued outbreak at the facility. She stated the Health Department witnessed staff entering and exiting contact precaution rooms with implement PPE and proper hand hygiene. Epidemiologist A stated she had been working with the DON and the Infection Preventionist (IP) for several months. She stated the continued outbreak could be a result of the facility staff not implementing TBPs. She stated not implementing PPE and hand hygiene put all residents at risk of being exposed to the infection. Interview attempt on 02/14/2025 at 12:26 PM, to the DON by telephone was unsuccessful. Interview attempt on 02/14/2025 at 12:40 PM, to IP A by telephone was unsuccessful. Interview conducted on 02/14/2025 at 5:00 PM, the Administrator could not articulate a structured system designed to effectively mitigate the risk of C. auris transmission. He stated the DON was working with the health department and was aware of the health department's recommendation. He could not explain who was monitoring to ensure the plan and recommendations were being followed. The Administrator stated he was not aware of the number of residents effected with C. auris. Interview conducted on 02/14/2025 at 5:30 PM, the Regional Corporate Nurse stated staff were expected to follow contact precautions when dealing with residents with Candida auris to prevent its spread. This included using personal protective equipment (PPE) such as gloves and gowns, hand washing, properly disinfecting surfaces, and isolating infected or colonized patients when necessary. He stated when failure to use proper TBP placed other residents at risk for being exposed to the infection. Interview conducted on 02/15/2025 at 10:00 AM, IP B was not able to articulate how staff were monitored for compliance. Infection Preventionist B (IP B) stated the DON resigned after being contacted on 02/14/2025 regarding the health department's recommendation and plan of correction. IP B stated she reached out to the health department's Epidemiologist A to request the plan of correction on 02/14/2025, after the state surveyor requested the information. Infection Preventionist B (IP B) stated she was working with the Regional Corporate Nurse and weekend Supervisor to complete an audit of residents who had acquired the infection at the facility. Interview conducted on 02/15/2025 at 12:00 PM, the Administrator said staff were notified of the Candida auris outbreak when he onboarded in 11/2024. The Administrator could not provide a plan to mitigate the risk at the time of the meeting. The Administrator stated the facility would adhere to infection control policy moving forward. The Administrator did not have knowledge of what the infection control policy indicated. The Administrator stated the DON resigned yesterday, 02/14/2024, after she was notified a state surveyor was in the facility. Interview conducted on 02/15/25 at 1:00 PM with Administrator who stated the facility IP A and IP B were training on transmission-based precautions and were responsible for the tracking a trending of communicable diseases within the facility. He stated he was notified by the DON of concerns related to IP A's performance and ability to maintain the infection control responsibilities, a couple of weeks back (could not recall the specific date). He stated approximately a week ago Infection Preventionist B assumed the role of the facility's Infection Preventionist. He was unable to explain IP A's failures and what action were implemented to correct the failures since identified. He stated the Infection Preventionist role was to prevent and contain the spread of infections. He stated the DON was responsible for overseeing the Infection Preventionist duties and responsibilities were being implemented. The Administrator did not explain his active role of preventing and mitigating the spread of Candida auris and communicable diseases within the facility. The Administrator stated IP A was terminated from the facility this week but could not recall the date. The Administrator stated IP B assumed the role as the Infection Preventionist last week. The Administrator stated the DON was responsible for ensuring the tracking and trending was completed by the Infection Preventionist. He stated the Infection Preventionist and the DON had been working with the local health department epidemiologist, but he was not knowledgeable of the current recommendations. Interview conducted on 02/15/2025 at 6:00 PM, the DNP (medical provider) stated failure to properly monitor and mitigate the spread of Candida auris could lead to severe adverse outcomes. Initially, infections may cause serious complications, particularly in immunocompromised individuals, leading to increased mortality rates and death. She stated staff were expected to follow contact precautions when dealing with Candida auris to prevent its spread. This included using personal protective equipment such as gloves and gowns, practicing strict hand hygiene. Failure to adhere to these precautions could further exacerbate the outbreak. She stated she was aware of the spread through the facility. She was not able to identify the total number of residents infected. She stated she believed staff implemented the appropriate contact precautions when dealing with resident Candida auris. She stated she could not attest to how often staff washed their hands or entered a contact isolation room without PPE. She could not explain why the facility had such an increase in residents who acquired the infection while admitted at the facility. Record review of local health department plan of correction, 04/2024 read advised to take the corrective actions listed in the recommendations below: 1. PPE: a. Patient should be on contact precautions. Staff should be using gowns and gloves upon entering the patients room. b. Clear signage to indicate patients are on TBPs with proper indications for precautions and PPE requirements. c. Follow transmission-based precautions, including the use of personal protective equipment by personnel and prefer single patient- use items. e. Making sure PPE, gowns, and gloves are accessible and used appropriately. 2. Handwashing: a. Appropriate hand decontamination following cleaning of C. auris - exposed body fluids/areas. b. Frequent handwashing by staff with soap and water, followed by alcohol-based hand rub. c. Monitor adherence of staff to hand hygiene practices. 3. Cleaning: Shared medical equipment should be cleaned and disinfected thoroughly . Thes was determined to be an immediate jeopardy (IJ) on 02/15/23 due to the above failures. The administrator was notified and provided the IJ template on 02/15/23 at 6:45p.m. The immediacy was lowered on Tuesday, 02/18/2025 at 2:05p.m. with the facility Administrator and DON, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal - Infection Prevention and Control - Accepted 02/16/2025 at 11:00am 1. Candida auris Education The Regional Nurse Consultant initiated education on 02/15/2025 provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Staff will be educated prior to initiating their next shift. Staff will show competency and understanding of education through testing. Education on Candida auris, including testing will occur in Facility Orientation. Education and Testing will be completed by 02/16/2025 2. Environmental Cleaning Education On 2/14/25 the Regional Nurse Consultant initiated education provided to housekeeping staff on cleaning schedules for residents affected by Candida auris and the requirement to clean/disinfect twice a day and using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Housekeeping staff will be educated prior to initiating their next shift. Education will be completed on 02/16/2025. The Administrator will ensure compliance. 3. Infection Control Education The Regional Nurse Consultant initiated education on 02/14/2025 with all staff on Handwashing and Equipment Disinfection between resident rooms. Staff will be educated prior to initiating their next shift. Education will be completed by 02/16/2025 4. 1:1 Education The Regional Nurse Consultant provided 1:1 education with the Infection Preventionist, Weekend RN Supervisor, and Administrator on 2/15/25 on Candida auris, Infection Prevention Program Policy to include surveillance. 5. Medical Director Notification The Administrator notified the Medical Director on 02/15/2025 of the IJ template and will be updated on the POR as indicated. 6. Surveillance The Regional Nurse Consultant audited 100% of resident's charts on 02/15/2025 to identify residents with a presence of Candida auris and whether the infection was facility or community acquired. Outcome: (12) facility acquired & (16) Community acquired. Active surveillance listing will be maintained by the Facility Infection Preventionist from 02/15/2025 forward to include Infection Type and acquired status (Facility vs Community). 7. Sustainability The Administrator is responsible for reviewing all compliance reports (including health department recommendations) and taking immediate corrective action where needed. The Infection Preventionist or Weekend RN Supervisor will conduct Daily audits for PPE compliance and environmental cleaning logs will continue for 30 days and then as needed. The Infection Preventionist will collaborate with the health department as directed and will ensure recommendations are carried out timely. 8. Policy / Recommendation Review The Administrator reviewed the Infection Control Program Policy and Procedure and the Candida auris policy and procedure on 02/15/2025 and no updates were required. The Regional Nurse Consultant, IP, and Administrator reviewed the current Health Department recommendations on 02/14/2025 and initiated Candida auris training (see number 1) and increased environmental cleaning (see number 2). Completion date 2/16/2025. Monitoring of the plan of removal included the following: Observation on 02/17/2025 at varies times, between 9:00am and 5:00am on the 100, 300 and 400 halls during rounds revealed contact precaution signs posted, bins were placed on outside their room doors, and bio-hazard box (boxes used to discard PPE) in the room. Staff were seen donning and doffing PPE, washing hands, and using hand sanitizer. Observation on 02/18/2025 at varies times, between 9:00am and 5:00am on the 100, 300 and 400 halls during rounds revealed all residents identified with Candida Auris were on isolations, with contact precaution signs posted, bins were placed on outside their room doors, and bio-hazard box in the rooms. Staff were seen donning and doffing PPE, washing hands and using hand sanitizer. Observation on 02/18/2025 at 11:45 AM, revealed disposable trays we're being used to serve residents who were on contact isolation precaution. Trays were discarded bio-hazard box after use. Interview conducted on 02/17/2025 at 11:04 AM, RN E stated a resident with Candida Auris families were called and educated about the disease process. He said the nurses, CNAs, housekeeping, central supply, Respiratory Therapist were educated, about Candida Auris and TBPs. He staff knowledge and understanding was verified by taking and passing a facility provided test competency test. Interview conducted 02/17/2025 at 11:15 AM, the Housekeeping Supervisor stated she worked 6:00 AM to 3:00 PM and as needed. She said she was in-serviced on 02/15/2025 about Candida Auris, how it spread, hand washing, cleaning the equipment's, donning, and doffing PPE's. Identifying residents with Candida Auris with the sign posted. She said the facility had adequate bio-hazard box and bags. Interview conducted on 02/17/2025 at 11:25 AM, LVN M said residents' family were called and educated about Candida Auris disease process, contact isolation for Candida Auris, hand washing, cleaning the equipment's, donning and doffing PPE's and she care planned resident isolation with Candida Auris. Interview conducted on 02/17/2025 at 11:27 AM, revealed RT worked 6:30 AM to 7:00 PM, she had in-services on Candida Auris disease process, contact isolation for Candida Auris, hand washing, cleaning the blood pressure cuff, Accu checks equipment, donning and doffing PPE's. Interview conducted on 02/17/2025 at 11:33 AM, revealed LVN C worked 6:00 AM -2:00 PM for one year, had in-services on Candida Auris disease process, spray, contact isolation for Candida Auris, hand washing, cleaning the blood pressure cuff, Accu checks equipment , donning and doffing PPE's. Interview conducted on 02/17/2025 at 11:47 AM, CNA R stated she worked 6:00 AM to 2:00 PM and had in-services on Candida Auris disease process, spray, contact isolation for Candida Auris, hand washing, donning, doffing PPE's. CNA R was observed to don gloves and a gown to feed Resident #4 on contact isolation. In an interview with the Regional Nurse Consultant and the Facility Administrator on 02/18/2025 at 12:30 PM, the Administrator said the Medical Director was informed of the outbreak. Interview attempt on 02/18/2025 at 1:40 PM with the Medical Director by telephone was unsuccessful. Interview conducted on 02/18/2025 at various times, 9:00am - 5:00pm, with (LVN S, CNA Y, CNA D, CAN S, RT O) revealed they were able to verbalize understanding of all in-services provided on hand hygiene, donning and doffing PPE, contact precaution and transmission-based precautions, and verified knowledge of systems in place as of 02/18/2025. Interview conducted on 02/18/2025 at various time, the Housekeeping Supervisor and Housekeeping staff verbalized TBPs to prevent the spread of Candida auris. All were verbalized knowledge of cleaning schedules for residents affected by Candida auris and the requirement to clean and disinfect twice a day using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Record review revealed Regional Nurse Consultant provided education on 02/15/2025, 02/16/2025, 02/17/2025, and 02/18/2025 provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Record review revealed daily cleaning audits logs were being conducted as of 02/17/2025, by Housekeeping Supervisor. Record review of trainings revealed Regional Nurse Consultant provided 1:1 education with the IP B, Weekend RN Supervisor, and Administrator on 2/15/2025 on Candida auris, Infection Prevention Program Policy to include surveillance. Record review of clinical documentation revealed the Regional Nurse randomly selected residents revealed the families was educated on Candida auris and the prevention measures to be used when entering and exiting residents isolation rooms. The Facility Administrator and Regional Nurse Consultant was informed the Immediate Jeopardy was removed on 02/18/2025 at 1:30 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of a 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 observation, record review, and interview, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 4 of 4 halls (100 Hall, 200 Hall, 300 Hall, and 400 Hall) reviewed for call light systems. 1. The facility failed to repair or replace the call light system for the entire building after five months when inclement weather caused the system to fail on 05/02/2024 through 10/09/2024. Resident #2, Resident #3, and Resident #4, who were all physically and cognitively capable of using a call light system had no means to call for staff assistance. 2. The facility failed to have adequate interventions in place for CR #1, who was alert, oriented, and quadriplegic (a condition that causes a person to lose the ability to move all four limbs and the body from the neck down), to call for staff assistance and resulted in family members calling 911 after attempting to call the facility 45 times when CR #1 experienced a change of condition (shortness of breath). EMS noted CR #1 was tachycardic (134 BPM) (when the heart beats faster than normal, usually more than 100 beats per minute while resting), diaphoretic (sweating profusely), and febrile (103 degrees F) (with fever) with an oxygen saturation (the percentage of oxygen-saturated hemoglobin in the blood) of 89% (normal range is between 95% and 100 %) on 09/10/2024. An IJ was identified on 11/14/2024 at 11:49 a.m. The IJ template was provided to the facility on [DATE] at 11:49 a.m. While the IJ was removed on 11/15/2024, the facility remained out of compliance at a scope of pattern with severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on 11/14/2024. These failures could place residents capable of operating a call light system or adaptive call buttons at risk of experiencing a delay in receiving urgent medical care in emergency situations and delayed assistance with activities of daily living. Findings include: Record review of CR #1's face sheet dated 09/10/2024 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 was diagnosed with non-pressure chronic ulcer (a non-healing wound) of the skin, acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and pressure ulcer of the sacral region (the triangular bone that connects the spine to the pelvis and forms the back wall of the pelvis), stage 4 (the most severe type of pressure ulcer and involves full thickness tissue loss with exposed bone, tendon, or muscle). He was discharged to an acute care hospital on [DATE]. Record review of CR #1's electronic health record revealed he did not have a completed MDS. Record review of CR #1's Observation Detail List Report dated 09/04/2024 revealed CR #1 could make himself understood, he understood others, and he had no short-term or long-term memory concerns. Record review of CR #1's care plan revised on 09/05/2024 revealed the following care areas: * Baseline Care Plan: will identify my care needs, risks, strengths, and goals for the first 48 hours. Goal included: My initial goal is to have access of services to promote adjustment to my new living environment. Approach included: * Activities and Functional Level for daily Care: I will receive the necessary setup, cueing, support and assistance level for activities of daily living. * Anticoagulation therapy will be administered as ordered by the physician. * Behavioral need will be evaluated for impact on quality of life, safety, and safety of others. * I will be receiving skilled care and my discharge planning, goals, community referrals, transportation, health knowledge deficits, and follow-up will be discussed and planned with me and as needed with selected representatives. I will remain in place for long-term or hospice care. A comprehensive plan of care will be developed following a complete evaluation of my needs, strengths, and personal preferences. * Pressure Ulcer/Injury. Trauma wound to back of head related to immobility. Goal included: Trauma wound to back of head will heal without complications. Approach included: Avoid shearing resident's skin during positioning, transferring, and turning; Conduct systematic skin inspection weekly; Treat area per doctor orders. * Pressure Ulcer/Injury. Stage 4 Pressure injury/ulcer wound to sacrum related to immobility. Goal included: Resident's ulcer will heal without complications. Approach included: Apply dressings per doctor orders; Assess the pressure ulcer for stage, size, granulation tissue (a new connective tissue that forms in a wound during the healing process), and condition of surrounding skin weekly; Keep resident off load wound; Turn and reposition as needed, and as tolerated. Record review of CR #1's Physician's Progress Note dated 09/09/2024 revealed, . [CR #1] is an [AGE] year-old male with no previous medical history whose hospitalization started with a gunshot wound to his right neck in 05/2024. He sustained a transection of right ICA and right vertebral artery with blast injury (physical trauma resulting from direct or indirect exposure to an explosion) of C2 (the second cervical vertebra) and involvement of spinal canal. This has resulted in quadriplegia (a condition that causes a person to lose the ability to move all four limbs and the body from the neck down), tracheostomy placement (a surgical procedure that creates an opening in the neck and into the windpipe, or trachea to provide an airway for breathing), and chronic respiratory failure requiring continuous invasive mechanical ventilation. His course was complicated by a pneumothorax (when air leaks into the space between the lungs and chest wall) s/p chest tube placement and removal, multi-drug resistant pneumonia, multi-drug resistant urinary tract infection, and a significant sacral wound requiring I&D (minor surgical procedures to release pus or pressure built up under the skin) on 08/19/2024. He has been treated with multiple antibiotics, however, most recently was placed on Ceftazidime for a 4-week course due to his sacral wound, which per the infectious disease team that was seeing him, should continue until 09/20/2024 . [CR #1] is awake and alert and in no distress . Vital Signs: Pulse - 99 BMP, Blood Pressure - 122/67, O2 Saturation - 99 Room Air, Respiratory Rate - 18 Breaths per minute . Record review of CR #1's nursing progress notes for September 2024 revealed: * On 09/09/2024, at 1:45 p.m., LVN C wrote, Resident on day 5 of Ceftazidime 1 gram IV for Pneumonia. Indwelling Catheter intact, patent (open and functioning properly, with minimal blockage), and draining . * On 09/11/2024, at 3:17 p.m. (this entry was recorded as a late entry for 09/09/2024 at 11:13 p.m.), LVN A wrote, Resident is alert and oriented x 4 (a medical term that indicates a patient is awake, alert, and oriented to person, place, time, and event), was asked if he needed any PRNs or anything during this nurse first round, resident denied needing anything. Vital signs were taken by nighttime CNAs. IV line was flushed after antibiotic therapy finished. No s/s of distress or pain noted during this round. * On 09/10/2024, at 3:40 a.m., LVN A wrote, 911 showed up to facility for patient by [family member] request. Paramedic suctioned the patient, there was no secretions coming out. He repeatedly kept suctioning and bleeding was observed on the tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck). Vital signs were taken - BP: 114/68, HR: 137, RR: 20, T: 97.9 [degrees Fahrenheit], O2 Sat: 99%. Resident had complained of SOB, RT assessed and O2 Sats were WNL for this patient. Resident is A&O x 4 and requested to be transported to the hospital. Resident will be taken to a local acute care hospital. RP notified of transfer. DON was notified. * On 09/10/2024, at 5:38 a.m., RT B wrote, Lung Sounds: Diminished; Respirations Rhythm/Pattern: Regular/Unlabored. Cough Present? No. Shortness of Breath present? No. Shortness of Breath (dyspnea): None of the above. Oxygen in use? Yes (Liter Flow) 5. Use of vent: Yes . Restlessness present? No. Anxiety present? No . Resident's [family member] called 911 to take resident to the hospital. Resident complaining that he cannot breathe. SPO2 WNL at 99%. Paramedic immediately began suctioning resident's tracheostomy, no secretions noted. Paramedic repeatedly suctioned and bleeding through the tracheostomy started. RT suctioned small amount of secretion through nose and mouth. Resident alert and oriented. No respiratory distress noted. RT has provided respiratory care. EMS left at 4:00 a.m. * On 09/10/2024, at 2:30 p.m., the DON wrote, This writer spoke with RP regarding concerns about phone calls last night. She expressed her concerns. Provided RP with this writer's phone number to call. Explained that new cordless phones are being provided. RP stated she will be bringing [CR #1] back. She stated he has a low fever and will be getting a supra pubic catheter while at the hospital and the return to the facility. * On 09/10/2024, at 3:35 p.m., the Administrator wrote, Spoke to family member and apologized of the phone not being answered timely and gave her my cell phone number to reach out with any questions or concerns . Record review of CR #1's EMS record dated 09/10/2024 revealed, . Last known well - 09/10/2024 at 1:00 a.m. Signs and Symptoms: Shortness of Breath (Primary) . Call Received: 3:23 a.m. Dispatched: 3:25 a.m. On Scene: 3:33 a.m. At Patient: 3:36 a.m. Depart Scene: 4:13 a.m. 3:41 a.m. - Pulse: 134, RR: 22, Temperature: 103.5 [degrees Fahrenheit] . Was dispatched to facility for a breathing problem. We responded emergency traffic and arrived on location without incident or delay. Dispatch advised that the patient's family member called 911 but was not on location. We entered the facility and found the patient lying in bed. Patient contact was made an initial assessment was performed . Patient was A&O x 4. Patient tracheostomy tube was occluded with mucus and was immediately suctioned and cleared. Patient breathing was accelerated with equal chest rise and fall, clear lung sounds, denied any chest pain but was in moderate distress. Patient skin was hot to touch and diaphoretic (sweating profusely), strong and rapid pulses, and no obvious signs of injury or bleeding noted. Further assessment showed patient was running a fever and had increased capnometry (amount of carbon dioxide in exhaled air). Patient family member was contacted at this time. She advised that she had called the facility multiple times since 1:00 a.m. to find out why [CR #1] was having difficulty breathing but eventually called 911 after getting no response. Patient vitals were obtained at this time and are as noted in report. EMS requested additional staff to make location for additional manpower to assist in moving the patient and assisting ventilations during transport . Patient tracheostomy tube was flushed and suctioned . Patient showed sinus tachycardia that would gradually increase in rate during patient care . Record review of CR #1's hospital records revealed on 09/10/2024, at 4:29 a.m. his temperature was 103.5 degrees Fahrenheit, and his heart rate was 158. IV fluids and acetaminophen were ordered. The document read in part, . 09/10/2024, at 9:42 a.m. History and Physical . Today 09/10/2024 brought by EMS with worsening shortness of breath. According to his family member, he has been 'feeling hot' for the past two days, having shortness of breath since last night. According to her, he has been with a lot of respiratory secretions. He reports no symptoms at the time of my interview, only asking for ice chips. He reports no chest pain, no nausea, no vomiting, or diarrhea. ED course: Mild hypernatremia (high concentration of sodium in the blood) with slight leukocytosis (high white blood cell count) with mild anemia. Calcium slightly elevated with mild liver enzymes elevation. Chest x-ray was consistent with right lower lobe pneumonia versus atelectasis (complete or partial collapse of a lung). EKG with sinus tachycardia. Patient was treated with IV Meropenem (antibiotic used to treat infection) in the ED and admitted for further evaluation and treatment . Impression and Plan Diagnosis: acute on chronic respiratory failure, acute sepsis (a life-threatening complication of an infection), anemia, aspiration pneumonia (a lung infection due to a relatively large amount of material from the stomach or mouth entering the lungs) . Record review of Resident #2's face sheet dated 09/17/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with acute respiratory failure with hypoxia, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic obstructive pulmonary disease (a group of lung diseases that make it hard to breathe), history of tracheostomy, and dependence on respirator. Record review of Resident #2's MDS dated [DATE] revealed he could make himself understood; he had a BIMS score of 15 (cognitively intact); and he required extensive assistance from one staff member with bed mobility, transfers, eating, and toilet use. Record review of Resident #2's care plan revised 06/20/2024 revealed the following care areas: * Resident is at risk for falls due to weakness. Goal included: Resident will be free of falls. Approaches included: Implement exercise program that targets strength, gait, and balance. Place call light/ call bell within reach all the time and respond to call light/ call bell promptly. * Resident has a chronic established contractures of bilateral (both sides) upper extremities due to cerebral palsy (upon admission). Goal included: Resident will receive measures to correct or prevent further progression of current contractures from developing to allow for proper positioning and adequate hygiene of extremities. Approach included: PT/OT to establish most appropriate contracture management program and work on compensatory strategies to improve independence with functional tasks. * Resident able to communicate well with the staff: alert and oriented x 3-4 (3: person is alert and oriented to person, place, and time, but not what is happening to them. 4: fully alert), verbal, speaks and understands English, understood and able to understand other. Goal included: Resident needs will be communicated to the staff and will ensure that they are met. Approaches included: Allow resident time to speak. Avoid interrupting. Encourage verbalization. Record review of Resident #3's face sheet dated 09/17/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with metabolic encephalopathy (a group of neurological disorders that occur when the brain is affected by chemical imbalance in the blood), cognitive communication deficit (difficulty with communication that is caused by a disruption in cognition) , aphonia (loss of voice), dysphagia (difficulty swallowing), tracheostomy status, and dependence on a respirator, acute and chronic respiratory failure, cerebral infarction (when blood flow to the brain is blocked, resulting in brain tissue death), and end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #3's MDS dated [DATE] revealed he was usually understood by others; he had a BIMS score of 15 (cognitively intact); and he required substantial/maximal assistance from staff with eating, oral hygiene, and toileting. Record review of Resident #3's care plan revised 10/03/2024 revealed the following care areas: * Resident has impaired communication related to unclear speech and aphonia (loss of voice). Resident is usually understood and understands other. Goal included: Resident will be able to make basic needs known daily. Approaches included: Allow adequate time to respond, repeat as necessary. Anticipate and meet needs. Ensure/provide a safe environment: call light in reach, adequate low glare light. * Resident is at risk for falls due to muscle weakness, decreased coordination, and impaired physical and functional mobility. Goal included: Resident will be free from minor/major fall related injuries. Approaches included: Implement exercise program that targets strength, gait, and balance. Keep call light/call bell within easy reach. Ensure prompt staff response. Record review of Resident #4's face sheet dated 11/19/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with acute and chronic respiratory failure with hypoxia, anemia (when the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen all through the body), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus), dysphagia, history of transient ischemic attack (a brief stroke-like attack) and cerebral infarction, aphonia, cognitive communication deficit, and history of tracheostomy. Record review of Resident #4's quarterly MDS dated [DATE] revealed she understood others and made herself understood; she had a BIMS of 8 (moderate cognitive impairment); and she was dependent on staff for eating, hygiene and bathing. Record review of Resident #4's care plan revised 10/23/2024 revealed the following care area: * Resident is at risk for falls due to weakness. Goal included: Resident will be free of falls. Approaches included: Increased staff supervision with intensity based on resident need. Place call light/call bell within reach all the time and respond to call light/call bell promptly. Observation of all four of the facility's halls (100 Hall, 200 Hall, 300 Halls, and 400 Hall) and random rooms on all four halls inside the facility (101, 103 - 100 Hall, 204 - 200 Hall, 306 - 300 Hall, and 402, 413, 414 - 400 Hall) on 09/10/2024, starting at 12:45 p.m. until 3:15 p.m. revealed residents had cowbells (a hand percussion instrument), squeeze toys, and buzzers to use at beside and in bathrooms when they needed staff assistance. Further observation of the facility during this timeframe revealed there were multiple bedside tables placed haphazardly on each hall with chairs. Facility staff were observed sitting in the chairs at random times. Observation and interview of Resident #2 in room [ROOM NUMBER] (on the 100 Hall) on 09/10/2024, at 1:16 p.m. revealed he was alert and oriented. He stated his family supplied him with a buzzer which played a musical sound to use when he needed staff assistance. He stated because of his hands, he would not be able to operate a regular call button and would require an adaptive call button. The sound from the buzzer was loud inside the resident's room and could be heard from outside the resident's room. The sound of the buzzer became more and more faint further down the hall. Resident #2 stated he pushed the buzzer multiple times, depending on the urgency of what he needed. He stated staff responded timely most of the time, but sometimes, staff took longer to respond, just as they did when the call light system was in working order. He said he had not experienced any negative outcomes because of the broken call light system. Observation and interview with CR #1 on 09/10/2024 at 3:30 p.m. revealed he was in a room in the ER of a local acute care hospital. CR #1 was alert and had a tracheostomy connected to a ventilator. CR #1 also had on a neck brace. CR #1 was sweating heavily. CR #1 did not initially verbalize words. He blinked once for yes answers and twice for no answers. CR #1 indicated no facility staff went to his room early that morning (09/10/2024) until EMS arrived. He indicated he did not know what time facility staff last checked on him. He indicated he felt hot and sick while waiting for staff to reposition him. CR #1 indicated he had trouble breathing and needed to be suctioned that morning, but he did not have a way to call the staff directly for help. He indicated he was sweating that morning and then he said, Help. CR #1 indicated he wanted a nurse. While waiting for a hospital nurse to come, CR #1 said, Ice chips. CR #1's hospital nurse stated CR #1 was febrile (had a fever) with a temperature of 103.5 degrees Fahrenheit when he arrived in the ER, and he was being admitted for sepsis. The nurse took CR #1's temperature and stated it was 99.9 degrees Fahrenheit. The nurse stated CR #1 was tachycardic upon arrival to the ER at 158 BPM. Observation and interview of Resident #3 in room [ROOM NUMBER] (on the 400 Hall) on 09/17/2024 at 1:18 p.m. revealed he was alert but had a tracheostomy connected to a ventilator and could not communicate verbally. There was a red cowbell on a bedside table in the space between Resident #3 and his roommate's bed. The bell was not within reach of Resident #3. Resident #3 could answer questions with gestures and head nods. He indicated he did not have a bell to ring if he needed help from staff because the call light system did not work. He indicated the red bell on the table was not his. He indicated he was new to the facility, and nobody ever gave him a bell or device to use when he needed help from staff. He indicated he could move both of his hands and arms. Observation of Resident #3, at that time, revealed he could move both arms and hands. He shrugged his shoulders to indicate he did not know how he would let staff know he needed help. At that time, RT E was in the hallway outside of Resident #3's room. RT E stated Resident #3 was alert and oriented. RT E stated the red bell on the table belonged to Resident #3 because his roommate was unable to operate the bell. Resident #3 indicated nobody ever told him the red bell was his to ring when he needed help from staff. RT E asked Resident #3 to demonstrate his ability to ring the bell. Resident #3 placed his hand around the bell and attempted to ring it, but the sound was slightly muffled. RT E provided Resident #3 with a buzzer, and he demonstrated he could operate it successfully. Observation and interview with a Resident #4 in room [ROOM NUMBER] (100 Hall) on 09/17/2024 1:40 p.m. revealed she was alert with a tracheostomy and could not communicate verbally. Observation of Resident #4's room revealed she did not have a bell or other device to operate if she needed help from staff. She could answer questions with gestures and head nods. She indicated she did not know where her bell was, and she did not know how long it had been missing. Observation of Resident #4 at that time revealed she could move her arms and hands. She indicated she did have a bell at one time, but she had not seen it in a while. She indicated she had not had the bell for at least multiple days. She shrugged her shoulders to indicate she did not know how she would alert staff if she needed help. In a telephone interview with CR #1's RP on 09/10/2024 at 11:35 a.m., she stated EMS told her that CR #1 had a high temperature when he was admitted to the hospital on [DATE]. She stated CR #1 was able to communicate with an eye tracker system on his tablet which allowed him to text (which turned the text to voice) with his eyes since he could not move his limbs and the facility did not have a call light he could use. She said the device allowed CR #1 to call phone numbers when he needed help. She said she let the staff know when he was admitted on [DATE] to keep an eye on him because he had problems with his breathing between the hours of 2:00 a.m. - 3:00 a.m. and 6:00 a.m. - 7:00 a.m. She said she had not been able to reach the staff by phone during those hours. She said CR #1 was able to tell her he had snot all over his face on the morning of 09/10/2024. She said CR #1 knew when he needed to be repositioned and suctioned and he recalled everything perfectly. She said he was nonverbal now, but he was very aware and alert. She said she had to call 911 on 09/10/2024 because nobody answered the phone and staff only called her to let her know CR #1 was going to the hospital. She said earlier during the night shift, (on 09/09/2024) at 9:31 p.m., CR #1 contacted her and said he had not been repositioned. She said he could not recall what time he was last repositioned, before then, but he said it had been a long time. She said she called the facility at 9:34 p.m. and someone answered the phone and went to assist CR #1. She said on 09/10/2024, the problem started at 1:45 a.m. when CR #1 called another family member and indicated he could not breath, he had mucus coming out of his nose, and he needed to be repositioned. She said that family member called her at 1:53 a.m. She said she called the facility at 1:53 a.m., but nobody ever answered the phone. She said on at 2:38 a.m., she asked CR #1 if anybody came to assist him and he texted No, please call the facility. She said she told CR #1 she was calling right then. She said at 2:40 a.m., she called the facility more times and CR #1 indicated that he was hot, he needed a breathing treatment, and he need to be repositioned. She said at 2:49 a.m., CR #1 indicated nobody came to assist him yet and he had a lot of snot on his face. She said at 2:50 a.m., CR #1 got anxious and texted, Help! She said two other family members got involved and started calling the facility. She said at 3:00 a.m., CR #1 indicated that nobody had went to assist him. She said CR #1 stopped texting at 3:05 a.m., but she was still calling the facility over and over from 3:03 a.m. - 3:19 a.m. She said she called 911 at 3:21 a.m. She said EMS called her from their personal cell phone at 3:47 a.m. and said CR #1 had a face full of snot and needed to be suctioned. She said EMS told her CR #1's other vital signs were fine, but he had a high temperature. She said EMS took CR #1 to the hospital because he wanted to go. She said the facility's staff called her at 4:30 a.m. to let her know CR #1 was being transported to the hospital. She said another family member called the facility 28 times and she called 17 times. She stated she previously told facility staff (she could not recall the names of staff she talked to) that CR #1 experienced anxiety at certain times during the night. In an interview with RT B on 09/12/2024 at 3:15 a.m., he stated he worked with CR #1 on Saturday (09/07/2024), Sunday (09/08/2024), and Monday 09/09/2024) (respiratory therapists work 12-hour shifts, so RT B was on shift the morning of 09/10/2024). He stated CR #1 complained of shortness of breath a few times during his shift, but his oxygen saturation was good at 99% and he was not in distress. He said he thought CR #1 experienced anxiety because his vital signs were fine, he was breathing fine, and it was common for residents with new tracheostomies to have anxiety. RT B said he checked on CR #1 every two hours, and he was called to CR #1's room a lot to suction secretions from his nose and mouth. RT B said CR #1 always called his RP and she called them at the facility. He said CR #1 often had a lot of secretions from his nose and mouth. He said CR #1 was uncomfortable with the secretions, so he suctioned him, but CR #1 was not in an emergency. He said he heard the phone ring a lot on Tuesday morning (09/10/2024) and the nurse (he could not recall which nurse answered the phone) answered a few times. RT B said LVN A told him CR #1's RP wanted them to check him to see if was ok, so they went to check him immediately after his RP called. He said CR #1's vital signs were perfect. He said CR #1 made sounds with his mouth and grimaced, so he suctioned his nose, mouth, and tracheostomy. He said CR #1 had some snot (secretions from his nose) on his face, but not a lot. He said LVN A was CR #1's nurse, and she was assigned to work half of two halls, so she was not on CR #1's hall the whole shift. RT B said CR #1 was not sweating when he checked him. He said between 1:45 a.m. and when EMS arrived, he had been in CR #1's room three times. He said he went in when EMS came, so that was his 4th round into CR #1's room. He said he was surprised when he saw EMS in the building, and they immediately suctioned CR #1 because of SOB. He said nothing came from CR #1's tracheostomy and EMS went in again and again until CR #1 started bleeding. RT B said he told EMS to stop. He said when EMS arrived, CR #1 had a medium amount of nose and mouth secretions. He said he called LVN A to come when EMS arrived because she was on another hall. He said he saw LVN A check CR #1's vital signs, including his temperature when EMS arrived. He said CR #1's heart rate was a little high, but he thought it was from anxiety. RT B said CR #1's temperature was fine at that time and he was not sweating. He said CR #1's RP insisted EMS take him to the hospital. In an interview with the Administrator on 09/12/2024, at 12:45 p.m., she stated the call light system was still broken and had been broken for several months since a thunderstorm caused it to go out in April 2024, or May 2024. She stated lightning struck the whole panel during the storm and the system could not be fixed. She stated she went out and bought bells and squeeze toys because the bells were too heavy for some residents to use. She said they also placed tables and chairs for nursing staff to sit out on each hall and check residents more frequently. She said she also implemented the use of walkie-talkies, so if an RT needed a nurse quickly, they could call on the walkie-talkie. She said contractors tried to replace the system and said they would come back when they were paid. She stated she did not know when the contractors would be paid by corporate. She said residents asked for updates every month during resident council meetings, but she had to tell them she did not have answers. She said she heard residents say it took too long for staff to come when they rang the bells/buzzers, but some residents also had that complaint before the call light system broke. In an interview with the DON on 09/12/2024, at 2:15 p.m., she stated she was familiar with CR #1, and she had just spoken to his RP. She said CR #1's RP said she called the facility multiple times that morning (09/10/2024) and felt CR #1 did not get adequate care. She said the RP said she and other family members called over 50 times. She said a nurse only answered once and went in to help CR #1, but nobody answered the other times. The DON said she investigated, and the nurse (LVN A) verified she went in and checked on CR #1. She said the nurse told her the phone probably did ring that many times, but she was in another room at the time. The DON said that was probably why CR #1's RP called 911. She said since that incident, they had gotten cordless phones for the nurses on each hall. The DON said CR #1 was already gone to the hospital when she arrived on [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 of 2 residents (CR#1 and CR#2) reviewed for quality of care. 1. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR #1, after he missed 3 to 4 days of dialysis, his doctor gave orders for hospital evaluation and treatment, and the Dialysis Nurse expressed concerns of fluid overload. 2. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR#2, after his doctor gave orders for a blood transfusion, which was an emergency situation. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of CR#1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia (not enough oxygen in the body all at once-acute, or over time-chronic); hypokalemia (low blood potassium levels); End-Stage Renal Disease (an individual's kidneys no longer function and require a regular course of long-term dialysis or a kidney transplant to maintain life); and hypertensive heart disease without heart failure (changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). Record review of CR#1's care plan, dated [DATE], reflected CR#1 was at risk of falls related to weakness and impaired mobility. Record review of CR#1's progress notes, dated [DATE], reflected the following: at 12:06 PM, CR#1 was found unresponsive at 11:25 AM. Nurse called out to resident, no response, sternal rub performed, no response. Pulse checked, undetected. Nurse immediately called code blue and began ambu (provides respiratory support to patients in emergency and non-emergency situations) bagging resident. When RT Aide walked in to assist with bagging, nurse began compressions. No blood pressure reading obtained due to condition, blood glucose 215 at time of first round of compressions. 11:30 AM AED pads placed on resident no shock advised. 911 was called and CPR continued until arrival of EMS. Multiple rounds of CPR done, when EMS arrived monitor placed, and no pulse detected. EMS called of death 11:45 AM. Further review of CR#1's progress notes, dated [DATE], reflected the following: Dialysis nurse verbalized concerns for fluid overload due to inability to perform dialysis Saturday and today [DATE]. CR#1 received orders to be sent out to the ER do restores function to port and receive dialysis in hospital. Transport scheduled to pick up resident with 2 hours. Resident in bed resting, no distress noted at this time vs WNL, no c/o pain or discomfort at this time. Record review of CR#1's Dialysis Center Treatment Detail Report, reflected the following: [DATE], Treatment Nurse Assessment: Time: Pre-6:42 AM and Post: 10:31 AM-Comment: Patient Treatment terminated early due to problematic CVC. MD notified. Record review of CR#1's dialysis center patient notes, reflected the following: CR#1 treatment terminated early due to problematic access . Patient had 118 minutes remaining at the time of treatment was discontinued. Notified Dialysis MD, ordered the patient be sent out to the hospital to treat and evaluate catheter. Record review of CR#1's Dialysis Communication form, reflected the following: [DATE], Dialysis Access Notes: problematic, alarmed throughout treatment, catheter problematic treatment terminated early. MD notified. 2. Record review of CR#2's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR #2 had diagnoses which included diagnoses of Metabolic Encephalopathy (problems with your metabolism, like low blood sugar or excess brain fluid, cause brain dysfunction); Dysphagia (difficulty swallowing); End-Stage Renal Disease (an individual's kidneys no longer function and require a regular course of long-term dialysis or a kidney transplant to maintain life); Type 2 Diabetes (a chronic condition that happens when an individual has persistent high blood sugar levels, due to their pancreas' inability to produce enough insulin, or their body not utilizing insulin properly, or both); Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease causing restricted or obstructed airflow and breathing problems); and, Unspecified Acute Myocardial Infarction (also known as a heart attack, which occurs when blood flow to the heart muscle is abruptly cut off, causing permanent damage to the heart muscle). Record review of CR#2's admission MDS, dated [DATE], reflected the resident's BIMS score was 8, which indicated moderate cognitive impairment. The resident had minimal difficulty in hearing, unclear speech pattern, was able to make himself understood sometimes and usually understood verbal content. The resident was dependent on staff for all ADL's and maximal assistance with oral hygiene. The resident was receiving oxygen therapy, scheduled suctioning, ventilator, dialysis, and speech therapy five days a week for 45 minutes. Record review of CR#2's care plan, last revised on [DATE], did not reflect goals or interventions related to dialysis. Further review of the care plan reflected the resident was dependent on staff for all activities of daily living, had some confusion, needed assistance with communication. The resident also received tube feedings via enteral pumps and was at risk for swallowing problems and weight loss. Interventions included monitoring by aides and nursing staff for choking/aspiration hazard. Record review of CR#2's progress notes, dated [DATE] at 9:43 AM, reflected the following: At 6:30 AM, the dialysis nurse reported CR#2 had low hemoglobin of 6.7 and received orders from the doctor to be transported to the nearest hospital for a blood transfusion via non-emergency medical services. Non-emergency services arrived at 9:45 AM, CR#2 was stable, transported to the hospital, RP and MD/NP notified . During an interview on [DATE] at 1:00 PM, Dialysis Nurse A said CR#1 had a Central Venous Catheter. She said on [DATE], CR#1 started dialysis, but CR#1 was not able to complete the full treatment. She said his ordered treatment for dialysis was for three hours and 30 minutes . She said he only completed one hour and 30 minutes of treatment . She said the resident's dialysis machine kept beeping. She said CR#1 recently received a new catheter, and the catheter was not working on [DATE]. She said she contacted the Dialysis MD who gave an order to transfer CR#2 to the hospital to have his catheter assessed and to receive further dialysis treatment. Dialysis Nurse A said CR#2 was taken back to his room. She said she verbally informed CR#1's assigned nurse, RN A , the resident needed to be transferred to the hospital to have his catheter assessed and receive further dialysis treatment. She said RN A verbally told her that RN A was going to call an ambulance to have CR#2 transferred to the hospital. She said this conversation occurred around 8:30 AM on [DATE]. She said hours later she heard a code blue being called. She said if an ESRD patient went without dialysis treatment they were at risk for experiencing confusion, fluid overload, and sepsis . In an interview with RN A on [DATE] at 3:00 PM, she said CR#1 was on Dialysis. She said the protocol for residents on in-house dialysis was to check their vital signs prior to being transported to dialysis. She said the facility nurses assigned to dialysis residents and the dialysis nurses communicated verbally. She said there was also a communication form that consisted of information on the resident, pre and post dialysis treatment. She said when she arrived at work on [DATE], CR#1 was already in dialysis. She said around 8:30 AM, Dialysis Nurse A informed RN A, CR#1 could not be dialyzed, and the Dialysis MD ordered CR#1 to be sent to the hospital. She said Dialysis Nurse A told RN A, CR#1's port was malfunctioning. She said she scheduled non-emergency medical transportation for CR#1 to be transferred to the hospital. She said the transportation service told RN A it would be 2 hours before non-emergency medical transportation would arrive at the facility. She said she did not call 911. She said she assessed CR#1 and the resident did not show any signs of distress. She said CR#1 verbalized to RN A he was tired. She said being tired was a common side effect after dialysis. She said she checked on CR#1 at 11:15 AM, and RN A found CR#1 unresponsive in his bed. She said she called a code blue throughout the facility. She said CPR was started on CR#1, EMS arrived, and CR#1 was pronounced deceased at 11:45 AM. She said if a resident did not have dialysis treatment, the resident was at risk for fluid overload, sepsis, and other serious injuries, which included death . In an interview with LVN C on [DATE] at 2:42 PM, she said one of the things she was responsible for was getting report from the nurses on which residents were sent out to the hospital that day and why, so she knew what beds in the facility remained empty and available. She said she was familiar with CR#2. She said the resident would open his eyes if you spoke to him, but he was difficult to understand. She said from what she could remember CR#2 was sent to the hospital on [DATE] for respiratory distress and hypoxia. She said that day, before the dialysis center began the resident's treatment, his bloodwork results showed his hemoglobin levels were low. She said she could not remember if it was nurse on the 300 hall or the DON who informed her about CR#2. She said the dialysis center was not able to perform dialysis due to CR#2's low hemoglobin. She said dialysis informed the facility nurse, and the facility set up transportation for him to be sent to the hospital. She said the facility had contracts with transportation companies set up. She said she reviewed the information entered into CR#2's electronic health record that day but could not recall all of the documentation off the top of her head. She said if the resident's pulse oximeter was good, 90 and above, it was not an emergency and 911 did not need to be call for the resident. She said she did not know how long it took non-emergency medical transportation to arrive at the facility to take CR#2 to the hospital. She said she did not know what care CR#2 received after the doctor gave the order for the resident to be sent to the hospital and the time the transportation company arrived. She said a nurse assessment of a resident consisted of checking vital signs, capillary refill, and checking whether the resident was at their baseline or not. She said the resident was opening his eyes, which was his baseline. She said the DON was responsible for reviewing nursing documentation in the resident's electronic health records. She said nurses should document their assessment information underneath the progress notes or events within the resident's electronic health record. She said she did not review the documentation entered by the nurse on [DATE] for CR#2. She said she only checked the vital signs entered into CR#2's electronic health record because she wanted to know why the resident was sent out to the hospital. She said she always checked the vital signs in a resident's electronic health record when she was notified a resident was being sent out to the hospital. She said she did not review whether the nurse completed an assessment on CR#2 on [DATE]. She said she did not remember which nurse was working with CR#2 at the time because this all occurred before her shift started that day. She said CR#2 was ordered to be sent to the hospital for low hemoglobin and he needed a blood transfusion. She said the dialysis notified the nurse on the floor that the resident was ordered to be sent to the hospital for treatment. She said this was not an emergency. She said if the resident experienced a change in condition after coming back from dialysis, and the resident's doctor said the resident needed to be sent out immediately, they would have done that. She said the nurses received their orders directly from doctors and the doctor never specified the resident needed to be sent out immediately. She said if a resident became synoptic, their lips were turning blue, had low 02 saturation, had shortness of breath, then the resident would have been considered as having an emergency. She said she was not on the floor at the time, so she would not be able to say what sort of care would have been provided to between 6:30 AM and 9:45 AM. She said the aides and nurses were at least responsible for making sure the resident was ready and prepared to be sent out to the hospital before non-emergency medical transportation arrived at the facility. She said if the facility received confirmation of a critical lab result, the nurses were going to call the doctor for further instruction. She said CR#2's order to be sent out came directly from the nephrologist. She said it would have depended on what the residents baseline was, and what the nurse saw at the time to determine whether a situation was critical. In an interview with the DON on [DATE] at 9:55 AM, she said CR#1 received dialysis treatment on Mondays, Wednesdays and Fridays. She said she reviewed all the information regarding the situation with CR#1 on [DATE] but could not recall details. She said she reviewed the 24-hour report every morning. She said because she reviewed so much information daily, it was difficult to recall specifics about what exactly occurred with CR#1 on [DATE]. She said in reviewing the documentation nothing stuck out to her. She said the situation was handled properly. She said CR#1's assigned nurse was aware his port was not working. She said a clogged port was not a reason to send a resident out to the hospital by 911, unless there was a significant change in condition , or the doctor gave a STAT order. She said she was aware transportation services were scheduled for CR#1 but did not know the length of time between the order given by the physician and the resident being found unresponsive. She said CR#1 was assessed by RN A and CR#1 did not exhibit signs of distress. She said that was the reason the contracted non-emergency medical transportation service was contacted and not 911.She said she believed CR#1's nurse used their best judgement after receiving orders from the physician for CR#1. She said she would have to review the details again to determine whether the length of time was an issue. In an interview with the DON on [DATE] at 4:42 PM, she said she reviewed documentation in CR#2's electronic health record on [DATE] but was not aware of what care was provided to the resident between 6:30 AM and 9:45 AM. She said nurses were trained to use their best judgment in knowing when to contact emergency services for residents. She said she did not know how long CR#2 remained at the facility after an order for CR#2 was given by his nephrologist. She said if the nephrologist would have given a STAT order or the nurse observed a change in condition or signs of distress, 911 would be contacted for emergency medical treatment. She said CR#2's baseline hemoglobin level was low and CR#2 never showed any signs or symptoms of distress on [DATE]. She said there was no standard timeframe for the contracted medical transportation company to arrive at the facility. She said the facility contracted with a particular company that had necessary equipment to provide life saving measures to individuals on ventilators and trachs. She said using the transportation company was a way of ensuring the safety of the residents. She reiterated that nurses would need to use their best judgement to utilize emergency services to send residents to the hospital after scheduling and waiting for the contracted transportation. She said the nurses knew to call 911 when residents were experiencing a medical emergency. She said she was not aware of the length of time between the physician's order was given and the time the transportation company arrived to take the resident to the hospital. She said based on CR#2's history; she did not see an issue with CR#2 waiting three hours to be transported to the hospital for a blood transfusion. She stated CR#2 was pronounced deceased at the hospital much later than [DATE]. Interview with Regional Nurse Consultant A and the DON on [DATE] at 3:10 PM, the Regional Nurse Consultant said the nurses who provided care to dialysis residents were going to be looking for desaturation and the ventilator machine was going to alarm which allowed them to know there was something malfunctioning. The nurses were going to be looking at vital signs and oxygen levels. She said if there was an issue with the port, the dialysis center would set up an appointment at the hospital to have the shunt replaced. She said it was not a guarantee or a proficient tool to visually assess how much fluid a resident on dialysis retained. She said where the fluid was going to go in the body, was going to be around the organs because the fluid had nowhere else to go. That was the reason why the nurses monitored for the vital signs and oxygen levels as signs and symptoms of distress in residents on dialysis . She said there was no way of seeing fluid overload during a visual assessment. She said the best practice was for nurses to go by the residents' blood pressure standards and airway standards. She said the best practice for contacting emergency services was for residents experiencing chest pain or a GI bleed, which was an automatic call to 911. She said the dialysis residents were just like any other residents when it came to acute situations. The nurses were trained to monitor the same vital signs for residents whether they were on dialysis, or not. Both the regional nurse and the DON agreed that most individuals on dialysis that might have experienced fluid overload did not experience pain. The regional nurse said they would more so experience shortness of breath. The DON said CR#1 was not showing any signs of distress or any signs or symptoms prior to beginning dialysis, because if he had, they would not have begun dialysis. She said the dialysis center ran labs and checked vital signs before starting a resident's dialysis, and CR#1's labs came back normal. She said it was part of the protocol for the dialysis center to check vital signs again at the end of dialysis treatment. The DON said the dialysis enter checked CR#1's vitals, and he was stable at that point. The DON said when CR#2 came from dialysis there was no indication the resident was experiencing any sort of symptoms or distress of any kind. Regional Nurse Consultant A said she reviewed CR#1's doctor orders, and he was only being sent to the hospital to have his shunt replaced. Regional Nurse Consultant A said there would have had to be a break, possibly a day or two, between the resident receiving dialysis treatment and having a shunt replaced. She said an individual would have to be NPO for a certain amount of time, a surgeon had to be available for, and schedule the surgical procedure to replace a shunt. The DON said having a shunt replaced would take some time to set up and was not an immediate kind of thing anyway. She said the nephrologist decided whether, a resident moved forward with dialysis treatment based on their assessment of the resident's weight and labs drawn the morning of the scheduled treatments. She said the results of the BUN/Creatinine ratio indicated to the nephrologist whether the resident was experiencing fluid overload. She said CR#1 was not examined by the coroner's office. She said if there was no coroner's examination completed on a body, no definitive cause of death was provided. She said the coroner would look at a resident's medical history and decide the cause of death, based on their history. The DON said when CR#2 came from dialysis there was no indication the resident was in any sort of distress, based on his vital signs. She said there was a dialysis information sheet with data documented before and after dialysis. The DON said the form listed how much fluid in liters were pulled off the resident during dialysis. She said any pertinent information, like vital signs, pre and post weight, and issues or concerns were documented by the dialysis center nurse on the information sheet. The DON said if there was something that went on or was noticed during dialysis, the dialysis nurse would bring the information sheet directly to the nurse assigned to the resident on the hall. She said if there was an emergency during dialysis, they would call 911 immediately from the dialysis center. She said if there was no issue, once dialysis was closed for the day, the dialysis nurse placed the information sheet in a folder on the medication cart of the nurse assigned to the resident's hall. She said the nurse assigned to the resident was responsible for reviewing the information sheet by the end of their shift. The DON said after the information sheet was reviewed it went to the nurses' station for filing with medical records. The DON said none of the residents' primary doctors were responsible for monitoring dialysis care. She said dialysis was monitored specifically by the residents' Nephrologist and Urologist. She said if it was not anything that was critical or acute going on with a resident on dialysis the nurses were not going to contact the residents' physicians. The DON said there was no special sort of care, monitoring or assessments done on residents who were on dialysis. Regional Nurse Consultant A said people who lived out in the community and were on dialysis were able to go home all the time after treatment, with no special monitoring. She said the residents at the facility who received dialysis were no different. The Regional Nurse said the special care that differentiated residents who were on dialysis was, on each shift the nurses checked the dialysis residents' shunt for bleeding. The DON said the only follow up done by the nurse once a resident was ordered to be sent to the hospital by the nephrologist or urologist due to concerns during dialysis, was to keep an eye on the resident until transport arrived. She said then, the nurse would document in the resident's electronic health record what time transport arrived to pick the resident up, what hospital they were taken to, and the notifications made to herself, the doctor and the family. The DON said there was no set timeframe for when a resident who returned from dialysis needed to be checked on by any staff. She said she could not say the resident would be checked on within 5 minutes of returning from dialysis, but at some point, after returning from dialysis either the nurse, CNA or RT would check on the resident. She said most times, it was RT who saw the resident first because they had to hook the residents back up to their ventilators and/or trachs. Regional Nurse Consultant A and the DON agreed that there was no standard to checking on a resident or performing any sort of assessment once they returned from dialysis. They both stated that staff were simply laying their eyes on the resident. In an interview with RN C on [DATE] at 10:50 AM, she said if a resident's dialysis port was malfunctioning, she would call the doctor. She said if the MD ordered the resident be transferred to the hospital, she would call 911. She said because the resident had not had dialysis for days she would call 911. She stated when a resident was not dialyzed the resident was prone to fluid overload, electrolytes would not be good, the resident would be confused and the level of consciousness would be affected. In an interview with the Administrator on [DATE] at 8:38 AM, she said she became aware of the timeframe between the orders for CR#1 and CR#2 to be sent to the hospital and non-emergency transportation arriving at the facility when the facility received the IJ on [DATE]. She said it was her expectation of the DON to review the 24-hour report on a daily basis and discuss things like this during their afternoon daily call. She said it was her expectation of the nurses to be able to exercise good judgment and follow best practices when they provided care to residents. She said CR#2 should have been assessed after he returned from dialysis. She said after the IJ was called; the facility reviewed information they collected as part of an audit of residents on dialysis. She said she became aware of communication issues between the dialysis center staff and nursing staff, and a lot of the information required on the communication form between the center and nursing were not completed by nursing staff prior to residents being sent to dialysis. She said she did not think three hours was an appropriate amount of time for any resident who needed emergency medical treatment to wait for transportation, even if a doctor did not explicitly give an emergency order. She said any resident was put at high clinical risk in a situation like that. She said all staff were currently being trained and in-serviced. She said the nurses were being trained to recognize that an order for a resident not being dialyzed, even with notification to the doctor was an emergency and residents could be sent out via emergency services to receive the needed treatment at the hospital. She said the nurses could still utilize the non-emergency transportation, but only for things like routine visits, or when the timeframe of arrival was within reason, based on the resident's condition. She said three hours was not an acceptable timeframe for CR#2 or any other resident on dialysis that needed emergency medical treatment. She said nurses were also being trained to conduct full assessments on residents every 15 minutes, document their findings in the resident's chart, contact the doctor if a change in condition was noted, or call 911 and notify the doctor, the DON, and the RP after. In an interview with Regional Nurse Consultant B on [DATE] at 4:23 PM, she said she was made aware of the delays in transportation for emergency medical treatment for CR#1 and CR#2, understood and agreed they were cause for concern. She said she was working with the Administrator to get the DON and Regional Nurse Consultant A trained on facility expectations. She said she was also working with the DON and Regional Nurse Consultant A to ensure the rest of the staff were trained and exhibited competency in communication expectations, recognizing signs and symptoms in residents, conducting thorough assessments, documenting those assessments, and making proper notifications. In an interview with Regional Nurse Consultant B on [DATE] at 12:58 PM, she said if there was any delay in non-emergency medical transportation for any reason, the nursing staff were aware they needed to contact the DON for further directives. She said if transportation was delayed for a doctor's appointment or a routine procedure, they could contact the doctor for further directives. She said however, if the resident was dealing with something that could cause an infection or worsening of their condition, the staff were aware they needed to contact 911 immediately. She said the staff also understood they were not doctors and could not determine how a delay in transportation would affect a resident. So, to air on the side of caution, the staff knew they would call 911 in those instances. She said they would still notify the doctor, but they were not going to wait on non-emergency medical transportation. She said identifying the IJ situations highlighted the fact that there was a missing piece of the puzzle with nursing staff. She said all the tools were there for all staff to use, they were not utilizing them. She said the DON was completing in-services and trainings with staff, but she was not requiring nursing staff to show competency. She said the DON was not following up or doing thorough reviews of nursing documentation enough to identify situations that needed to be addressed or improved. She said now, the staff were clear they were going to be required to show competency of their skills. She said the nursing staff were re-trained and re-in-serviced on change of condition, SBAR, completing a proper shift change with oncoming staff, communication, assessments, reporting, making the necessary notifications, and follow through. She said they were continuing to work through educating the entire staff. She said another big takeaway was the lack of communication, internally, when it came to nursing and the dialysis center staff. The staff were now clear that while the dialysis center functioned separately from the facility, there was overlap in work. She said the facility nurses and the dialysis nurses now understood they were all intertwined, and not separate. She said they were all essentially part of the same team and communication from dialysis was also to be shared with residents' primary physicians. Record review of the facility's Charting and Documentation policy, revised [DATE], reflected the following: All services provided the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident's medical record: a. objective observations; b. medications administered; c. treatments or services performed; d. changes in the resident's condition; e. events, incidents or accidents involving the resident; and f. progress toward or changes in the care plan goals and objectives .7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individuals who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, reflected the following: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition .g. need to transfer the resident to a hospital/treatment center; i. specific instruction to notify the physician of changes in the resident's condition .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. impacts more than one area of the resident's health status; c. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (CR # 1) reviewed for dialysis. The facility failed to ensure CR # 1 received hemodialysis treatments as ordered by his physician. CR # 1 exhibited symptoms of fluid overload and required emergency medical care. In addition, Resident #1's dialysis access port malfunctioned, and Resident # 1 did not receive dialysis for 4 days.CR # 2 missed dialysys treatments on [DATE] and [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:50 pm. While the IJ was removed on [DATE] at 11:41 am, the facility remained out of compliance at scope of isolated with the potential of more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of missing vital treatment, serious health side effects and death. Finding include: Record review of CR # 1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. CR # 1 had diagnoses which included Acute and chronic respiratory failure with hypoxia (absence of oxygen in the tissue to sustain bodily functions), Hypokalemia (low potassium), End stage renal disease (the kidney can no longer function properly) , and Hypertensive heart disease without heart failure (a condition that happens when chronic blood pressure causes changes in the heart left ventricle, left atrium, and coronary arteries. Record review of CR #1's orders, start date [DATE], reflected dialysis catheter dressing change to be done by dialysis nurse only (Monday, Wednesday and Friday (start date [DATE]), Dialysis: Monday, Wednesday, and Friday (once a day at 6:00 am) (start date [DATE]), If the dialysis center is unable to perform hemodialysis as scheduled transfer resident to nearest hospital. As needed (prn1, prn2, and prn 3), monitor catheter site for s/s infection (every shift). Notify MD/NP. Record review of CR#1's MDS, dated [DATE], reflected no BIMS (severe cognitive impairment), partial/moderate assistance with eating, oral hygiene, showering /bath, and personal hygiene and he required dialysis. Record review of Resident # 1's Care plan, start date [DATE], reflected Resident #1 had a risk of falling related to weakness and impaired mobility. Record review of CR#1's Treatment Details Report from the dialysis center, dated [DATE], reflected Treatment Type: In-Center Hemodialysis Treatment. No data available for the following: machine setup nurse prescription verification pre-treatment verification, pre-treatment fluid calculation treatment nurse assessment, access, labs, Intradialytic/vitals stat line. Record review of CR#1's Treatment Details Report from dialysis center, dated [DATE] reflected, Treatment Type: In-Center Hemodialysis Treatment). Pre-Treatment Vitals on [DATE] at 6:04 AM-(1) Comments (Pre) Patient has new CVC placed faint blood noted to CVC exit site. No s/s trauma or infection present. Patient denies pain CVC dressing changed prior to treatment initiation. Comments (Post) Staff will receive Cathflo this evening and indwelling it for next treatment. No time notated. (2) Comments (Pre) Patient received alert and in stable condition. Patient denies pain or discomfort. Comments (Post) Patient treatment was not performed because of catheter malfunction. The MD would like for to have Cathflo instilled into the catheter over the weekend. The staff will go pick up over the weekend and come back to instill it. (3) Comment- Arterial lumen (allows for the free flow of oxygenated blood from the heart to the veins and capillaries) is not pushing on pulling. MD is aware he orders Cathflo but there is not in the Den. Attempting to get Cathflo from SNF. Record review of CR#1's Treatment Detail Report from dialysis center, dated [DATE], reflected Treatment Nurse Assessment: Time: Pre-6:42 AM and Post: 10:31 AM-Comment: Patient Treatment terminated early due to problematic. Record review of CR#1's progress notes, dated [DATE] at 12:06 PM, reflected CR#1 was found unresponsive at 11:25 AM. Nurse called out to resident, no response, sternal rub performed, no response. Pulse checked, undetected. Nurse immediately called code blue and began ambu(a bag valve mask used to provide respiratory support) bagging resident. When RT Aide walked in to assist with bagging, nurse began compressions. No blood pressure reading obtained due to condition, blood glucose 215 at time on first round of compressions. 11:30 AM AED pads placed on resident no shock advised. 911 was called and CPR continued until arrival of EMS. Multiple rounds of CPR done, when EMS arrived monitor placed, and no pulse detected. EMS called of death 11:45 AM. Dialysis nurse verbalized concerns for fluid overload due to inability to perform dialysis Saturday and today [DATE]. CR#1 received orders to be sent out to the ER to restores function to port and receive dialysis in hospital. Transport scheduled to pick up resident with 2 hours. Resident in bed resting, no distress noted at this time vs WNL, no c/o pain or discomfort at this time. CVC. MD notified. Record review of CR#1's dialysis center patient notes, dated [DATE], reflected, CR#1 returned from hospital unable to treat on scheduled day due to watery stool noticed in den at treatment time. Per hospital discharge documents patient tested positive for C. diff and is receiving PO ABX. In addition, the patient was admitted due to malfunction of gastrostomy tube diarrhea, and GI/PEG tube exchange. At the time of exchange the patient was also noted to have an ileus (inability of the intestine to contract normally and move waste out of the body). The dialysis MD updated about pa record review of CR#1's dialysis center patient notes, dated [DATE], reflected, Resident #1 patient status and ok with schedule adjustment. Record review of CR#1's dialysis center patient notes, dated [DATE], reflected, [CR#1] treatment terminated early due to problematic access. Patient had 118 minutes remaining at the time of treatment was discontinued. Notified Dialysis MD, ordered the patient be sent out to the hospital to treat and evaluate catheter. Venous pressure continuously high causing the machine to alarm often Cathflo was previously tried prior to being sent out. Record review of CR#1's orders form SNF dialysis, dated [DATE], reflected Please place Cathflo in Arterial Lumen for 45 minutes. Today DX: Dysfunction/clotted Lumen. If patient cannot receive Cathflo today, he will have to wait until Monday for treatment when Cathflo is available. Record review of CR#1's orders form SNF dialysis, dated [DATE], reflected Please send patient out to the hospital to dialyze. Unable to treat due to problematic CVC, Venous pressure continuously elevated. Record review of CR#1's dialysis SNF Services Communication form, dated [DATE], reflected Pre-Treatment Report Nurse-isolation reason: C. Diff, fall precaution - yes, Mental status- alert, pain assessment-none, VS: BP 116/60, Pulse 78, R 20, Temperature 97.2, Fo2 Sat 99%, O2-4/Vent- time vital and weight obtained 5:38 AM. Dialysis Access Notes problematic, alarmed throughout treatment, catheter problematic treatment terminated early. MD notified There were no dialysis SNF Services Communication form for [DATE] and [DATE]. During an interview on [DATE] at 1:00 PM Dialysis RN A she stated CR#1 had a CVC catheter (central venous catheter). CR#1' was sent out to the hospital on [DATE] because he had a loose stool, peg tube malfunction, vomiting. CR#1 returned to the facility last Wednesday ([DATE]) or Thursday ([DATE]). She stated on [DATE] she was not aware Resident # 1 returned to the facility. She stated the SNF staff did not inform the dialysis center CR#1 returned. She stated after realizing CR#1 returned she stayed late for him to dialyzed. She stated when she attempted to get CR#1's weight she noticed he had loose stool on him. He tested positive for C-DIFF (loose stool and you have to use bleach). She stated she contacted the MD and informed him as to the situation. She stated the MD gave approval for CR#1 to receive dialysis on [DATE]. She stated Dialysis RN B attempted to dialyze CR#1 on [DATE]. CR#1was not dialyzed on [DATE] because CR#1's catheter did not work. She stated Dialysis notified the Dialysis MD. The Dialysis MD gave an order to put Activase in the catheter. She stated Activase breaks up the clot and allow the blood to flow. She stated CR#1's port continued to malfunction. She stated the Dialysis MD gave an order to have the resident dialyzed on Monday. She stated on [DATE] CR#1 received dialysis. She stated he was unable to complete dialysis due the malfunction of CR # 1's port. She stated he received dialysis for 3 hours and 30 minutes, however, he only received 1 hour and 30 minutes of treatment. She stated the dialysis machine kept beeping. She stated CR#1 received a new catheter, and the catheter was not working. She contacted the Dialysis MD and was informed to have the resident transferred to the hospital. Dialysis RN B stated CR#1 was taken back to the SNF. She stated she informed CR#1's Nurse the resident needed to be transferred to the hospital to have his catheter assessed and dialysis RN A stated she was going to call an ambulance to have the resident transferred. She stated this occurred around 8:30 AM. She stated hours later she heard a code blue (code that indicates a patient needs immediate medical attention). She stated if an ESRD patient went without dialysis for three to four days they could have confusion, fluid overload, and septic. During an interview with Dialysis RN B on [DATE] at 2:30 PM, she stated on [DATE] CR#1 came to the den for dialysis treatment. She stated CR # 1's arterial was not pushing and pulling. She stated the reversed the venous pressure and it was high, and it kept alarming. She stated it would start at two hundred and the dialysis machine kept cutting off. She stated she contacted the Dialysis MD, and she told him CR#1 had a new catheter from the hospital. The Dialysis MD asked if the facility had any Cathflo and they did not. She stated later that day she went to the clinic and got Cathflo. She stated she returned to the facility. She stated Cathflo was administered to CR#1. She stated once the Cathflo was administered there was a 45-minute wait. She stated she informed the Dialysis MD, and she was given an order that CR#1 could be dialyzed on Monday. During a telephone interview on [DATE] at 3:00 PM with RN A, she stated CR#1 was on Dialysis. She stated protocol for resident's who received in-house dialysis was the resident's vital signs were taken prior to being transported to dialysis. She stated the resident was transported the in-house dialysis center with the Nurse, RT, CNA, and Transporter. She stated the SNF and Dialysis communicated verbally. She stated there was a communication form which consisted of pre and post dialysis information. She stated that when she arrived CR#1 was in dialysis. She stated on [DATE] around 8:30 am the Dialysis RN A stated CR#1 could not be dialyzed, and CR# 1 needed to be sent to the hospital. She stated Dialysis RN A informed her that CR#1's port was malfunctioning, and CR#1 had fluid overload. She stated she scheduled non-emergency transport for CR#1 to be transported to the hospital. She stated the transport service informed her that it would be 2 hours before the transport would arrive. She stated she did not call 911. She stated she assessed CR#1 to include checking blood pressure and pulse rate and there were signs of distress. She stated CR#1 verbalized he was tired which was a common side effect after dialysis. She stated she checked on CR #1 at 11:15 AM and went to check on CR#1 and he was unresponsive. She stated she called a code blue. She stated they began CPR and EMS arrived, and CR# 1 was pronounced deceased at 11:45 AM. She stated if a resident did not have dialysis for three to four day they could have fluid overload, septic, and other serious injuries to include death. Record Review of The National Kidney Foundation website, undated, reflected if you miss your dialysis treatment, you may feel the effects of fluid overload, which include shortness of breath due to fluid in your lungs. If this happens, you may need to go to your hospital's emergency department for dialysis. During an interview with the DON on [DATE] at 9:55 AM, she stated CR#1 received dialysis on Monday, Wednesday and Friday. She stated CR#1 was in the hospital from [DATE]-[DATE]. She stated she did not why the Dialysis nurse did not know CR#1 returned to the facility. She stated Dialysis had access to the Matrix. She stated CR#1 staff was aware his port was not working. She stated Resident #1 had C-DIFF, however, this would not prevent him or any resident from having dialysis. She stated when a resident had C-DIFF the stool was continuous. She stated if a resident's port was clogged the resident would be scheduled to go out and looked at by a vascular doctor. She stated a clogged port was not a reason to send a resident out to the hospital by 911. She stated CR#1 was assessed by RN A and there were no signs of distress, therefore, the contracted ambulance service was contacted and not 911. . During an interview on [DATE] at 10:50 AM, RN C stated when a resident was on dialysis they must be placed on the dialysis schedule. She stated when a resident returned from dialysis the nurse should assess the resident to include vital signs. She stated if a resident's dialysis port was malfunctioning, she would call the doctor. She stated that if the MD ordered the resident be transferred to the hospital, she would call 911. She stated because the resident had not had dialysis for days she would call 911. She stated when a resident was not dialyzed the resident was prone to fluid overload, electrolytes would not be good, the resident would be confused and the level of consciousness would be affected. Record review of the facility's Abnormal Findings Job Aid policy, dated [DATE], reflected any abnormal findings or findings outside of any patient specific physician ordered parameters discovered pre, intra or post treatment data collection will be discontinued and immediately reported to the licensure nurse. An assessment by the nurse prior to initiation of dialysis, during dialysis, and/or prior to discharge will be triggered by an abnormal finding. The medical record should indicate the finding, the intervention, physician notification, physician orders and the patient response. Record review of the facility's Hemodialysis policies and procedures, dated [DATE], reflected the following: patient data the nursing assessment, patient identity, prescription and machine settings, Pre-treatment data collection/ assessment, Intradialytic data collection assessment, post treatment data collection/assessment and abnormal findings. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:50 PM. The Administrator was notified. The Administrator was provided the IJ template on [DATE] at 2:50 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:23 PM: PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered the facility on [DATE] for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F698 and F684 as stated below: F698 Dialysis Services CR#1 Passed away on [DATE] Immediate action: On [DATE] DON under the guidance of the Regional Nurse Consultant initiated an in-service with all direct care staff training will be completed by [DATE]. o Notifying Physician and Family of Resident Change of Condition/or have not receive their full dialysis. The physician should be notified as soon as possible after identifying a change of condition/or have not received their full dialysis, assessed resident needs, and provided necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contacted for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to SOB, vital signs, mental status changes, functional decline, desaturation, etc. o Symptoms include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Change of Condition and policy was reviewed, no changes were made. Staff in-service on current policy. o Staff in-service to pre-dialysis assessment and post assessment documentation in Matrix. o Communications between dialysis and nursing will be documented in Matrix. o Continue weekly core team meetings with dialysis. o Location where dialysis schedule is at. o Nurses will review dialysis schedules with transport daily. o How codes should be run. o Location where the AED is at. o Shift report will go over admits and discharges. o Review all new orders daily by management. o [DATE] In-service on dialysis policy to all direct care staff and completion date [DATE]. o 100% audit on all residents to ensure anyone who was unable to do dialysis has been identified and MD notified completion date [DATE]. On going dialysis audit will be done in IDT morning clinical meeting. o DON/Designee will audit all residents who have dialysis in IDT morning clinical meeting to make sure they have received their dialysis or if unable to do dialysis then MD/DON was notified. Facility Plan to ensure compliance quickly: o All nursing staff will be in-service on the above-listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions/ or have not fully received dialysis will be identified and physician notification has been made. This audit began [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that: o A physician is to be notified immediately of changes of condition or have not received dialysis. o This in-service began [DATE] and will be completed by [DATE]. On [DATE] The facility Administrator, ADON, and Regional Nurse Consultant held an ad hoc QAPI meeting with the Medical Director, via phone, to discuss: o F698 - Dialysis Services - IJ Cited o Plan of Removal and actions taken to ensure continued compliance. QAPI: o The above actions will be reviewed monthly in QAPI to ensure continued compliance. Monitoring of the plan of removal included: During interviews on [DATE] from 10:30 AM - 4:00 PM - three CNA's, five RN's, four LVN's and six RT's stated they were in-serviced before their shifts in: Change of Condition, Recognizing and Reporting Acute Change of Condition, Symptoms included for the need for emergency ambulance services, Documentation of events ( Change of Conditions), SBAR and Stop and Watch, Staff in-service to pre and post dialysis assessment documentation, communications between dialysis and nursing will be documented in Matrix, Nurses will review dialysis schedule with transport daily, shift reports will go over admits and discharges. Staff stated they were competent in all trainings. Record review of General In-Service for All Direct Care Staff and RT, dated [DATE], reflected the following in-services: Change of Condition, Recognizing and Reporting Acute Change of Condition, Symptoms included for the need for emergency ambulance services, Documentation of events ( Change of Conditions), SBAR and Stop and Watch, Staff in-service to pre and post dialysis assessment documentation, communications between dialysis and nursing will be documented in Matrix, Nurses will review dialysis schedule with transport daily, shift reports will go over admits and discharges, MD/NP/DON or designee will determine if resident needs to go by 911 or non-emergency transport and will be documented in resident chart. Record review of In-services for DON, dated [DATE], reflected: Change of Condition, Recognizing and Reporting Acute Changes of Condition, Symptoms include the need of emergency ambulance services, Documentation of events (change of condition, SBAR, and Stop & Watch, Pre and Post dialysis assessment documentation in Matrix, Communication between dialysis and nursing , continue weekly core team meetings with dialysis, nurses will review dialysis schedules with transport daily, shift reports will go over admits and discharges, review all orders daily by management, Education provided to 100% nursing staff on monitoring of residents who experience change in condition while waiting on emergency services, and MD/NP/DON or designee will determine if resident needs to go by 911 or non-emergency transport and will be documented in resident chart. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 11:41 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal arm 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 that is not immediate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the resident's physician; and notify the resident representative for 1 of 3 residents (CR #1) reviewed for change of condition, in that, The facility staff failed to immediately notify the physician when CR#1 started vomiting up a brown substance repeatedly on [DATE]. The facility failed to notify the physician that CR #1 insulin NPH was discontinued when CR#1 was having high glucose readings for 6 days. CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 3:58pm, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could expose residents to low quality of care, worsening of condition, hospitalization, and death. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Current admission was on [DATE] with diagnoses of type 2 diabetes (A chronic condition that affects the way the body processes blood sugar, resulting in too much sugar in the body), kidney failure, cerebral infarction (cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), malnutrition, hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), high blood pressure, sepsis (Sepsis is a serious condition in which the body responds improperly to an infection, causing a cascade of changes that damage multiple organ systems, leading them to system failure, sometimes even death), and heart disease. Review of CR #1's MDS dated [DATE] revealed CR #1 was diagnosed with Diabetes Mellitus, high blood pressure, cerebral infarction, and hemiplegia. MDS also revealed CR #1 was on insulin medication, oxygen therapy treatment, suctioning, and tracheostomy care. Review of CR #1's care plan revealed CR #1 was at risk hypoglycemia / hyperglycemia episodes due to diabetes mellitus. The care plan goal was that CR #1's blood sugar will be managed effectively, and the care plan intervention was to do a quick check as ordered and report any abnormal findings to the Physician and family members. Review of Physician order dated [DATE] revealed Accu check with insulin Lispro (AdmeLOG) sliding scale SQ 142 - 180 = 2 units 181 - 220 = 4 units 221 - 240 = 5 units 241 - 260 = 7 units 262 - 280 = 9 units 282 - 300 = 10 units >300 = 12 units and call MD Four Times A Day 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM Record review of CR#1's blood sugar vitals revealed: [DATE] at 5:34 am 598 mg/dL [DATE] at 11:28 pm 319 mg/dL [DATE] at 11:28 pm 283 mg/dL [DATE] at 1:01 pm 381 mg/dL [DATE] at 10:57 am 468 mg/dL [DATE] at 8:15 am 556 mg/dL [DATE] at 8:02 am 468 mg/dL [DATE] at 7:01 pm 300 mg/dL [DATE] at 11:33 am 386 mg/dL [DATE] at 9:31 am High (above 600) [DATE] at 8:24 am High (above 600) [DATE] at 1 pm 414 mg/dL [DATE] at 9:27 pm 250 mg/dL [DATE] at 5:52 pm 289 mg/dL [DATE] at 1:16 pm 365 mg/dL [DATE] at 5:32 pm 313 mg/dL [DATE] at 12:04 pm 398 mg/dL [DATE] at 9:24 am 388 mg/dL [DATE] at 8:43 pm 382 mg/dL [DATE] at 10:42 am 320 mg/dL [DATE] at 10:24 am 365 mg/dL [DATE] at 7:24 pm 269 mg/dL [DATE] at 1:55 pm 139 mg/dL [DATE] at 8:39 am 139 mg/dL [DATE] at 10:36 pm 159 mg/dL [DATE]at 11:57 am 300 mg/dL On [DATE] at 11:25am in an interview with CR#1's family member, she stated CR#1 had an infection that was not treated and by the time CR #1 got to the ER she was septic and died on [DATE] at the hospital. CR#1's family member stated there were instances where the Physician stated he did not know about CR#1 and admitted that he did not know CR#1. CR#1's family member stated she went to check CR#1 out of the facility on thanksgiving day, but CR#1 was throwing up that day and no one knew why she was throwing up. CR#1's family member stated she did not want to take CR#1 out of the facility not knowing what was happening. CR#1's family member stated no one knew why CR#1 was throwing up and it was odd for CR#1 to be throwing up so something must have been wrong with CR #1 on that day ([DATE]). CR#1's family member stated the staff (unknown) said CR#1 threw up twice that morning. On [DATE] at 1:58pm with former ADON C she stated she could not remember what happened with CR#1. She stated CR#1 did get sent out to the hospital on the night shift. She stated if someone was throwing up, it is a change in condition, and they needed to do something about that. She stated they needed to call the Nurse Practitioner, Responsible Party, and everyone that needed to be called. On [DATE] at 12:24pm in an interview with CNA A, she stated she remembered CR#1 threw up on [DATE] on thanksgiving day. CNA A stated they noticed CR#1 threw up and she (CNA A) went to tell the Nurse (did not remember who the nurse was). CNA A stated CR#1's emesis was brown and it was a lot. CNA A stated she told the nurse and she went to check CR#1. CNA A stated she did not recognize any other changes in condition for CR #1 on that day. On [DATE] at 12: 38pm in an interview and record review of CR#1's clinical record with the DON, she stated CR#1 came to them from home with dementia, old CVA history, sepsis with shock, malnutrition, diabetes, High blood pressure, and pressure ulcers when admitted . The DON stated CR#1's blood sugars were in the 400's and 500's. She stated CR#1 could spike and go up to 402 within 30 minutes of each other and then went back down to 126. She stated CR#1's blood sugars started going consistently higher on [DATE]. She stated they were holding CR#1's tube feeding, and administered the insulin sliding scale. The DON stated in CR#1's clinical record, the physician note dated [DATE] revealed CR#1's Pt's diabetes is controlled at this time. Will continue to monitor for stability. BS: 557mg/dL, the Physician wrote that it was controlled and will continue to monitor. The DON stated she was not going to second guess a physician when he stated the blood sugar was 557 and that it was controlled. On [DATE] at 3:05pm with LVN B, she stated she worked on [DATE] and [DATE] in the hall where CR #1 was. She stated on [DATE], she went to assess CR#1 and she called CR#1's Physician and told the NP that CR#1 was not doing well. LVN B stated CR#1's O2 Saturation was still okay at the time she came to the shift. She stated when she assessed CR#1 she was just quietly looking, and CR #1 was a quiet person. LVN B stated when she was handing over to the night nurse (LVN A), she and the nurse they checked CR #1's O2 saturation it was below 90. LVN B stated CR#1's O2 saturation was the problem, and she called the RT, and the Respiratory Therapist came to check CR#1's oxygen and it was low so they sent CR#1 out to the hospital on [DATE]. LVN B stated she reported to LVN A because she (LVN A) worked that night. Review of progress note revealed no documentation by LVN B of notification to physician regarding CR #1's condition on [DATE]. On [DATE] at 10:21am in an interview with CNA B she stated CR#1 came from the 100 hall doing well and moved to the 200 Hall and after some time, CR#1 stopped eating well the staff had to feed her and she refused sometimes. CNA B stated CR#1 was not really eating enough by mouth when she came to the 200 hall and she had a feeding tube. CNA B stated the day she went with her daughter for Thanksgiving on [DATE] CR#1 was throwing up a lot on that day. CNA B stated she told the nurse on the floor and CR#1's family member that CR#1 was throwing up. She stated the nurse came to the room to speak with the family member and they decided with the family member whether to take CR#1 home for the day or not because of her throwing up. CNA B stated she remembered the day they sent CR#1 to the hospital she was throwing up also. On [DATE] at 11:21 am with RN C, she stated she took care of CR #1 on 100 hall on [DATE], and on 200 hall on [DATE]. She stated when she took care of CR #1 on 100 hall on [DATE] she checked CR#1's blood sugar and it was very high and that was the only thing she knew that happened that day. She stated she called the Physician, and he told her to give CR#1 a dose of insulin, but she could not remember the units. She stated when they call Physician's number usually they would speak with anyone who picked the line, it could be one of the nurse practitioners working with the physician, but she did not know who specifically she spoke with on that day ([DATE]) on thanksgiving day. RN C stated CR#1's family member wanted to take her out to eat on the thanksgiving day, but she (RN C) told the family member that they had to take care of CR#1's blood sugar before the family member could take CR #1 out. She stated she could not remember if CR#1 was throwing up. She stated there were so many things that happened that day and many families came to pick their family up so she did not recall if she wrote any notes or any assessments. Record review of CR #1's Medication Administration Record (MAR) for the month of [DATE] revealed there was no documentation of blood sugar checked and no insulin administered to CR #1 on the 9pm check schedule on [DATE] when LVN A worked. On [DATE] at 1:00pm in an interview with LVN C, she stated she worked the morning shift on [DATE], but she no longer worked at the facility. She stated if she did a blood sugar and it was 500 she would call the Physician and she would reassess the resident to make sure it's the right reading. She stated if the resident had a sliding scale she would administer the insulin and she would check if they were on continuous feeding and they would pause the feeding. She stated she would also do a water flush for the tube feeding and call the physician. She stated the first thing she would do was to administer the insulin sliding scale and go from there. She stated if the blood sugar was that high in the 500s, she would check it every 30 min and keep rechecking it. She stated if she was able to get the blood sugar down from 500 to 380 within an hour she would still alert the physician and would continue to follow up with the blood sugar. She said she could not remember the patient specifically because she always working with a lot of nurses and orienting them, and that she was not a primary nurse on the floor. She stated she could not recall anything about CR #1, and she could not recall anything happening to CR #1 on 11/30 2023. On [DATE] at 2:39pm in an interview with the Lead NP, she stated she knew all the residents in the facility because she comes to the building everyday. NP stated CR#1 was on 2 different insulins (NPH and Lispro) when she was admitted to the facility. She stated on [DATE] a nurse (she did not remember the nurse) told her that the resident's blood sugar was running too low, and she gave verbal order to the nurse to discontinue the insulin lispro for CR#1 because her blood sugar was low at that time. The Lead NP stated she did not give any order to discontinue the NPH. She stated CR#1 was on NPH 40 units 3 times a day, the nurse was to discontinue only the insulin Lispro, and leave the NPH insulin without any changes. She stated that the nurse erroneously discontinued both insulin (NPH and Lispro). The NP stated if blood sugar was high the nurse was supposed to call and let them know that the resident's insulin was discontinued, because the resident (CR #1) was supposed to be on the NPH as a basal coverage for the resident. She stated insulin lispro was not meant for treating residents with hyperglycemia, she stated the lispro is a short acting insulin which was in place to bring the blood sugar down in case the resident's blood sugar spiked. She stated there should be a scheduled insulin NPH which would be covering the resident for up to 12 hours, The lead NP stated she did not know the insulin NPH was discontinued, she did not check the resident's record, because she believed when they gave order to the nurses, they were supposed to carry out the order accordingly. She stated she was always in the building and most nurses would come to her to get order for anything happening with any resident and she would give verbal order at times. She stated whenever she or any other team members give order, they would always communicate with other team members, so they all be on the same page. The NP stated if a patient started throwing up, she would expect the staff to call them for any change in condition. The Lead NP stated she was at the building on the [DATE] and the resident's vital signs were all good and there was no need to send the resident to hospital. On [DATE] at 2:43pm in an interview with LVN A she said CR#1's blood sugar on [DATE] at 11:28pm was 319. LVN A stated CR#1 was sent out because she was declining compared to the last time she took care of CR #1 on the 100 hall. She stated she got shift report from thee day/evening shift nurse and she took over CR #1's care. She stated on [DATE] during the night shift, she tried to call the physician, but they don't really respond in the middle of the night. She said the physician did respond early in the morning around 5:00am. LVN A said CR#1's oxygen sat was what they were mainly worried about, her oxygen was low in the 80s so they got orders to put CR #1 on oxygen. LVN A said CR#1 was not acting the same like when she was on 100 Hall. She said on [DATE] at 5:34 am CR#1's blood sugar was up to 598 so they gave CR#1 some insulin. LVN A said with CR#1 was declining - oxygen saturation was 88% and resident was placed on non-rebreather with oxygen at 10 liters, but they still could not get CR #1's oxygen level up, the resident (CR #1) was not looking good, and her blood sugar was high, so she got orders to send the CR#1 out to hospital at around 5:00am when she got through to the physician. She said CR #1 was barely trying to open her eyes and that was a big difference from CR#1's normal self, CR #1 appeared lethargic, she knew CR #1 to be more alert than how she appeared on [DATE]. LVN A said EMS came at 6:20 am. Record review of CR #1's progress note documented by LVN A on [DATE] revealed Rsd breathing but non-responsive. bs 598 per Dr order gave 15units of lispro @05am and to send rsd out to hospital v/s 160/78, hr 128, t-97.4, O2 88% w/ non-breather mask on 10L oxygen. Non-emergent line contacted eta 0600 . On [DATE] at 3:13pm in an interview with LVN B she stated on [DATE] CR#1 had elevated blood sugar at 313. She stated CR#1 was on insulin sliding scale and every time blood sugar was beyond the normal she would give the insulin. She stated on [DATE] she handed CR #1's care over to LVN A to send CR#1 out because the oxygen saturation was low even after they placed CR#1 on oxygen and it was still low. LVN B stated she worked the 2 to 10 pm shift and LVN A worked the 10pm to 6am. She stated before giving CR#1 oxygen it was low and her O2 saturation remained low. LVN B stated she could not remember the date, but the time she charted at 11:28pm she was still at the facility even after she finished her schedule at 10pm she was still doing her chart before leaving for the night. LVN B stated she did not write notes on the resident (CR #1), but she told LVN A that CR#1's oxygen saturation was not ok and she kept following up with the nurse until she (LVN B) left the facility. LVN B stated she gave CR#1 insulin sliding scale. She stated if she did not write it down she must have missed it to document because she was overwhelmed, because their new system where they document was not user-friendly. She stated she took CR#1's blood sugar earlier during the shift and the value was 313, but she documented it at 11:28pm . She did not recall if she followed up to recheck the blood sugar again, she only documented it into the system at 11:28pm when she had the chance to document. She stated if the blood sugar was that high she was supposed to continue to recheck the blood sugar to make sure it was coming down because high blood sugar could affect the resident negatively if not treated. On [DATE] at 3:57pm in an interview with the DON, she said if CR#1 has a blood sugar above 300 the nurses were to call the Physician to get order. The DON said besides the Physician's order, the nurses were to use nursing judgement and check the blood sugar every 30 minutes to an hour if the resident's blood sugar was still high, and if there are further orders they check with the Physician again. She stated in 30 min to an hour they would be able to identify if the blood sugar was going down, but they don't want to give more insulin because the insulin was still working. The DON stated CR#1's blood sugar was coming down, but then she had a meal in between which could have brought her blood sugar up again. The DON stated blood sugar is a patient specific thing and 300 was high for CR#1 and the nurses were expected to use their nursing judgement to recheck CR #1's blood sugar more frequently to see the blood sugar trending down. The DON said based on the CR#1's blood sugar level and overall change in condition, CR #1 should have been sent by emergency 911 and not non-emergency ambulance. She said the situation with CR #1, high blood sugar and low O2 sat while on non-rebreather mask with 10liters oxygen, was a change in condition and needed prompt interventions. She said when the nurses are given orders by the Physician, nurses were supposed to carry them out, and in this situation she would have implemented the order to send resident out rapidly. The DON stated she was not sure of CR #1 was throwing up on the [DATE]. She stated if a resident throws up only once then she would watch it because it could have been something they ate that did not agree with them, but if it is something that is happening consistently it is a change in condition. The DON said she was not aware that CR#1 vomited multiple times at the facility on Thanksgiving morning. On [DATE] at 4:21pm in an interview with the Primary Physician, he stated he was the primary Physician for CR #1, but he was not the one who was called on the day ([DATE]) when resident was sent to the hospital, he said probably they called the medical director. He stated he was not aware and could not recall anyone called him for CR #1 throwing up on any day. He stated it was an emergency if a resident was having a change in condition, becoming lethargic with low oxygen level at 88% while on non-rebreather with 10 liters of oxygen and high blood sugar in the 500s. The Primary Physician also stated it is a possibility that the high blood sugar could have caused the resident to throw up. He stated when a sliding scale is given and residents blood spiked, the goal was to administer insulin so as to bring the resident's blood sugar down to the lowest level on the slightly scale. On [DATE] at 4:38pm in an interview with LVN D who discontinued the insulin NPH and Lispro for CR #1, she stated the NP gave her order on the [DATE] to discontinue the lispro and that was the only insulin she discontinued, she stated she only discontinued the sliding scale according to what the nurse practitioner (Lead NP) told her. She stated she did not recall discontinuing the insulin NPH for CR #1. Record review of CR #1's Physician order revealed insulin NPH and insulin Lispro was discontinued by LVN D on [DATE]. On [DATE] at 4:23pm in an interview with the facility Medical Director, the Medical Director he state I won't remember that patient at all he stated he was not the Physician for the patient and he stated the Primary Physician was the primary Dr. He said the protocol was that the facility would only reach out to him if the nurses were not able to reach to the NPs that worked with him or not able to reach other Physicians, they would call him. He stated he gets a lot of calls all the time with a lot of things, he said the resident there at the facility their acuity is very high, and they were doing their best to care for the residents. He stated he could not recall anyone calling him about CR #1 throwing up or having extremely high blood sugar of having any change in condition. He stated the nurses must have reached out to the primary care Physician and not him. Review of facility policy titled Change in a Residence Condition or Status Dated Revised February 2021 revealed, in part, The nurse will notify the resident's attending physician or physician on call where there has been it's significant change in residence physical emotional mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .A nurse will notify the residence representative when there is a significant change in the resident physical mental or psychosocial status .The nurse will record in the residence medical record information relative to changes in the resident medical or mental condition or status This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 2:57pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:17pm. PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered [facility] on [DATE], for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F580 as stated below: F580: Notify of Change in Condition Resident Status: The resident was discharged to an acute care hospital on [DATE] and did not return. Immediate action: On [DATE] DON under the guidance of the Regional Nurse Consultant initiated an in-service with all nursing staff (all nursing staff to include CNAs) on duty to cover the following topics, this training will be completed by [DATE]. o Notifying Physician and Family of Resident Change of Condition. The physician should be notified as soon as possible after identifying a change of condition, assessing resident needs and providing necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contact for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to vomiting, vital signs, mental status changes, functional decline, etc. o Symptoms that include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Notification of physician upon identifying a high blood sugar level. o Change of Condition policy was reviewed, no changes were made. Staff in-serviced on current policy. o An audit will be conducted of all residents receiving insulin to ensure orders are correct. This audit will be completed by [DATE]. o An audit will be conducted of all residents receiving blood sugar checks to ensure parameters are set. This audit will be completed by [DATE]. o An audit was completed of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. This audit will be completed [DATE]. o An audit of residents with diabetes was done to assess for high blood sugar levels or change of condition. This audit was started on [DATE] and will be completed [DATE]. Facility Plan to ensure compliance quickly: o All nursing staff will be in-serviced on the above listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions have been identified and physician notification has been made. This audit began [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that: o A physician is to be notified immediately of changes of condition. o This in-servicing began [DATE] and will be completed by [DATE]. On [DATE] The facility Administrator, ADON, and Regional Nurse Consultant held an ad hoc QAPI meeting with the Medical Director, via phone, to discuss: o F580 - Notify of Change of Condition - IJ Cited o Plan of Removal and actions taken to ensure continued compliance. QAPI: o The above actions will be reviewed monthly The State Surveyor confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: On [DATE] at 3:09pm interview with LVN E, she stated she only worked on weekends, she had not been trained in an in-service today, she said she saw some pieces of paper at the nurses station but nobody has told her anything. On [DATE] at 3:10pm in an interview with CNA C, he stated he had received in-service training when he came to the shift today, the training was about reporting to the nurse and DON immediately if they saw any changes in resident and to complete the Stop & Watch form. On [DATE] at 3:12pm in an interview with LVN F, he stated he was in-serviced today regarding abuse and neglect, documentation of SBAR when resident have change in condition and to document all intervention, he provided to his residents in the nurses note. He stated he was also trained about medication administration medications such as antibiotic insulin and other meds and to monitor blood sugar after administration of insulin to residents and to notify the Physician, the DON and the supervisors if there is any change in condition for his residents. He stated monitoring blood sugar for residents should be done every 30 to 40 minutes for every resident with high blood sugar and to continue to monitor the blood sugar until the blood sugar gets down to the level you don't need to give insulin. On [DATE] at 3:19pm in an interview with RT A, she said she had in-service training yesterday and today they were taught to make sure they document if any patient have change in condition and pay attention to abnormal changes in patient. and they have to communicate with the nurse Physician, NP, DON, and resident's family members. On [DATE] at 3:21pm in an interview with CNA D, she stated she had in service training yesterday about reporting any changes in resident at any point in time to the nurse immediately, she said changes could be if patient is not eating as they used to eat, not talking as they used to talk, not opening their eyes, not having enough bowel movement, not having enough urine, or patient is vomiting, patient has any skin issue, she said anything different in the normal condition of the patient she would report immediately to the nurse and to the DON so they can follow up with the necessary intervention. On [DATE] 3:13pm in an interview with CNA E she stated that she was trained this morning and few days ago about changes in condition of a patient to let the nurse know immediately if the CNA's notice any little change in the situation of the patient and to complete the stop and watch form. On [DATE] at 3:15pm in an interview with LVN G, he said he received an in service on Friday [DATE] and the training was about documentation reporting of changes in condition and sending patient out on emergency and completion of SBAR. he said he would send a patient out on emergency if the patient was having a serious change in condition or a life threatening condition, or if it is a situation with ABC (Airway Breathing Circulation) and the vitals like oxygen saturation was low and not able to get the oxygen up, or if the patient is having active bleeding that is uncontrollable, or if the patient stop breathing. He said he would also contact the Physician the DON and the family member if there's any changes in resident condition. On [DATE] at 3:20pm in an interview with RN D, she stated she had training yesterday Sunday ([DATE]), he said the training was about monitoring residents blood sugar, when resident had high blood sugar the nurses have to call the Physician to get order and continue to monitor the patient after administering insulin. RN D said the training also include monitoring patient for any change in condition, she stated clinically when your patient is not looking good to you must call Physician to let him or her know your findings and promptly carry out the order given by the Physician. On [DATE] at 3:37pm, in an interview with RT C, she said she received training on Friday about changes in condition of resident and to report to the nurse who was assigned to the resident, and to report to her manager the respiratory therapy manager and the DON and the Physician about whatever changes she found in her resident. She said she was also trained to check vital sign and documenting her findings or evaluation and what was done for the resident and who she told about the resident's condition. On [DATE] at 3:52pm in an interview with LVN H, she said she received training on Friday ([DATE]) about changes in condition if she noticed any changes in any resident she will call the Physician and also informed the DON. she said it depend on the degree of change if patient was having high temperature, or high blood sugar she will continue to monitor the patient and keep the Physician informed. She said if a resident have high blood sugar in the 500s she will call the Physician and get order and she will continue to recheck resident's blood sugar every 30 minutes to 1 hour. On [DATE] at 3:57pm in an interview with Weekend Supervisor, she stated she had received in-service training from the DON on Friday ([DATE]) about changes in condition of resident blood sugar check and follow up notify family members Physician and [NAME] whenever a resident had a change in condition or any abnormal love values abnormal vital sign. she said the training also included documentation of SBAR and documenting in progress notes in detail about every intervention performed for residents. Record review of the plan of removal was completed: - In-service training documentations were reviewed. - An audit of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. - Documentation of the Audit of current residents. - Impromptu QAPI meeting of the Administrator with the medical Director. - An audit of all residents receiving insulin to ensure orders are correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to recognize a change in condition for CR#1 when she began throwing up on [DATE] and some days after, and continuously having extremely high blood glucose levels for 6 days ([DATE] - [DATE]). CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. The facility delayed in sending CR#1 to the hospital by calling the non-emergency line taking the ambulance over an hour to come when CR#1 was nonresponsive, blood sugar was 598, and O2 Saturation was 88% while on nonrebreather mask with 10 liters oxygen on [DATE]. The facility failed to monitor blood glucose levels adequately when CR#1's blood glucose level continued to spike with numbers above 600. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 3:58pm, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures could expose residents to low quality of care, worsening of condition, hospitalization, and death. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Current admission was on [DATE] with diagnoses of type 2 diabetes (A chronic condition that affects the way the body processes blood sugar, resulting in too much sugar in the body), kidney failure, cerebral infarction (cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), malnutrition, hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), high blood pressure, sepsis (Sepsis is a serious condition in which the body responds improperly to an infection, causing a cascade of changes that damage multiple organ systems, leading them to system failure, sometimes even death), and heart disease. Review of CR #1's MDS (Minimum Data Set) dated [DATE] revealed CR #1 was diagnosed with Diabetes Mellitus, high blood pressure, cerebral infarction, and hemiplegia. MDS also revealed CR #1 was on insulin medication, oxygen therapy treatment, suctioning, and tracheostomy care. Review of CR #1's care plan revealed CR #1 was at risk hypoglycemia / hyperglycemia episodes due to diabetes mellitus. The care plan goal was that CR #1's blood sugar will be managed effectively, and the careplan intervention was to do accu checks as ordered and report any abnormal findings to the Physician and family members. Record review of CR #1's Physician order dated [DATE] revealed insulin NPH and insulin Lispro was discontinued by LVN D on [DATE]. Record review of CR #1's physician orders revealed there was no order for insulin NPH from [DATE] through [DATE]. Review of CR #1's Physician order dated [DATE] revealed the following: Accu check with insulin Lispro (AdmeLOG) sliding scale SQ 142 - 180 = 2 units 181 - 220 = 4 units 221 - 240 = 5 units 241 - 260 = 7 units 261 - 280 = 9 units 281 - 300 = 10 units >300 = 12 units and call MD Four Times A Day 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM Record review of CR #1's [DATE] MAR revealed there was no insulin NPH administered to CR #1 from [DATE] through [DATE]. Further review revealed there was no documentation of blood sugar checked and no insulin administered to CR #1 on the 9pm accu check schedule on [DATE] when LVN A worked. Record review of CR#1's blood sugar vitals from (date) to (date) revealed no continued follow up on CR #1's blood sugar when the blood sugar was high: [DATE]: 5:34 am 598 mg/dL On [DATE] 11:28 pm 319 mg/dL 11:28 pm 283 mg/dL 1:01 pm 381 mg/dL 10:57 am 468 mg/dL 8:15 am 556 mg/dL 8:02 am 468 mg/dL [DATE] 7:01 pm 300 mg/dL 11:33 am 386 mg/dL 9:31 am High (above 600) 8:24 am High (above 600) 1 pm 414 mg/dL [DATE] 9:27 pm 250 mg/dL 5:52 pm 289 mg/dL 1:16 pm 365 mg/dL [DATE] 5:32 pm 313 mg/dL 12:04 pm 398 mg/dL 9:24 am 388 mg/dL [DATE] 8:43 pm 382 mg/dL 10:42 am 320 mg/dL 10:24 am 365 mg/dL [DATE] 7:24 pm 269 mg/dL 1:55 pm 139 mg/dL 8:39 am 139 mg/dL [DATE] 10:36 pm 159 mg/dL 11:57 am 300 mg/dL Record review of CR #1's progress note documented by LVN A on [DATE] revealed Rsd breathing but non-responsive. bs 598 per Dr order gave 15units of lispro @05am and to send rsd out to hospital v/s 160/78, hr 128, t-97.4, O2 88% w/ non-breather mask on 10L oxygen. Non-emergent line contacted eta 0600 . On [DATE] at 11:25am in an interview with CR#1's family member, she stated CR#1 had an infection that was not treated and by the time CR #1 got to the ER she was septic and dies the [DATE]. CR#1's family member stated there were instances where the Physician stated he did not know about CR#1 and admitted that he did not know CR#1. CR#1's family member stated she went to check CR#1 out of the facility on thanksgiving day, but CR#1 was throwing up that day and no one knew why she was throwing up. CR#1's family member stated she did not want to take CR#1 out of the facility not knowing what was happening. CR#1's family member stated no one knew why CR#1 was throwing up and it was odd for CR#1 to be throwing up so something must have been wrong with CR #1 on that day ([DATE]). CR#1's family member stated the staff (unknown) said CR#1 threw up twice that morning. On [DATE] at 12:24pm in an interview with CNA A, she stated she remembered CR#1 threw up on [DATE] on thanksgiving day. CNA A stated they noticed CR#1 threw up and she (CNA A) went to tell the Nurse (unknown). CNA A stated CR#1's emesis was brown and it was a lot. CNA A stated she told the nurse and she went to check CR#1. CNA A stated she did not recognize any other changes in condition for CR #1 on that day. On [DATE] at 10:21am in an interview with CNA B she stated CR#1 came from the 100 hall doing well and moved to the 200 Hall and after CR#1 stopped eating well the staff had to feed her and she refused sometimes. CNA B stated CR#1 was not really eating enough by mouth when she came to the 200 hall and she had a feeding tube. CNA B stated the day she went with her family member for Thanksgiving on [DATE] CR#1 was throwing up a lot on that day. CNA B stated she told the nurse on the floor and CR#1's family member that CR#1 was throwing up. She stated the nurse came to the room to speak with the family member and they decided with the family member whether to take CR#1 home for the day or not because of her throwing up. CNA B stated she remembered the day they sent CR#1 to the hospital she was throwing up also. On [DATE] at 11:21 am with RN C, she stated she took care of CR #1 on 100 hall on [DATE], and on 200 hall on [DATE]. She stated when she took care of CR #1 100 hall on [DATE] she checked CR#1's blood sugar and it was very high and that was the only thing she knew that happened that day. She stated she called the Physician, and he told her to give CR#1 a dose of insulin, but she could not remember the units. When they call Physician's number usually they would speak with anyone who picked the line, it could be one of the nurse practitioners working with the physician, but she did not know who specifically she spoke with on that day ([DATE]) on thanksgiving day. CR#1 used to have insulin scheduled for her blood sugar, she stated she was shocked that CR#1 was not on insulin when she took care of her on that day because CR#1's blood sugar was so high, 402 mg/dL, that she had to call the Physician. She stated CR#1 used to have insulin NPH and sliding scale. RN C stated CR#1's family member wanted to take her out to eat on the thanksgiving day, but she (RN C) told the family member that they had to take care of CR#1's blood sugar before the family member could take CR #1 out. RN C stated she followed up and rechecked the blood sugar and it was lower than what it was before, but she did not remember what the value was and she was not sure if she documented it. She stated she should have put what the blood sugar came down to. She stated she could not remember if CR#1 was throwing up. She stated there were so many things that happened that day and many families came to pick their family up so she did not recall if she wrote any notes or any assessments. On [DATE] at 1:58pm with former ADON C she stated she could not remember what happened with CR#1. She stated CR#1 did get sent out to the hospital on the night shift. She stated if someone was throwing up, it was a change in condition, and they needed to do something about that. She stated they needed to call the Nurse Practitioner, Responsible Party, and everyone that needed to be called. On [DATE] at 2:12pm in an interview with RN B, she stated she walked in on [DATE] and CR#1 did not have any signs and symptoms, CR #1 was acting normal, the blood pressure was normal and then she checked CR#1's blood sugar and CR#1's blood sugar was pretty high in the 491mg/dl, so she called the physician. RN B stated she looked through CR#1's physician orders and saw that her orders for insulin had been discontinued by the physician and she did not know why it was discontinued. RN B stated on the weekend of [DATE] and [DATE], CR#1's blood sugar was in the 300's and they did not document any interventions from the nurses. RN B stated she worked at the facility on [DATE] and [DATE], and it was her first-time taking care of with CR#1. RN B stated she knew that blood glucose of 300 was not a normal thing. RN B stated no one informed her that CR#1 had been throwing up on [DATE] on the thanksgiving day. On [DATE] at 12: 38pm in an interview and record review of CR#1's clinical record with the DON, she stated CR#1 came to them from home with dementia, old CVA history, sepsis with shock, malnutrition, diabetes, High blood pressure, and pressure ulcers when admitted . The DON stated CR#1's blood sugars were in the 400's and 500's. She stated CR#1 could spike and go up to 402 within 30 minutes of each other and then went back down to 126. She stated CR#1's blood sugars started going consistently higher on [DATE]. She stated they were holding CR#1's tube feeding, and administered the insulin sliding scale. The DON stated in CR#1's clinical record, the physician noted dated [DATE] revealed CR#1's Pt's diabetes is controlled at this time. Will continue to monitor for stability. BS: 557mg/dL, the Physician wrote that it was controlled and will continue to monitor. The DON stated she was not going to second guess a physician when he stated the blood sugar was 557 and that it was controlled. On [DATE] at 3:05pm with LVN B, she stated she worked on [DATE] and [DATE] in the hall where CR #1 was. She stated on [DATE], she went to assess CR#1 and she called CR#1's Physician and told the NP that CR#1 was not doing well. LVN B stated CR#1's O2 Saturation was still okay at the time she came to the shift. She stated when she assessed CR#1 she was just quietly looking, and CR #1 was a quiet person. LVN B stated when she was handing over to the night nurse (LVN A), she and the nurse they checked CR #1's O2 saturation it was below 90. LVN B stated CR#1's O2 saturation was the problem, and she called the RT, and the Respiratory Therapist came to check CR#1's oxygen and it was low so they sent CR#1 out to the hospital on [DATE]. LVN B stated she reported to LVN A because she (LVN A) worked that night. On [DATE] at 12:33pm in an interview with RN A she stated she was on orientation with LVN C on that day on [DATE]. She said it seemed the problem started during the night shift, but they were waiting for Physician because they were trying to reach the Physician during the night. She said if resident was having change in condition and Physician was not answering the call, the expectation was to call 911 and inform her supervisors that she was going to send the patience to hospital. She said on that day they were calling the Physician back and forth. She stated when she came to the shift on that morning they got reports that the resident's blood sugar was spiking. They discontinued CR #1 feeding tube and flush her tube with water, she said she was not used to that patient so she did not know if the patient was having a change in condition, if it was a patient she was used to she would know if CR#1 was having even any slight changes in her condition. RN A stated on [DATE] she was a PRN staff and she took care of CR#1 and she did not think CR#1's blood sugar was high that day at 6:30pm, but on [DATE] RN A stated she was coming on-board as a full time staff and was on orientation with LVN C. RN A stated on [DATE] the night duty nurse reported CR#1's blood sugar was spiking and CR#1 continued having high blood sugar. RN A stated she called the Physician and they did not respond. RN A stated CR#1's blood sugar was high on [DATE], and the Physician (she was not sure if it was a Physician or the NP) got back to them at around 10:00am but before the MD got back to them they applied the sliding scale and they also gave CR#1 bolus fluid. RN A stated to be very honest, she did not notice if the resident (CR#1) was having any change in condition, if it was a patient that she was used to she would be able to say if the patient had a change of condition. She stated that same CR#1 was sent out to the hospital. RN A stated the resident (CR#1) had a lot of health issues going on with her, she said to be very frank, when the woman started having hyperglycemia they (nurses) should have given her insulin, but they delayed. RN A stated she was not able to make notes because she was doing orientation and was not used to the documentation system, and she could not find a place to make the notes and the intervention. She stated making the notes was not easy because she was trying to know the patient at the same time. On [DATE] at 1:00pm in an interview with LVN C, she stated she worked the morning shift on [DATE], but she no longer worked at the facility. She stated if she did a blood sugar and it was 500 she would call the Physician and she would reassess the resident to make sure it was the right reading. She stated if the resident had a sliding scale she would administer the insulin and she would check if they were on continuous feeding and they would pause the feeding. She stated she would also do a water flush for the tube feeding and call the physician. She stated the first thing she would do was to administer the insulin sliding scale and go from there. She stated if the blood sugar was that high in the 500s, she would check it every 30 min and keep rechecking it. She stated if she was able to get the blood sugar down from 500 to 380 within an hour she would still alert the physician and would continue to follow up with the blood sugar. She said she could not remember the patient specifically because she always working with a lot of nurses and orienting them, and that she was not a primary nurse on the floor. She stated she could not recall anything about CR #1, and she could not recall anything happening to CR #1 on 11/30 2023. On [DATE] at 2:39pm in an interview with the Lead NP, she stated she knew all the residents in the facility because she comes to the building everyday. The Lead NP stated CR#1 was on 2 different insulins (NPH and Lispro) when she was admitted to the facility. She stated on [DATE] a nurse (she did not remember the nurse) told her that the resident's blood sugar was running too low, and she gave verbal order to the nurse to discontinue the insulin lispro for CR#1 because her blood sugar was low at that time. The Lead NP stated she did not give any order to discontinue the NPH. She stated CR#1 was on NPH 40 units 3 times a day, the nurse was to discontinue only the insulin Lispro, and leave the NPH insulin without any changes. She stated that the nurse discontinued both insulin (NPH and Lispro) by error. The NP stated if blood sugar was high the nurse was supposed to call and let them know that the resident's insulin was discontinued, because the resident (CR #1) was supposed to be on the NPH as a basal coverage for the resident. She stated insulin lispro was not meant for treating residents with hyperglycemia, she stated the lispro was a short acting insulin which was in place to bring the blood sugar down in case the resident's blood sugar spiked. She stated there should be a scheduled insulin NPH which would be covering the resident for up to 12 hours. The lead NP stated she did not know the insulin NPH was discontinued, she did not check the resident's record, because she believed when they gave an order to the nurses, they were supposed to carry out the order accordingly. She stated she was always in the building and most nurses would come to her to get order for anything happening with any resident and she would give verbal order at times. She stated whenever she or any other team member give an order, they would always communicate with other team members, so they all be on the same page. The Lead NP stated if a patient started throwing up, she would expect the staff to call them for any change in condition. The Lead NP stated she was at the building on the [DATE] and the resident's vital signs were all good and there was no need to send the resident to hospital. On [DATE] at 4:38pm in an interview with LVN D who discontinued the insulin NPH and Lispro for CR #1, she stated the NP gave her order on the [DATE] to discontinue the lispro and that was the only insulin she discontinued, she stated she only discontinued the sliding scale according to what the nurse practitioner (Lead NP) told her. She stated she did not recall discontinuing the insulin NPH for CR #1. On [DATE] at 2:43pm in an interview with LVN A she said CR#1's blood sugar on [DATE] at 11:28pm was 319. LVN A stated CR#1 was sent out because she was declining compared to the last time she took care of CR #1 on the 100 hall. LVN A said CR#1's oxygen saturation was what they were mainly worried about, her oxygen was low in the 80s so they got orders to put CR #1 on oxygen. LVN A said CR#1 was not acting the same as when she was on 100 Hall. She said on [DATE] at 5:34 am CR#1's blood sugar was up to 598 so they gave CR#1 some insulin. LVN A said with CR#1 was declining oxygen saturation was 88% and resident was placed on non-rebreather with oxygen at 10 liters, but they still could not get CR #1's oxygen level up, the resident (CR #1) was not looking good, and her blood sugar was high, so she got orders to send the CR#1 out to hospital. LVN A stated when she took care of CR#1 on the 100 hall CR #1 was getting insulin NPH in the morning but it was discontinued on [DATE] and she did not know why it was discontinued. LVN A stated she also took care of CR #1 on [DATE] and checked CR #1's blood sugar on [DATE] but could not recall what it was and whether she gave insulin or not. She stated on [DATE] during the night shift, she tried to call the physician, but they don't really respond in the middle of the night. She said the physician did respond early in the morning around 5:00am. She said CR #1 was barely trying to open her eyes and that was a big difference from CR#1's normal self, CR #1 appeared lethargic, she knew CR #1 to be more alert than how she appeared on [DATE]. LVN A said EMS came at 6:20 am. LVN A said she did not recheck CR#1's blood sugar or the oxygen saturation. She stated everything during the shift was going so fast I guess I did not recheck. LVN A said she called the non-emergency line because 911 was called if the resident was not stable. She said CR#1 was still trying to open her eyes, so she thought it was not an emergency, she did not think she needed 911. LVN A stated if a resident was coding and not breathing she would call 911 but CR #1 was still breathing only that she appeared lethargic, O2 low, and blood sugar high. LVN A stated she did not realize the situation with the resident was an emergency because the resident was not in comatose, she stated, I felt it was getting to that point and she had to send her out. On [DATE] at 3:13pm in an interview with LVN B, she stated CR#1 had elevated blood sugar at 313 on [DATE]. She stated CR#1 was on insulin sliding scale and every time blood sugar was beyond the normal she would give the insulin. She stated on [DATE] she handed CR #1's care over to LVN A to send CR#1 out because the oxygen saturation was low even after they placed CR#1 on oxygen and it was still low. LVN B stated she worked the 2 to 10 pm shift and LVN A worked the 10pm to 6am. LVN B stated she could not remember the date, but the time she charted was 11:28pm and she was still at the facility even after she finished her schedule at 10pm. She stated she was still doing her charting before leaving for the night. LVN B stated she did not write notes on the resident (CR #1), but she told LVN A that CR#1's oxygen saturation was not okay and she kept following up with the nurse until she (LVN B) left the facility. LVN B stated she gave CR#1 insulin sliding scale and rechecked, she stated if she did not write it down she must have missed it to document because she was overwhelmed, because their new system where they document was not user-friendly. She stated she took CR#1's blood sugar earlier during the shift on [DATE] and the blood sugar value was 313, but she documented it late at 11:28pm. She did not recall if she followed up to recheck the blood sugar again, she only documented it into the system at 11:28pm when she had the chance to document. She stated if the blood sugar was that high she was supposed to continue to recheck the blood sugar to make sure it was coming down because high blood sugar could affect the resident negatively if not treated. on [DATE] at 3:57pm in an interview with the DON, she said if CR#1 has a blood sugar above 300 the nurses were to call the Physician to get order. The DON said besides the Physician's order, the nurses were to use nursing judgement and check the blood sugar every 30 minutes to an hour if the resident's blood sugar was still high, and if there are further orders they check with the physician again. She stated in 30 minutes to an hour they would be able to identify if the blood sugar was going down, but they do not want to give more insulin because the insulin was still working. The DON stated CR#1's blood sugar was coming down, but then she had a meal in between which could have brought her blood sugar up again. The DON stated blood sugar was a patient specific thing and 300 was high for CR#1 and the nurses were expected to use their nursing judgement to recheck CR #1's blood sugar more frequently to see the blood sugar trending down. The DON said based on the CR#1's blood sugar level and overall change in condition, CR #1 should have been sent by emergency 911 and not non-emergency ambulance. She said the situation with CR #1, high blood sugar and low O2 saturation while on non-rebreather mask with 10liters oxygen, was a change in condition and needed prompt interventions. She said when the nurses are given orders by the physician, nurses were supposed to carry them out, and in this situation she would have implemented the order to send resident out rapidly. The DON stated she was not sure if CR #1 was throwing up on the [DATE]. She stated if a resident threw up only once then she would watch it because it could have been something they ate that did not agree with them, but if it was something happening consistently it was a change in condition. The DON said she was not aware CR#1 vomited multiple times at the facility on Thanksgiving morning. On [DATE] at 4:21pm in an interview with the Primary physician, he stated he was the primary physician for CR #1, but he was not the physician who was called on the day ([DATE]) when resident was sent to the hospital, he said the facility could have called the medical director. He stated he was not aware and could not recall anyone called him for CR #1 throwing up on any day. He stated it was an emergency if a resident was having a change in condition, becoming lethargic with low oxygen level at 88% while on non-rebreather with 10 liters of oxygen and high blood sugar in the 500s. The Primary physician stated it is a possibility that the high blood sugar could have caused the resident to throw up. He stated when a sliding scale was given and residents blood spiked, the goal was to administer insulin so as to bring the resident's blood sugar down to the lowest level on the slightly scale. On [DATE] at 4:23pm in an interview with the facility Medical Director, he stated I won't remember that patient at all he stated he was not the Physician for the patient and he stated the Primary physician was the primary physician. He said the protocol was that the facility would only reach out to him if the nurses were not able to reach to the NPs that worked with him or not able to reach another physician s, they would call him. He stated he received a lot of calls all the time with a lot of things, he said the residents at the facility had very high acuity, and they were doing their best to care for the residents. He stated he could not recall anyone calling him about CR #1 throwing up or having extremely high blood sugar of having any change in condition. He stated the nurses must have reached out to the primary care Physician and not him. Review of facility policy titled 'Blood Sugar Checks' undated revealed in part, residents receiving insulin should be monitored according to the ordered sliding scale and as needed. Review of facility policy titled 'Pulse Oximetry (Assessing Oxygen Saturation)' dated 'revised [DATE]' revealed in part, normally SpO2 is between 90 and 100 percent .if SpO2 is less than acceptable level for resident's condition, notify the physician. Review of facility policy titled Change in a Residence Condition or Status Dated Revised February 2021 revealed, in part, a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .A nurse will notify the residence representative when there is a significant change in the resident physical mental or psychosocial status .The nurse will record in the residence medical record information relative to changes in the resident medical or mental condition or status This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 2:57pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:17pm. The plan of removal reflected the following: PLAN OF REMOVAL Name of facility: Date: [DATE] The Texas Department of Health and Human Services entered [facility] on [DATE], for a P1 Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F684 as stated below: F684: Quality of Care Resident Status: The resident was discharged to an acute care hospital on [DATE] and did not return. Immediate action: On [DATE] DON, under the guidance of the Regional Nurse Consultant initiated an in-service with all nursing staff (all nursing staff to include CNAs) on duty to cover the following topics, this training will be completed on [DATE]. o Notifying Physician and Family of Resident Change of Condition. The physician should be notified as soon as possible after identifying a change of condition, assessing resident needs and providing necessary services. If the physician is unable to be reached, the DON and/or designee should be notified and the Medical Director contact for treatment plan. o Recognizing and Reporting Acute Changes of Condition. Changes of condition include, but are not limited to vomiting, vital signs, mental status changes, functional decline, hyperglycemia, etc. o Notification of physician upon identifying a high blood sugar level. o Monitoring and follow-up of changes of conditions. o Symptoms that include the need for emergency ambulance services. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Change of Condition policy was reviewed, no changes were made. Staff in-serviced on current policy. o Residents receive treatment as per physician orders. o Documentation of events (Change of Condition), SBAR and Stop & Watch. o Residents receive treatment as per physician orders. o An audit will be conducted of all residents receiving insulin to ensure orders are correct. This audit will be completed by [DATE]. o An audit will be conducted of all residents receiving blood sugar checks to ensure parameters are set. This audit will be completed by [DATE]. o An audit was completed of residents with changes of conditions, within the last 30 days, to ensure the resident physician was notified. This audit will be completed [DATE]. o An audit of residents with diabetes was done to assess for high blood sugar levels or change of condition. This audit was started on [DATE] and will be completed [DATE]. o The nurse referenced in the IJ narrative was identified and in-serviced on following physician orders and discontinuation of medications. In-service completed on [DATE]. o 1:1 in-service was completed with LVN-A on assessing and monitoring resident who experience a change of condition; residents receive treatment as per physician orders; and residents receive emergency services timely, if required. Inservice completed on [DATE]. Facility Plan to ensure compliance quickly: o All nursing staff will be in-serviced on the above-listed topics prior to beginning their next scheduled work shift. o The DON and/or designee will conduct audits of the 24-hour report to include review of progress notes to ensure that all changes of conditions have been identified and physician notification has been made; physician orders written in the previous 24 hours; and any resident hospital transfer to ensure emergency services were utilized, when appropriate. This audit began on [DATE]. Demonstration of and acknowledgement that all licensed nurses are aware of the above: o The DON/ADON and/or designee will contact all licensed nurse staff and get a verbal ack[TRUNCATED]