**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a residents, the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 10 residents (Resident #1) reviewed for quality of care, in that: The facility failed to transcribe Resident #1's hospital order for insulin glargine on admission according to discharge instructions, and failed to administer the medication for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/7/25. The IJ template was provided to the facility on 2/7/25 at 5:01 PM. While the IJ was removed on 2/8/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for hyperglycemia related to missing medication doses. Findings include: Record review of Resident #1's face sheet printed 02/06/2025 revealed a [AGE] year-old female admitted on [DATE] after recent hospitalization with a diagnosis of UTI and new on-set CHF exacerbation with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's admission MDS, dated [DATE], reflected it was pending completion and submission. Record review of Resident #1's hospital discharge instructions, dated [DATE], revealed Resident #1 had an order for 17u Insulin Glargine 1x daily. Discharge instructions did not indicate blood glucose level checks. Record review of Resident #1 February 2025 MAR revealed the facility did not transcribe an order for 17u Insulin Glargine until 02/06/2025. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1 blood sugar levels after receiving 17units of insulin glargine revealed 2/7/25 at 10:30 AM blood sugar level of 219 mg/dL. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview on 02/05/25 at 4:30 PM with ADON LVN G, the DON, the Regional Nurse, and the Administrator, the DON stated LVN G was notified by Resident#1's family member that the resident was supposed to received daily insulin administration. LVN G confirmed an order for insulin glargine 17u daily was listed on Resident #1's discharge instructions from the hospital, dated 01/30/2025, and contacted physician for insulin orders and administered 17u insulin glargine at 4:27 PM. The Administrator stated this event would be called in to the state as a medication error. In an interview with the DON on 02/06/2025 at 4:45 PM, the DON confirmed that Resident #1 had not received insulin for 6 days from 01/31/25-02/5/25, putting the resident at risk for hyperglycemia (elevated blood sugar levels) with both short-term (hyperglycemia, diabetic ketoacidosis) and long-term (damage to kidneys, eyes and nerves) effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. [Facility Name] Tag Cited: F684 Alleged Issues: The facility failed to enter and obtain the appropriate prescribed medication for resident upon admission and notify the physician when medication was 'unavailable' or not administered. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed an admission Drug Regimen review and reconciliation on all new admissions along with the Medical Director date range of 1/30/2025 to current. An admission drug regimen review and reconciliation tracker was created and put in place by the DON on 2/07/2025, review as completed 2/07/2025. A resident medication administration audit report was conducted by DON and MDS coordinator on 2/08/2025 to ensure medication availability for each resident. Change of condition assessment audit was reviewed on 2/07/2025 for date range of 1/30/2025 to current. Change of condition assessment audit was conducted by the DON on 2/07/2025. Change of condition assessment audit will be monitored in daily clinical meeting Monday through Friday with IDT team conducted by the DON or designee. Saturday and Sunday the change of condition review audit will be performed by the DON or designee. 2. Education DON and ADON in serviced on notifying MD when medications are not transcribed accurately or not available and documenting MD recommendations on 2/07/2025 by VP of Clinical. DON and ADONs were educated on change of condition. When a resident has a change of condition or before sending the resident out, DON must be notified, MD must be notified, and a change of condition must be opened and completed. In service provided by the VP of clinical on 2/07/2025. One on one education provided to nursing staff regarding the Charge Nurse calling the Medical Director and review the hospital discharge medication list, once reconciled enter all orders at the time of admission, complete admission note, ensure that drug regimen review is completed, and all assessments completed. Education completed by DON and ADON's on 2/07/2025. One on one education provided to nursing staff in regard to notifying MD when medications are not available and to provide a progress note with MD recommendations when medications are not available. Education provided by DON and ADONs on 2/07/2025. Staff that were not physically present in the facility were contacted via phone and education reviewed with them by the DON and ADONs on 2/07/2025. 3. Monitoring The admission Drug Regimen Review and Reconciliation tracker on new admissions will be reviewed daily in morning clinical meeting by the IDT Team Monday through Friday. Saturday and Sunday, the admission Drug Regimen Review and Reconciliation will be completed by the DON or designee. An audit of every MAR will be conducted Monday through Friday in the clinical meeting by the DON or designee to ensure medication availability for all residents. Saturday and Sunday, the medication administration audit will be completed by the DON or designee. The admission Drug Regiment Review and Reconciliation tracker will be presented at the monthly Quality Assurance Performance Improvement (QAPI) meeting for a minimum of three months. 4. QAPI Committee Review: An Ad Hoc QAPI committee meeting was completed 2/07/2025. 5. Plan of Removal date: 2/07/2025 The Plan of Removal was accepted on 02/08/2025 at 5:29 p.m., and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Interview with DON and Administrator on 2/08/2025 verified the Admissions Drug Regimen Review and Reconciliation was completed for all residents admitted since 1/20/2025. This surveyor completed 7 of 7 admissions reviews from 1/30/2025-2/7/2025 with no errors noted. Record review on 2/08/2025 verified medication administration audit report was conducted by MDS Coordinator and DON. Verified Change of Condition assessment audit was completed by DON 2/8/2025 and verified Change of Condition assessment audit in place with Administrator. 2. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated aware of how to complete a change of condition and understands importance of accurate medication reconciliation for new admissions. RN I stated understanding of how to input orders into EMR, identify and report change of condition and need to clarify admitting orders with MD. LVN J stated understanding of importance of verifying admitting orders and confirming with MD as well as date input in EMR. LVN C stated inservices received for change of condition, medication reconciliation and understands importance. LVN K stated understands process of medication reconciliation for admissions and need to take time in reviewing discharge instructions, verbalized understanding of change of condition notifications. LVN L stated understanding of change of condition and understands need to clarify all discharge instructions for admissions and verify with MD. LVN M stated received inservices for change of condition and clarification of medication reconciliation for discharge instructions on new admissions. LVN N stated understanding of importance of completing new admissions and discharge instructions / medication reconciliation on all new admissions and notifying MD for change of conditions. LVN AE stated received inservices on identify and reporting change of condition and importance of completing accurate medication reconciliation on all admissions. LVN O stated received inservices for change of condition and new admissions. Stated understands how to complete medication reconciliations and date input in EMR. LVN Q stated understands how to complete new admission assessments, change of condition assessments and medication reconciliation according to discharge instructions. LVN S stated understanding of need for clarification and accuracy for new admissions and following discharge instructions, notifying MD and completed change of condition assessments. LVN T stated received inservices for change of condition and understands importance of notifying MD and verify new admission orders. LVN U stated understanding of process for new admissions and need to ensure accurate transcription and notification of MD to verify orders. LVN V stated received inservices for change of condition, medication reconciliation for new admissions and understands how to input into EMR. LVN X stated understands need to accuracy when completing new admission medication reconciliation and notifying MD of change of condition. 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) regarding completing a Change of Condition assessment, completing new and re-admission medication reconciliation and admission assessments according to admission Checklist to include verifying orders (all orders, but specifically insulin orders) and transcribing orders in EMR. Inservice Training and Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interview on 2/08/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication reconciliation process for admissions. Inservice Training and Training log for 27 of 27 FT/PRN Staff review and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/8/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication availability, who to contact and how to access Emergency medication system. Inservice Training & Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN nurses with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Record review on 2/08/2025 of In-service log and training provided reviewed. All nurses interviewed were able to identify how to complete a Change of Condition assessment, how to verify orders for new admissions according to discharge instructions by transcribing and verbalizing to physician (or designee) to include how to input information in EMR including parameters and sliding scale needs for insulin orders. Through interview and observation, staff members were able to demonstrate they received identified inservices and demonstrated knowledge of subject matter through surveyor questions. 3. Record review on 2/08/2025 of admission Drug Regimen and Reconciliation Tracker that will be kept by the Administrator and/or DON during clinical meeting. DON verbalized she will review MAR in clinical meetings to ensure medication availability. On 2/08/2025, Administrator confirmed admission Drug Regimen Review and Reconciliation tracker will be reviewed at least quarterly in QAPI meeting. 4. On 2/08/2025, Administrator confirmed QAPI meeting was completed 2/07/2025. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. 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 jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmacological services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to acquire, receive, dispense, and administer Resident #1's scheduled insulin 17u Insulin Glargine daily as ordered for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on 2/07/2025 at 5:01 PM. While the IJ was removed on 2/08/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This deficient practice could place resident at risk for adverse side effects of hyperglycemia. Findings include: Record review of Resident #1's face sheet printed 02/06/2025 revealed a [AGE] year-old female admitted on [DATE] after recent hospitalization with a diagnosis of UTI and new on-set CHF exacerbation with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's hospital discharge instructions dated 01/30/2025 revealed Resident #1 had an order for 17units Insulin Glargine 1 x daily. Hospital discharge instructions dated 01/30/2025 did not include orders to check blood glucose levels. Record review of Resident #1's February 2025 MAR dated 02/06/2025 revealed the facility failed to transcribe orders for daily insulin until 02/05/2025. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1 blood sugar levels after receiving 17units of insulin glargine revealed 2/7/25 at 10:30 AM blood sugar level of 219 mg/dL. In an interview with LVN G on 2/5/25 at 4:30: PM, LVN G stated she was notified by Resident #1's family member that Resident #1 received daily insulin. LVN G stated she confirmed the hospital discharge medication listing and that the admitting nurse had failed to transcribe the order for 17units Insulin Glargine daily. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview with DON on 02/06/25 at 4:45 PM, the DON stated she was informed by LVN G of the missed order for daily insulin Glargine on Resident #1's admission [DATE]. The DON confirmed LVN G notified the resident's physician on 2/025/2025 at 4:30 PM and obtained orders for 17units Insulin glargine daily. The DON confirmed the resident had not received insulin for 6 days from 01/31//25-02/5/25, putting her at risk for hyperglycemia (elevated blood sugar levels) with both short-term and long-term effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. [facility] Tag Cited: F755 Alleged issues: The facility failed to provide pharmacological services to meet the needs of Resident #1 when admitting nurse did not reconcile Insulin Glargine to Resident #1's medication record as per hospital discharge instructions. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed a chart audit on all residents receiving insulin on 2/07/2025 with audit date beginning 1/30/2025. An insulin tracker reconciliation process was put in place for an audit to be completed daily by DON or designee to ensure insulin is administered correctly and in a timely manner. Insulin Tracker will be monitored by DON or ADON daily in clinical meeting with the IDT Team Monday thru Friday. On weekends, Insulin Tracker will be monitored by DON or designee. The DON completed an admission Drug Regimen review and reconciliation on all new admissions with the Medical Director with a date range of 1/20/2025-current. An admission Drug Regimen Review and Reconciliation tracker was created and put in place by the DON on 2/07/2025 and review was completed 2/07/2025. 2. Education An inservice was conducted for the DON and ADONs by the VP of Clinical on 2/07/2025 on reconciliation of medications for all admissions. One on one education provided to clinical staff that upon admission, discharge medication list will be reconciled with MD via phone (verbal), or in person with charge nurse. Once the charge nurse has completed the medication reconciliation, the DON or designee will review the reconciliation to confirm accuracy. The DON or designee will track the reconciliation on the admission drug regimen/reconciliation log. Tracking began on 1/30/2025, conducted by the DON. DON and designee will educate nursing staff before the next shift and newly hired nurses. IDT Team were educated on the importance of timely insulin administration provided by DON on 2/07/2025. Staff that were not physically present in the facility were contacted via phone and education provided to them by the DON and/or ADONs on 2/07/2025. DON and ADONs will educate nursing staff before the next shift. 3. Monitoring The reconciliation of medications with MD will be monitored by the DON or ADONs by using the admission Drug Regimen Review and Reconciliation tracker. The tracker log consists of signing off on the MD reconciliation review of discharge medications list and reviewing the order listing in daily clinical meeting Monday-Friday by the DON or designee and IDT Team. Saturday and Sunday, tracker will be monitored by the DON or designee. Reconciliation tracking log was initiated for new admissions beginning 1/30/2025 to current by the DON. The insulin monitoring tracker will be presented at the monthly Quality Assurance Performance meeting. 4. QAPI Committee Review: Ad Ad Hoc QAPI committee meeting was completed on 2/07/2025. The Plan of Removal was accepted on 02/08/2025 at 5:29 p.m., and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Record review on 2/8/25 for 12 of 12 residents with insulin orders (chart audit), insulin tracker and drug regimen review completed. Verified available insulin medication matched order for 3 of 3 residents [Resident #1, Resident #3, Resident 4] on 2/8/25 at 11:30 a.m Record review on 2/08/2025 verified in-service and education was completed for 28 of 28 FT / PRN staff [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON] and 8 of 8 Agency staff on 2/07/2025. 2. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated aware of how to complete a change of condition and understands importance of accurate medication reconciliation for new admissions. RN I stated understanding of how to input orders into EMR, identify and report change of condition and need to clarify admitting orders with MD. LVN J stated understanding of importance of verifying admitting orders and confirming with MD as well as date input in EMR. LVN C stated inservices received for change of condition, medication reconciliation and understands importance. LVN K stated understands process of medication reconciliation for admissions and need to take time in reviewing discharge instructions, verbalized understanding of change of condition notifications. LVN L stated understanding of change of condition and understands need to clarify all discharge instructions for admissions and verify with MD. LVN M stated received inservices for change of condition and clarification of medication reconciliation for discharge instructions on new admissions. LVN N stated understanding of importance of completing new admissions and discharge instructions / medication reconciliation on all new admissions and notifying MD for change of conditions. LVN AE stated received inservices on identify and reporting change of condition and importance of completing accurate medication reconciliation on all admissions. LVN O stated received inservices for change of condition and new admissions. Stated understands how to complete medication reconciliations and date input in EMR. LVN Q stated understands how to complete new admission assessments, change of condition assessments and medication reconciliation according to discharge instructions. LVN S stated understanding of need for clarification and accuracy for new admissions and following discharge instructions, notifying MD and completed change of condition assessments. LVN T stated received inservices for change of condition and understands importance of notifying MD and verify new admission orders. LVN U stated understanding of process for new admissions and need to ensure accurate transcription and notification of MD to verify orders. LVN V stated received inservices for change of condition, medication reconciliation for new admissions and understands how to input into EMR. LVN X stated understands need to accuracy when completing new admission medication reconciliation and notifying MD of change of condition. 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) regarding completing a Change of Condition assessment, completing new and re-admission medication reconciliation and admission assessments according to admission Checklist to include verifying orders (all orders, but specifically insulin orders) and transcribing orders in EMR. Inservice Training and Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interview on 2/08/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication reconciliation process for admissions. Inservice Training and Training log for 27 of 27 FT/PRN Staff review and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/8/2025 with 11 of 27 FT/PRN Nurses and 4 of 4 Agency Nurses on duty 2/08/2025 verified they received in-service from DON or ADON regarding medication availability, who to contact and how to access Emergency medication system. Inservice Training & Training log for 27 of 27 FT/PRN Staff reviewed and 8 of 8 Agency Nurses for completion. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN nurses with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Record review on 2/08/2025 of In-service log and training provided reviewed. All nurses interviewed were able to identify how to complete a Change of Condition assessment, how to verify orders for new admissions according to discharge instructions by transcribing and verbalizing to physician (or designee) to include how to input information in EMR including parameters and sliding scale needs for insulin orders. Through interview and observation, staff members were able to demonstrate they received identified inservices and demonstrated knowledge of subject matter through surveyor questions. 3. Record review on 2/08/2025 of facility initiated tracker that will be reviewed in clinical meetings. Confirmed monitoring process by Administrator and DON. Completed record review on 2/08/2025 of facility tracking form. Observation on 2/08/2025 at 11:45 AM of insulin administration for 1 of 1 residents (Resident #3) completed with no errors. Confirmed with 11 of 21 FT/PRN Nurses that they received competency training for insulin administration and order implementation. 1 PRN nurse LVN Q had not received competency training and has not worked since November 2025. LVN Q is aware that he will need to complete competency training prior to start of next scheduled shift (no shift identified at this time). [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. 4. Interview with Administrator on 2/08/2025 confirmed that tracking system will be reviewed at least quarterly during QAPI meeting. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. 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 jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure Resident #1 was administered Insulin Glargine 17units daily for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on 2/07/2025 at 5:01 PM. The IJ was removed on 2/08/2025. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective actions. This failure placed resident at risk for adverse side effects to include increase in blood glucose levels and life-threatening complication of Diabetic ketoacidosis. Findings include: Record review of Resident #1's face sheet, dated 02/06/2025, revealed a [AGE] year-old female admitted [DATE] with diagnoses of UTI and new on-set CHF with co-morbidity of DMII (a long-term condition in which the body does not make enough insulin). Record review of Resident #1's hospital discharge instructions, dated [DATE], revealed an order for 17u Insulin Glargine 1x daily. Hospital discharge instructions did not include monitoring of blood glucose levels. Record review of Resident #1's blood glucose levels revealed the following results: 2/5/25 @ 6:21 PM 233 mg/dL, 2/6/25 @ 9:28 AM 446 mg/dL, 2/6/25 @ 4:52 PM 274 md/dL, and 2/6/25 @ 5:13 PM 274 mg/dL. Blood glucose levels were not checked prior to 2/5/25. Record review of Resident #1's Baseline Care Plan, dated 01/30/2025, revealed resident was a Type II Diabetic and was receiving insulin. Record review of Resident #1's admission MDS, dated [DATE], revealed the MDS was pending completion and submission. Record review of Resident #1's February 2025 MAR revealed the facility did not transcribe an order for 17u Insulin Glargine until 02/06/2025. In an interview with LVN G on 2/5/25 at 4:30: PM, LVN G stated she was notified by Resident #1's family member that Resident #1 received daily insulin. LVN G stated she confirmed the hospital discharge medication listing and that the admitting nurse had failed to transcribe the order for 17units Insulin Glargine daily. An interview and observation of Resident #1 on 2/6/25 at 3:24 PM revealed Resident #1 sitting up at edge of bed with bedside table in place going thru her mail. The resident was wearing personal clothing items, presented clean, well-groomed, odor free, and wearing prescription glasses in place, that were clean and serviceable. The resident was hard of hearing, but was amiable and accepting of surveyor interaction. Resident #1 stated she told her family member yesterday [02/05/205] that she had not received her insulin like she did at home but did not mention it to facility staff. Resident #1 stated she notified her family member. Resident #1 stated she administers her own insulin at home. Resident #1 verbalized she felt fine today and was pleased that correct orders were now in place. Resident #1 stated she had lived with diabetes for years, did not feel any different. In an interview with DON on 02/06/25 at 4:45 PM, the DON stated she was informed by LVN G of the missed order for daily insulin Glargine on Resident #1's admission [DATE]. The DON confirmed LVN G notified the resident's physician on 2/025/2025 at 4:30 PM and obtained orders for 17units Insulin glargine daily. The DON confirmed the resident had not received insulin for 6 days from 01/31//25-02/5/25, putting her at risk for hyperglycemia (elevated blood sugar levels) with both short-term and long-term effects. The DON stated she expected all nursing staff to confirm discharge instructions and transcribe them to the EMR to ensure administration of medications. In an interview with Administrator on 02/06/25 at 5:00 PM, the Administrator stated the facility failed to provide necessary medication to Resident #1 per physicians' order. The Administrator stated she expected nursing staff to follow physicians' orders. In an interview with MD #1 on 2/6/255 at 5:45 PM, MD #1 (current physician as of 2/6/25) revealed that when he was notified of Resident #1's BS 446, he advised them to give 4u fast acting and re-check the resident's BS. MD #1 stated he did not like aggressive s/s for geriatric patients and would figure out where she was normally and adjust as needed. MD #1 stated he did not feel more adverse effects as the resident's levels were similar to the hospital levels. MD #1 stated his expectations were, of course are that they follow his orders and is is pleased with the fast action they took with termination of the nurse he spoke to personally regarding the 4u of Lantus administration. In an interview with MD #2 on 2/6/25 at 5:55 PM, MD #2 (admitting physician) stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue hospital orders and he evaluated the resident in person on 1/31/25. MD #2 stated he was not concerned when they told him about the missed Lantus dose of 17u because it is long acting and stays 36-40 hours, so not that damaging. MD #2 stated he had protocols in place for Glucagon and that a s/s for Lantus were not recommended anyway. Record review of the facility policy named, Reconciliation of medications on Admission, revised July 2017, revealed, admitting nurse should reconcile the discharge medications to include dose, route and frequency for all medications, notify physician to verify admitting orders and transcribe them accordingly to the EMR. Record review of the facility policy named, Administering Medications, revised April 2019, revealed, medications are administered in accordance with prescriber orders. This was determined to be an Immediate Jeopardy (IJ) on 2/7/25 at 5:01 PM. The Administrator and the DON were notified and provided the IJ Template on 2/7/25, and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 2/8/2025 at 5:29 PM. [facility Name] Tag Cited: F760 Alleged Issues: The facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer Insulin Glargine medication according to hospital discharge instructions and fast acting insulin as ordered by the physician. Plan of Removal 1. Immediate Actions The Medical Director was notified by the Administrator on 2/07/2025 of the Immediate Jeopardy. The DON completed a chart audit on all residents receiving insulin on 2/07/2025. An insulin tracker was implemented for an audit to be completed daily to assure insulin is administered correctly and in a timely manner. Audit completed by DON on 2/07/2025. Insulin Tracker will be monitored by DON or ADON daily in clinical meeting with IDT Team Monday thru Friday. On Saturday and Sunday Insulin tracker will be monitored by the DON or designee. The DON completed an insulin audit on 2/07/2025 to confirm insulin orders were in place and transcribed correctly. 2. Education An in-service was conducted with DON and ADONs by the VP of Clinical on 2/07/2025 in regard to the insulin order audit and educating staff on administration competency and glucometer use check off. One on one education to clinical staff regarding physician's orders for insulin administration are to be followed accurately and on time. Blood glucose monitoring orders are to be followed accurately an on time. Date will be documents in the residents' chart at time of administration. Completed by DON and ADON's on 2/07/2025. DON will educate nursing staff before their next shift and new hire nurses before they begin working. IDT Team members were educated on the importance of timely insulin administration. DON or designee will verify daily insulin tracker in clinical meeting (Monday through Friday, DON or designee Saturday and Sunday) on new admissions an insulin dependent residents by reviewing the MAR daily. Staff that were not physically present in the facility were contacted via phone and education reviewed with them by the DON and ADON's on 2/07/2025. DON and ADONs will have nursing staff educated before their next shift. 3. Monitoring The order listing will be reviewed daily in the morning clinical meeting by the IDT Team Monday through Friday. Saturday and Sunday, the order listing will be reviewed by the DON or designee and tracked on the insulin log. Interventions will be implemented with the insulin tracker log Monday through Friday in the clinical meeting with the IDT Members and monitored by the DON or designee on Saturday and Sunday. Insulin tracker will be monitored by the DON and Administrator for completion. The insulin monitoring tracker will be presented at the monthly QAPI meeting for a minimum of three months. Insulin / glucose administration competencies was observed and conducted by the DON and ADONs on 2/08/2025. Insulin / glucose competencies will be completed for new hire nurses during on boarding with DON or designee. 4. QAPI Committee An Ad Hoc QAPI committee meeting was completed 2/07/2025. The Plan of Removal was accepted on 02/08/2025, and the verification of the POR included the following: 1. Interview with Medical Director on 2/07/2025 at 4:45 PM verified he was notified of IJ. Record review of facility created tracker audit of all residents receiving insulin on 2/08/2025. Reviewed process of on-going monitoring with DON. Review for 12 of 12 residents with insulin orders to verify orders are in EMR system was completed on 2/0/2025 with no errors. Verification of administration of 3 of 3 residents insulin per MAR and observation of 1 of 1 residents (Resident #3) insulin administration was completed on 2/08/2025 with no errors. 2. Interview on 2/08/2025 with 11 of 27 FT/PRN Nursing Staff and 4 of 4 Agency staff on duty 2/08/2025 to confirm that they received in-service on administration of insulin. Observation completed on 2/08/2025 at 12:00 PM for 1 of 1 residents (Resident #3) insulin administration for accuracy of order and medication available. Verified with each nurse interview that they understood how to input orders into the EMR system, understood the process for following insulin orders and recording data accurately and timely. [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. Interviews on 2/08/2025 between hours of 7:30 AM - 7:00 PM with 17 of 27 FT/PRN Nurses: LVN H stated understands how to input insulin orders in EMR and complete change of condition assessments. RN I stated understand insulin parameters, how to input into EMR and notify MD for change of condition. LVN J stated understands how to input insulin parameters in EMR and how to complete change of condition assessments. LVN C stated understands how to complete orders for insulin with accurate parameters and need to notify physician of change of condition. LVN K stated understands change of condition assessments, need to notify MD and how to data input insulin parameters in EMR. LVN L stated understands how to complete insulin orders and change of condition assessment. LVN M stated understands how to put insulin orders in EMR per physicians orders and to notify MD of change of condition. LVN N stated understands how to input insulin orders in EMR and how to complete change of condition assessments. LVN AE stated understands how to recognize and report change of condition assessments and need to notify MD and understands how to input insulin orders and parameters in EMR. LVN O stated understands how to input insulin orders in EMR and understands what assessments / notifications are needed for change of conditions. LVN Q stated receives inservices on insulin orders and change of conditions. LVN S stated understands training on insulin orders administration and data input and change of condition notifications. LVN T stated understands need to notify MD for change of condition and understands how to input insulin orders in EMR, LVN U stated received inservices on insulin orders and identifying / reporting change of condition. LVN V stated understands how to complete insulin administration orders and input parameters in EMR and understands how to complete change of condition assessments. LVN X stated received inservices on insulin orders administration and date input in EMR and inservice on completing and recognizing change of condition 4 of 4 Agency Nurses on duty 2/08/2025 (LVN Z, LVN Y, LVN AI, LVN B) verified they received in-services and training from DON or ADON (RN DON AG, LVN ADON G, LVN ADON R, Admin LVN P) on competency for insulin administration, how to enter insulin parameters in EMR, insulin documentation and change of condition notifications. Reviewed / copied facility created insulin tracker that will be reviewed in clinical meeting. [6 Ft 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. All nurses interviewed were able to verbalize how to transcribe and date input insulin orders including blood sugar monitoring parameters in the EMR. All nurses interviewed verbalized understanding of need to notify physician of change of condition related to blood sugar levels. Verification of administration of 3 of 3 residents insulin per MAR on 2/8/25 at 11:30 AM [Resident #1, Resident #3, Resident #4] and observation of 1 of 1 residents (Resident #3) insulin administration was completed on 2/08/2025 at 11:45 AM with no errors. 3. Record review on 2/08/2025 of facility initiated tracker that will be reviewed in clinical meetings. Confirmed monitoring process by Administrator and DON. Completed record review on 2/08/2025 of facility tracking form. Observation on 2/08/2025 at 11:45 AM of insulin administration for 1 of 1 residents (Resident #3) completed with no errors. Confirmed with 11 of 21 FT/PRN Nurses that they received competency training for insulin administration and order implementation. 1 PRN nurse LVN Q had not received competency training and has not worked since November 2025. LVN Q is aware that he will need to complete competency training prior to start of next scheduled shift (no shift identified at this time). [6 FT 6a-6p, 5 FT 6p-6a, 12 PRN with varying shifts, 3 Administrative Nurses to include DON/ADON/ADON]. 4. Administrator verified QAPI meeting was completed with PIP in place in conjunction with this Plan of Removal. The Administrator was informed the Immediate Jeopardy was removed on 2/08/2025 at 7:37 PM. 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 jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 had adequate interventions and supervision in place to prevent accidents for Resident #1. Resident #1 had seven falls in 1 month (11/19/24, 11/25/24, 11/27/24 x2, 12/11/24 x2, and 12/13/24), the last of which resulted in injuries and hospitalization. An IJ was identified on 12/19/24. The IJ template was provided to the facility on [DATE] at 7:15 pm. While the IJ was removed on 12/21/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to monitor the implementation of the plan of removal. These failures placed the resident at risk for accidents and serious injuries. Findings included: Record review of Resident #1's admission Record, dated 11/14/24, revealed Resident #1 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: malignant melanoma of skin (skin cancer), osteoporosis (weak/brittle bones), muscle weakness, gait/mobility abnormality, lack of coordination, cognitive communication deficit (difficulty with thinking and language), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), memory deficit, frontal lobe and executive function deficit (damage to the frontal lobe of the brain causing impairment in executive function), hypertension (high blood pressure), cerebral infarction (stroke - disrupted blood flow to the brain), and syncope (fainting/passing out) and collapse. Record review of Resident #1's Comprehensive MDS assessment, dated 11/18/24, revealed Resident #1 had a BIMS score of 11, suggesting moderate cognitive impairment. Further review revealed Resident #1 had an impairment to a lower extremity, required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds. Or supports trunk or limbs) toileting hygiene, sit to stand, chair/bed-to-chair transfer, and toilet transfer; and was dependent (Helper does all the effort) to walk ten feet and picking up objects; required supervision/touch assistance to wheel 50 feet with two turns. Record review of Resident #1's Baseline Care Plan, dated 11/18/24, revealed Resident #1 had a history of falls. Record review of Resident #1's Order Summary, dated 12/15/24, revealed: Duloxetine 60 Mg once a day (used to treat Depression), Losartan Potassium 100 Mg once a day (used to treat high blood pressure), Metoprolol 100 Mg once a day (used to treat high blood pressure), and Tramadol 50 Mg as PRN (used to treat pain). Record review of Resident #1's Care Plan, dated 12/15/24, revealed: [Resident #1] has had an actual fall with no injury r/t Poor Balance and Unsteady gait 11/27/24 11/28/24, initiated on 11/28/24 and revised on 12/6/24. Interventions/Tasks for the focus included: Call don't fall signs in room initiated 12/6/24, Continue interventions on the at-risk plan, initiated 11/28/24, fall mat at bedside, initiated 12/6/24, Fall mat beside residents [sic] bed to help prevent injury due to falls out of bed, initiated 11/28/24, and PT consult for strength and mobility, initiated 11/28/24. Record review of the facility's incident log, dated 12/15/24, revealed Resident #1 had falls on 11/19/24, 11/25/24, two falls on 11/27/24, 12/11/24, and 12/13/24. Record review of Resident #1's Fall Risk Evaluation, dated 11/14/24, revealed a score of 2. Further review of the evaluation revealed it was incomplete. Further review of the evaluations revealed .If the total score is ten or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . Record review of Resident #1's Fall Risk Evaluation, dated 11/14/24 and completed on 12/15/24, revealed a score of 19. Fall Risk Evaluation, dated 11/19/24, revealed a score of 13; 11/25/24, revealed a score of 20; 11/28/24, revealed a score of 22; 12/11/24, revealed a score of 20; and 12/13/24, revealed a score of 17. Further review of the evaluations revealed .If the total score is ten or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . Record review of Resident #1's Therapy Screen, dated 11/25/24, revealed: fall screen; patient educated on calling nursing staff for assistance with obtaining clothing as pt reports she fell out of her chair trying to get clothes. She reports she slid out of her char [sic]. Per nursing pt found sitting on floor in front of her closet and in front of w/c .will continue to educate and monitor for any falls. Record review of Resident #1's Therapy Screen, dated 11/29/24, revealed: Fall screen .reported to have multiple falls recently. Pt educated on transfer training from w/c-toilet-w/c and w/c-bed-w/c with use of .grab bar. Pt given constant reminders to always call for assistance with all transfers. Record review of Resident #1's Therapy Screen, dated 12/11/24, revealed: Fall screen-Pt had 2 falls today, one in the morning when attempting to pick up a small piece of paper from the floor and Pt fell later in day when attempting to gather items from bedside with falling out of w/c. Nursing, therapy, and aides in room educating and reminding pt to use call light prior to standing or reaching for items. Pt is very unsafe and does not recall safety techniques .We will continue to educate pt on safety and precautions. Record review of Resident #1's Therapy Screen, dated 11/21/24, revealed: Patient sustained a fall from attempting to stand up from WC using the end of the bed rail for assistance and walk into the bathroom, patient ending up falling to the floor landing on her buttocks .educated on importance of asking for assistance and using call light. Record review of Resident #1's Progress Notes revealed: 11/19/24 - No progress notes regarding Resident #1's fall. 11/25/24 at 2:18 pm - This nurse called to room by CNA after resident was found on the floor. Upon entering room resident found in sitting position with legs out in front of her, non-skid socks in place. Resident in front of closet. Wheelchair with seat cushion upright, brakesunlocked [sic], positioned behind resident .Author: [LVN E] . 11/27/24 at 7:00 pm - Resident had unwitnessed fall in the bathroom. Resident stated she was trying to get up to wipe after using the bathroom. Resident stated that her surgical shoe, is what made her fall. Resident was found in the shower on her left side/back .Educated resident on using call light system for help and to not get up on her own .Author: [LVN D] . 11/27/24 at 11:35 pm - .SBAR .RESIDENT NOTED LYING ON RT SIDE ON FLOOR, NEXT TO BED, STATED I WAS TRYING TO ANSWER MY PHONE IT WAS RINGING, RESIDENT ASSESSED, VS TAKEN, NEURO CHECKS INITIATED PER FACILITY PROTOCOL, SKIN ASSESSMENT HEAD TO TOE DONE .FALL PRECAUTIONS INITIATED FLOOR MATTS [sic] IN PLACE, WILL CONTINUE TO MONITOR . 12/11/24 at 5:11 am - RESIDENT CONTINUES MONITORING UNWITNESSED FALL DAY 1/3 /C NEURO CHECKS, NO S/S ACUTE DISTRESS, NO C/O PAIN OR DISCOMFORT VOICED .WILL CONTINUE TO MONITOR. Author: [LVN F] . 12/13/24 at 1:53 pm - S/P Fall day 3/3 Resident continues to try and self-transfer. Resident needs constant monitoring and reorientation. Resident utilizes call light but does not wait for assistance. Resident educated on importance of waiting for staff assistance with transfers. Neuros assessed per protocol. Author: [LVN E] . 12/13/24 at 6:20 pm - .head to Toe assessment performed. resident unconscious, and resident breathing. Unable to arouse resident and assess pain. Awaiting EMS arrival. Author: [LVN D] . 12/13/24 at 6:25 pm - Awaiting EMS arrival. This nurse by residents [sic] side, reassuring resident that staff is with her. Resident still unconscious. Resident is still breathing. Author: [LVN D] . 12/13/24 at 6:33 pm - .at approximately [6:15 pm] [MA A] the medication aide alerted this nurse that our resident [Resident #1] was on the floor from an unwitnessed fall. resident was found on the floor face down, left arm underneath her body. Resident was unconscious. Blood evident on the [sic] floor. Residents nose was bleeding, Unsure from the way resident was laying if head laceration occured [sic]. Resident unable to respond to questions. Vitals 98.6 T, 159/95 BP, 80 Heart rate. EMS immediately called. resident finally able to respond to pain. Resident unable to tell us what hurt. EMS arrived on scene and assessed resident. Resident put in C-collar by Ems and taken out to hospital. ADON [LVN L] notified once resident was taken by EMS. MD notified as well. Residents' [sic] roommate said resident got upeven [sic] though she told her to call but resident did not listen to her. Roommate was the one who initiated and called for help. Author: [LVN D] . Record review of the facility's incident reports revealed: 11/19/24 at 10:51 pm - .Per CNA [CNA O], resident had witnessed fall. CNA [CNA O] stated that the resident was in her wheelchair and tried holding onto the edge of the bed to stand up to go to the bathroom. Upon trying to stand, [CNA O] stated she witness [sic] the resident slide down onto the ground from wheelchair. Per [CNA O] CNA, and resident, resident did not hit her head and landed strictly on bottom. No skin tears or bruising or pain present . 11/25/24 at 1:28 pm - .This nurse called to room by CNA after resident was found on the floor. Upon entering room resident found in sitting position with legs out in front of her, non-skid socks in place. Resident in front of closet. Wheelchair with seat cushion upright, brakes unlocked, positioned behind resident. Resident alert and oriented x3, respirations even and unlabored, denies pain. I was sitting on the edge of my wheelchair trying to reach in the closet when I jut plopped down straight on my but [sic] . 11/27/24 at 11:15 pm - .Resident was found lying on the bathroom floor in shower. Resident stated she tried to stand up and wipe herself. Resident stated that her surgical shoe is what caused her to fall. Resident was found lying on her left side/back. Resident denied pain at initial assessment. Neurological asssessment [sic], and pain assessment completed at this time .Resident stated she did not hit her head . 11/27/24 at 11:35 pm - .RESIDENT NOTED LYING ON RT SIDE ON FLOOR, NEXT TO BED, STATED I WAS TRYING TO ANSWER MY PHONE IT WAS RINGING, RESIDENT ASSESSED, VS TAKEN, NEURO CHECKS INITIATED PER FACILITY PROTOCOL, SKIN ASSESSMENT HEAD TO TOE DONE, HEAD NORMOCEPHALIC, NO S/S ACUTE DISTRESS, RESIDENT ABLE TO MOVE ALL EXTREMITITES, NO C/O PAIN OR DISCOMFORT, NON-SKID SOCKS ON AT TIME OF INCIDENT, RESIDENT NONCOMPLIANT CONTINUES TO ATTEMPT TRANSFERS WITHOUT ASSITANCE, POOR SAFETY AWARENESS, BED AT LOWEST POSITION. CALL LIGHT WITHIN REACH, REITERATED IMPORTANCE OF USING CALL LIGHT FOR ASSISTANCE, RESIDENT ACKNOWLEGES UNDERSTANDING STATING I KNOW ,I KNOW I SHOULD CALL, YOU ALL WILL BE HAPPY WHEN I LEAVE THIS PLACE, BLAME MY FALL TO THE PERSON CALLING MY PHONE AT THIS TIME . 12/11/24 at 4:35 am - .RESIDENT UNWITNESSED FALL , NOTED SITTING ON BUTTOCKS IN FRONT OF RECLINER, RESIDENT ASSESSED, HEAD TO TOE DONE, NO VISIBLE INJURIES NOTED, VS TAKEN, NEURO CHECKS INITITATED PER FACILITY PROTOCOL, NON-SKID SOCKS ON AT TIME OF INICIDENT, RESIDENT STATED I WAS TRYING TO PICK UP MY REMOTE TO WATCH TV, IT FELL RESIDENT REITERATED THE IMPORTANCE OF USING CALL LIGHT FOR ASSISTANCE, STATED YES , I KNOW, I DID NOT FALL I JUST SLID OFF MY CHAIR, NO NOTHING HURTS AND NO I DID NOT HIT MY HEAD, IM SORRY RESIDENT ASSISTED ONTO W/C AND IS NOW IN COMMON AREA WATCHING TV, WILL CONTINUE TO MONITOR, MD, AND ADON NOTIFIED, RESIDENT SELF RP. RESIDENT STATED I WAS TRYING TO PICK UP MY REMOTE TO WATCH TV, IT FELLSTATED YES, I KNOW, YOU DONT HAVE TO TELL ANYONE I JUST SLID OF MY CHAIR, NO NOTHING HURTS AND NO I DID NOT HIT MY HEAD, IM SORRY . 12/11/24 at 2:55 pm - .CNA came to grab this nurse to let her know resident had un-witnessed fall. Resident observed on her left hip in front of wheelchair. Resident stated no pain, and that she knows she is supposed to call for help transferring but just didn't call. Neuro assessment done and resident at neurological baseline. Resident able to move bilateral upper and lower extremities. Reeducated resident on call light use . 12/13/24 at 6:15 pm - .At approximately 18:15 [6:15 pm] the medication aide alerted this nurse that our resident [Resident #1] was observed on the floor from an unwitnessed fall by the CNA on the hall, however fall witnessed by resident's roommate. Resident was observed with her face down on the floor, and left arm underneath her body. Resident was unconscious, respiration noted, but unable to respond or answer any of my questions that were asked. Blood was evident on the floor underneath resident's face, nose noted to be bleeding at this time. Unable to move resident due to a possible neck or back Injury. Unsure from the way resident was laying if head laceration occurred. EMS immediately notified. This nurse continued to reassure resident that there was staff with her. this nurse stayed with resident until EMS arrived on scene. EMS then arrived on scene, where they also performed a head to toe assessment, at this time resident still unconscious. EMS then put resident into a C-Collar and resident began to respond and answer questions from EMS regarding her pain level and stated she hurt all over her body EMS immediately transported her out. ADON notified at 18:25 [6:25 pm] once resident was safe with EMS. [MD] notified at 18:40 [6:40 pm]. Resident Unable to give Description . Record review of Resident #1's Hospital B documentation, dated 12/17/24, revealed Dementia and diagnostic report on a CT scan of Resident #1's brain/head without contrast. The report, dated 12/13/24, revealed IMPRESSION: .subarachnoid hemorrhage .Left frontal scalp hematoma . During a telephone interview on 12/15/24 at 2:45 pm, LVN D said Resident #1 had fallen on 12/13/24 and was found on the floor in her room face down with her left arm under her body, there was blood on the floor, and blood was coming from her nose. LVN D said she was unsure if Resident #1 had a head laceration and was not moved because they were unsure if she had a neck injury. LVN D said Resident #1 was breathing but snoring and her vitals were normal. EMS was called, LVN D said Resident #1 did not wake up at all. LVN D said Resident #1 did not respond to questions from EMS but did open her eyes when EMS turned her over. LVN D further stated Resident #1 said she hurt all over. LVN D said the fall was unwitnessed by staff but Resident #1's roommate said Resident #1 was getting up out of her wheelchair and her roommate told her not to get up and to use the call light. LVN D said Resident #1 did not like to use her call light. LVN D further stated Resident #1 had been educated about using the call light. LVN D said Resident #1 would apologize for not using the call light to ask for assistance. LVN D said Resident #1 had sustained other falls with no injuries. LVN D said there were signs in each resident's room, reminding them to use the call light, especially if they have fallen, but could not recall if Resident #1 had or not. LVN D said she did not remember if the fall mat was next to Resident #1's bed. During a telephone interview on 12/15/25 at 2:53 pm, CMA A said on 12/23/24 she was preparing medications when she heard someone yelling for help. CMA A saw Resident #1 on the floor, checked to see if she was okay, and told the nurse. CMA A further stated Resident #1 was fast asleep that hit knocked her out, staff called EMS. CMA A said she had walked by earlier and Resident #1 was sitting in her wheelchair by her bed, facing the door. CMA A said Resident #1 was able to use the call light and was coherent to use it. CMA A said she had caught Resident #1 transferring from the bed to the chair and told her to use the light when she wanted to transfer. CMA A further stated she would remind Resident #1 to use the call light when she saw her. During a telephone interview on 12/15/24 at 3:05 pm, CNA B said on 12/13/24 Resident #1 fell within 20 minutes after the start of her shift. CNA B said she and the CNA from the previous shift just completed a hall walk to ensure her residents were safe. CNA B said she was assisting another resident across the hall in the restroom when she heard someone start to yell so she asked CMA A to see what was going. CNA B said she was told by CMA A that Resident #1 was on the floor. CNA B said Resident #1 had knocked herself out and she was snoring. CNA B said Resident #1 had to be in a state of unconsciousness when she landed because the position she was in was not natural. CNA B said during her round Resident #1 was sitting in her wheelchair. CNA B said this was only the second shift she worked on the skilled hall but had heard Resident #1 was a huge fall risk. CNA B said she saw Resident #1 trying to get up a few times on the shift prior and staff went in to redirect her, made sure the call light was in reach, and asked her to use it. CNA B said Resident #1 tried to get out of bed or her wheelchair without assistance. CNA B further stated she was not sure if Resident #1 had dementia, but staff had to reiterate. Interview on 12/15/24 at 2:15 pm, Resident #1's roommate said she was sitting in the room when she saw Resident #1 standing on12/13/24 but was unsure why she got up. Resident #1's roommate said she did not actually see her fall because it was dark. The state investigator did not observe a Call don't fall or fall mat in Resident #1's room. During an interview and observation on 12/16/24 at 4:45 pm, LVN D said Resident #1 was unsteady and had a surgical shoe that made her more unsteady. LVN D further stated Resident #1 could bare weight with assistance and was not able to walk on her own. LVN D said the fall mat in Resident #1's room might have contributed to the fall on 12/13/24 because of the surgical shoe. LVN D said Resident #1 was not on a toileting schedule and was able to tell staff when she needed to use the restroom. LVN D said she did not know how often Resident #1 was checked on the other shifts but on her shift the aides went up and down the hall about every thirty minutes and so did she. Resident #1's room was observed to be in the middle of the hallway with a table and two empty chairs outside the door. During an interview on 12/16/24 at 5:02 pm, CNA C said Resident #1 was asked her every 2 hours if she needed to use the restroom or she would let the staff know when she needed to use the restroom. CNA C said she tried to get to know her residents as much as possible or would find out from the therapy department the level of care residents required. CNA C said she did not know how to access the Kardex (document used to view the residents' level of need/care) and did think CNAs could have access to them. CNA C said Resident #1 was able to use the call light to call for assistance. CNA C further stated Resident #1 had started getting up more without help but was not sure when this started. CNA C said Resident #1 did not have a fall mat. CNA C said the staff told Resident #1 not to get up alone and Resident #1 would say yeah I know but she still got up without calling for help. CNA C said she had seen Resident #1 trying to stand at times and went in her room to assist her. CNA C said Resident #1 did not have special supervision and did not know how often the nurses went into her room. CNA C said she did not know what the facility's At risk plan or Fall protocol were. CNA C said if a resident fell staff were required to notify the nurse immediately and the nurses followed up with interventions. During an interview on 12/18/24 at 12:27 pm, LVN E said she did not think Resident #1 fell on [DATE] but remembered LVN F said Resident #1 had fallen on her shift. LVN E said Resident #1 did fall on 11/25/24 while looking for clothes in her closet. LVN E said she told Resident #1 not to get up and to use her call light. LVN E further stated she did not think Resident #1 had new interventions after 11/28/24. LVN E said Resident #1 never had a fall mat in her room and thought the fall mat would have put Resident #1 at a higher risk for falls. She stated she was never really in bed during the day, she was usually in the wheelchair or recliner, and she would self-transfer so she thought the mat would have tripped her. LVN E said the facility's fall protocol was to initiate neuro checks and make sure the residents' call light was within reach. LVN E said she did not think Resident #1 refused to use the call light but just forgot. LVN E further stated Resident #1 was forgetful and was confused at times, adding she thought Resident #1 had dementia. LVN E said she did not review resident care plans, did not know where to find them, and had not heard of any expectations regarding reviewing care plans. LVN E said she learned about the residents' level of care through the hospital paperwork, what the CNAs saw, shift report, and if the residents needed a higher level of care, therapy would usually let the staff know. LVN E said Resident #1's room was in the middle of the hallway where the CNAs sat to complete their documentation. LVN E further stated the CNAs sat at the table outside Resident #1's room from time to time. During an interview on 12/18/24 at 1:42 pm, the PTA said Resident #1 had had multiple falls during self-attempted transfers since her admission despite repeated education reminding her not to self-transfer. The PTA said she educated Resident #1 every day and she demonstrated no carry over between sessions, there was poor cognitive insight to her own deficits. The PTA said Resident #1's poor cognition was communicated to the nursing staff and documented in the daily notes that Resident #1 was a very high fall risk. The PTA said Resident #1 did not have a floor mat because she was not falling off the bed but fell during self-transfers, during functional tasks. The PTA said a fall mat would have probably put Resident #1 at a higher risk for falls and if staff had added a fall mat to Resident #1's care plan it was not communicated to her. The PTA said Resident #1's cognitive status was very poor since her admission, she had significant safety awareness deficits, and needed constant reminders. During an interview on 12/18/24 at 1:55 pm COTA K said Resident #1 was working on cognitive things during therapy, she was very forgetful, easily distracted, her problem solving and sequencing were bad. COTA K said she focused on the call light with Resident #1, because she had a lot of falls and just was not safe. COTA K said she thought Resident #1's cognition had gotten worse. COTA K said their main goal was to keep Resident #1 safe because her balance was poor. COTA K said Resident #1's condition had been communicated to the nursing staff. COTA K said the staff reminded Resident #1 to use the call light but it was about her remembering to use it. COTA K said Resident #1 did not have increased supervision other than her room door was kept open. COTA K said she had to repeat instructions to Resident #1 during therapy sessions because she forgot the task they were working on during the same session. During a telephone interview on 12/18/24 at 2:14 pm, Resident #1's family member said Resident #1's medical/surgical history had taken a toll on her cognitively. Resident #1's family member said Resident #1 had been feeling dizzy. Resident #1's family member further stated Resident #1's cognitive decline had been more than normal in the last couple of months and she got confused. Resident #1's family member said she did not know if Resident #1 remembered to use the call light and wait for assistance. During an interview on 12/18/24 at 2:31 pm, LVN L said she did not know if Resident #1 was falling due to lack of memory, but she kept trying to get up and would fall, and she had a surgical shoe and she would try to walk with that shoe. LVN L further stated Resident #1 was forgetful. LVN L said she did not think Resident #1 was not purposefully non-complaint. LVN L said Resident #1 had call don't fall sign, a fall mat, and verbal redirection on her care plan. LVN L said she could not say how long Resident #1 retained information regarding using the call light. LVN L said Resident #1's room was located by the CNAs table and there was a CNA at the table a lot of times. LVN L said Resident #1 was off balance because of the surgical shoe and did not start falling until after she got the surgical shoe. LVN L said she did not know why Resident #1 had not been moved closer to the nurses' station yet but thought it was because her room was close to the CNAs documentation station and there was always someone sitting there. LVN L said the MDS nurse was responsible for updating care plans and the care plans were reviewed during the morning meetings. LVN L further stated since she was assigned to the skilled hall, she also met with the therapy department on Tuesdays and Thursdays to review the residents' needs and goals. LVN L said nurses were expected to review resident care plans but did not know when or how often they were required to review them. LVN L said her expectation as a ADON was for nurses to review care plans if they notice a change in condition. Attempted interview on 12/19/24 at 9:45 am with the Physician was unsuccessful. During an interview on 12/19/24 at 10:54 am, LVN H said the facility's at-risk plan meant residents were at risk for falls and standard interventions were added to the care plans. LVN H further stated interventions included: monitoring the residents for falls and if they had an actual fall it was added to the care plan along with interventions. LVN H said according to therapy Resident #1 was impulsive and tried to be independent. LVN H further stated therapy worked on reminding Resident #1 to use the call light, adding Resident #1 did well for a while, but then returned to not using it. LVN H said a sign was put in Resident #1's room because visual reminders were more effective. LVN H said reminders to use the call light was added to Resident #1's care plan but no other interventions had been added. LVN H said moving Resident #1 closer to the nurses' station had not been discussed prior to the 12/13/24 fall. LVN H said she did not know if Resident #1's surgical boot had been discussed because she did not always work at the facility. LVN H said other interventions should have been put in place for Resident #1 if she continued to fall. LVN H further stated each fall should have been reviewed but she was not in the facility during some the days Resident #1 sustained falls. LVN H said incidents and related documentation were reviewed during the morning meetings as well as what the residents were doing prior to the incident. LVN H said interventions were then put in place depending on the action that caused the incident. LVN H said she did not know why this was not done after each of Resident #1's falls. LVN H said the facility policy regarding care plans was that they be reviewed quarterly and annually and updated if necessary. LVN H said as the MDS coordinator, she was responsible for ensuring care plans were updated. LVN H said she was not aware that the interventions on Resident #1's care plan had not been implemented and management was responsible for ensuring interventions were implemented. LVN H further stated she could not say whether additional interventions would have prevented additional falls for Resident #1. During an interview and observation on 12/19/24 at 3:20 pm, Resident #1 was sitting in the chair in her hospital room, green/purple discoloration was noted to the left temple, area around her left eye, and left hand. Resident#1 said she had gotten in an accident but did not remember how. Resident #1 said she fell at home on [DATE] on the floor, hit her head and put a hole in the paneling in the kitchen. Resident #1 said she was trying to cook. Resident #1 said she fell like four times while at the facility. Resident #1 said she understood that not calling for help was a safety issue and she needed to pay attention to that. Resident #1 said she had been feeling light-headed a lot lately and thought she had mentioned this to the doctor. Resident #1 said she mentioned feeling dizzy to the facility staff and was told to sit down if she felt like she was falling. Resident #1 said she did not remember what she was doing or where she was going when she fell on [DATE]. Resident #1 further stated she told them I would get there when I get there. Resident #1 said she was sure the surgical shoe caused her to fall because it slipped, and she told them that it was slipping and making her fall. Resident #1 said she ended up falling and was unable to get up. Resident #1 said at times when she put her feet down, she got confused about them moving or not. Resident #1 further stated she did not know how she got to the hospital. During an interview on 12/19/24 at 3:50 pm, the Hospital B LVN said Resident #1's memory was good in the morning but started getting confused around 2 pm. The Hospital B LVN said Resident #1 had a hemorrhage which was now stable and a rib fracture. The Hospital B LVN said Resident #1 had not fallen at the hospital, she was checked every hour, and asked if she needed anything during that time. Interview attempts with LVN F on 12/19/24 at 5:30 pm and 12/21/24 at 6:28 pm were unsuccessful. During an interview on 12/21/24 at 5:43 pm, CMA A said she did not remember seeing a call don't fall sign on Resident #1's wall or a fall mat. CMA A further stated she never saw anything in front of Resident #1's bed, never. CMA A said she had overheard Resident #1 had several falls. CMA A further stated Resident #1's interventions had not been communicated to her. CMA A said before Resident #1 fell on [DATE] she had not heard about a Kardex (document used to view the residents' level of need/care) or how to access it. CMA A further stated that Resident #1 did not have any additional interventions in place prior to 12/13/24. CMA A said Resident #1 always had her call light and was reminded to use it, but she did not use it. CMA A said she thought Resident #1 forgot to use the call light sometimes. During a telephone interview on 12/21/24 at 5:56 pm, LVN D said she did not remember if Resident #1 had a fall on 11/19/24 during her shift. LVN D said if Resident #1 had fallen on her shift, she [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 (Resident #1) of 5 residents reviewed for a change of condition. The facility failed to notify the physician and follow up on a change in condition for Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on 12/31/23. Resident #1 expired at the hospital on 1/1/24. An IJ was identified on 1/6/24. The IJ template was provided to the Administrator on 1/6/24 at 7:35 pm. While the IJ was removed on 1/10/24, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #1's face sheet, dated 1/5/24, revealed Resident #1 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1's diagnoses included: atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cognitive communication deficit, muscle weakness, hyperlipidemia (high cholesterol), hypertension (high blood pressure), atherosclerotic heart disease (damage in the heart's major blood vessels), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's MDS assessment, dated 10/7/23, revealed Resident #1 had a BIMS score of 3 (suggesting severe impairment) and active diagnoses of debility, cardiorespiratory conditions. Record review of Resident #1's orders included: Aspirin EC Tablet Delayed Release 81 MG; Give 1 tablet by mouth one time a day for Heart health, Clopidogrel Bisulfate Oral Tablet 75 MG; Give 1 tablet by mouth one time a day for CHF, Lisinopril Oral Tablet 10 MG; Give 1 tablet by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW 100/60 or 60, Maalox Max Oral Suspension 400-400-40 MG/5ML; Give 30 ml by mouth every 4 hours as needed for Indigestion; Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 MG; Give 12.5 mg by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW 100/60 OR PULSE BELOW 60. Record review of Resident #1's care plan, dated 10/23/23, revealed Resident #1 was at risk for complications related to atrial fibrillation/flutter with interventions of: Assess, document and report to physician as needed for the s/s of irregular heartrate (fast, slow, pounding), feelings of syncope (loss of consciousness for a short period of time) or collapse. Resident #1 had coronary artery disease (CAD) r/t atrial fibrillation, hyperlipidemia, and hypertension with interventions of: Monitor/document/report PRN any s/s of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating. Resident #1 had anemia with interventions of: Monitor/document/report PRN following s/s of anemia: pallor and syncope. Record review of Resident #1's ER record, dated 1/1/24, revealed Resident #1 was seen by provider at 9:24 am, chief complaint was AMS. According to review of electronic health records, Resident #1 had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels with history of stent x3), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and congestive heart failure (condition in which the heart can't pump blood well enough to meet the body's needs). Resident #1 presented to the emergency department from nursing home by EMS due to shortness of breath and had become unresponsive. Initial vital signs at 9:38 am were T 97 F, P 48, R 4, BP 55/30. Resident #1's general appearance was lethargic (diminished energy, mental capacity, and motivation) with agonal (abnormal pattern) breathing, dazed look, and bradycardia (week pulse). Resident #1 was actively dying, and family confirmed no CPR. Time of death was 9:31 am. Record review of nurse progress note written by LVN B, dated 12/28/23 at 9:16 am, revealed: Note Text: this nurse called to shower room. resident noted to be unresponsive and noted stool on floor. resident placed back in bed legs elevated. 142/80 92%ra 70 stat cbc cmp ordered. res alert at this time. no distress noted. family aware. No further assessment was completed. Record review of a nurse progress note written by LVN A, dated 12/31/23 at 11:17 pm , revealed: Messages: Subject: Abdominal pain [2023-12-31 19:31 :22 CST] [LVN A]: Resident has had complaints of nausea and abdominal pain. No emesis observed. Maalox 30ml administered and [slightly] effective. Resident now primarily has complaint of abdominal pain, tender on palpation. Bowel sounds present. CNAs report loose stools x 2 days with a sour smell. Resident has had very small amount of po fluids and food. Grunting and moaning observed. Baseline orientation is x 1. Last reported VS at [7:00 pm]-95/58, HR 74, T 97.8, RR 18 even and unlabored. Please advise. Participants: [LVN A] Additional notes: Awaiting provider orders. Report given to oncoming nurse for monitoring and follow up. Record review of Resident #1's EMR revealed there was no follow up communication from the NP and there were no progress notes for 12/29/23 and 12/20/23. Record review of Resident #1's vital signs, dated 1/1/24 at 7:18 am, revealed BP 99/54 and P 92. Record review of a nurse progress note written by LVN B, dated 1/1/24 at 7:20 am, revealed: . Skin warm & dry, skin color WNL and turgor is normal . No further assessment was completed. Record review of a nurse progress note written by LVN B, dated 1/1/24 at 9:00 am, revealed: NOTED SOB AND INCREASED CONFUSION. 02 SATS NOT REGISTERING. RESIDENT STATED GET HOSPICE FAST. I FEEL SICK I WANT TO GO TO HOSPITAL. ORDERS TO SEND TO ER FOR EVAL. FAMILY NOTIFIED. Record review of a nurse progress note written by LVN B, dated 1/1/24 at 10:07 am, revealed: RESIDENT EXPIRED IN THE ER. Record review of a nurse progress note, dated 1/2/24 at 8:29 am, written by LVN B: late entry 1/1/2024 vital signs 99/54 92 97.5 22 lung sounds clear in all lobes. upon arrival of ems o2 placed on resident but still unable to get 02 sat reading. report called to [hospital staff] in er. During an interview on 1/5/24 at 1:18 pm, the DON said she requested report from LVN C who worked on 12/31/23 10 pm - 6 am and requested a late entry be completed in Resident #1's record. The DON said she did not ask LVN C if she followed up with the physician regarding Resident #1's complaints of abdominal pain and nausea. During an interview on 1/5/24 at 1:39 pm, LVN B said she only completed a skin assessment on Resident #1 on 1/1/24 at 7:20 am because he was fine. LVN B said she went back later to check on him and tried to obtain an SpO2 but did not get a reading. She added she took a set of vital signs and Resident #1 said he was not feeling well, and the resident was sent to the hospital. LVN B said she was not aware of Resident #1's complaints of abdominal pain and nausea during the prior shift. She added they were required to give report and she did receive report from LVN C; however, LVN C did not mention anything about Resident #1's complaints. During an interview on 1/5/24 at 1:58 pm, LVN A said she had documented the communication with the provider and had given report to LVN C regarding Resident #1's complaint on 12/31/23. She said she was sure she obtained vital signs but did not document it because she was so busy, she added his vital signs were low, but he was also not eating or drinking. LVN A said Resident #1 had not eaten since lunch and his family said he had complained of an upset stomach. She added his abdomen was a bit tender when she touched him on 12/31/23. LVN A said Resident #1 was given chicken noodle soup for lunch and dinner, and he took a couple of bites. During an interview on 1/5/24 at 3:49 pm, RN A said she worked on 12/29/23 overnight shift as a CNA and Resident #1 did not complain of abdominal pain or nausea during her shift. She added, he did have a small amount of loose BM about the size of my palm and this was reported to the nurse. RN A said Resident #1 did not complain of any cramping or other issues, she added that he was usually confused. During an interview on 1/5/24 at 5:02 pm the physician said facility knew that, if a resident was unresponsive, they needed to call 911 so that more definitive care could be provided. The physician said the vital signs documented on 12/28/23 at 9:16 am looked fine, but if the Resident #1 went unresponsive, he expected the facility to have called 911. The physician said he would have expected the facility to monitor Resident #1's status for 72 hours following the incident. During an interview on 1/5/24 at 5:08 pm, the physician said he did not see any communication to him from the facility on 12/31/23 regarding Resident #1's condition and the communication was between LVN A and the NP per the progress notes. The physician said he did not see any response from the NP regarding Resident #1's complaint of abdominal pain and nausea and did not know if the NP responded in a timely manner. The physician added the facility knew he could be contacted if needed but that he did not have any missed calls from the facility. During an interview on 1/6/24 at 4:07 pm LVN C said she worked the night shift on 12/31/23 and was updated on Resident #1's condition and added that LVN A said to keep a close eye on Resident #1 and that LVN A contacted the NP on 12/31/23 and was waiting for a response. LVN C said she did not document on 12/31/23 and was asked to complete a late entry. She said she did communicate Resident #1's complaints of abdominal pain and nausea to the morning shift. LVN C said she did not see a response from the NP regarding Resident #1's complaint and let the morning shift know that it was pending. LVN C said that they normally waited for a response from the NP, she added they waited unless it was an issue that could not wait or the resident's condition worsened. During an interview on 1/6/24 at 6:24 pm, the NP said he had to look at his notes to see if he had been notified of Resident #1's complaints of abdominal pain and nausea. He added Resident #1 was not someone to look out for because he was pretty stable. At 6:31 pm the NP read the progress note dated 12/31/23 at 11:17 pm, he said he did note Resident #1's BP and said this was not the first time the resident had these s/s. The NP said, I guess there was a decline. The NP said he did not recall if he responded to the notification but if he had, he would not be able to prove it. During an interview on 1/6/24 at 7:45 pm, the DON said Resident #1's BP fluctuated a lot. She added that the physician was not notified of Resident #1's hypotensive episodes because he asked to be notified after 3 consecutive days, this was not in writing but was a verbal understanding. Record review of an email, dated 1/4/24 at 11:53 am, from the DON to LVN C read : Phone conversation with [LVN C] charge nurse 12/31-1/1, verbal report via phone [LVN C] stated no change in resident's condition reported on shift, VS taken and stable, resident at baseline with no complaints verbalized or noted with any abdominal pain. Record review of the facility policy, dated February 2021, titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . Record review of the facility clinical protocol, dated March 2018, titled Acute Condition Changes revealed .9. The attending physician, NP, or designee (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical director for additional guidance and consultation if d1ey do not receive a timely or appropriate response. The Administrator and the DON were notified of the Immediate Jeopardy on 1/6/24 at 7:35 pm and were provided with the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 1/8/24 at 8:28 pm and reflected the following: 1. Corrective Action: Administrator immediately ensured changes of condition are reported to DON, physician, NP or designee with documentation of attempts. The administrator immediately ensured that secured conversation via PCC and clinical phone numbers are available to all staff. Reeducated LVN, CNA, and RNs on the need for communication follow up with a change of condition with physician, NP or designee and document attempts. If unable to get contact will D/C resident to ER. Reeducation provided on procedure of reporting a change of condition immediately. Reeducation completed on 1/7/24. 2. Resident with potential to be Affected: The alleged deficient practice had the potential to affect Resident #1 who may have had a change of condition and failed to notify physician, NP or designee and all residents who have a change in condition. 3. Measures of Systemic Changes: RN, LVN, CNA and DON have been re- educated 1/7/24 on reporting change of condition immediately. Completion of training 1/7/24 by administrator and DON provided to in-house staff and agency. For those unable to attend a teams meeting link was provided to watch what was discussed. Prior to the start of shift staff member will sign a reeducation form stating they watched and understood the information. Reeducation provided during shift change prior to starting shift. Reeducated on reporting change in condition to physician, NP or designee and documenting attempts to contact. Reeducated to escalate to next contact immediately if no response and D/C to ER if no contact is made. DON or designee to monitor daily via secure conversation review or as deemed necessary. As documented in the citation, will continue to contact appropriate clinical staff with a change of condition and escalate as necessary. Physician, NP or designee will be notified by the facility staff of residents who have a change of condition immediately and escalate to next contact until communication is obtained with a physician, NP or designee or D/C to ER. Monitoring: DON or designee will follow up on change of condition and orders will be reviewed daily or as designated necessary via UDA and 24-hour report review. DON or designee will report change of conditions in daily Stand-Up Meeting, and immediately correct any abnormal findings, and report those findings to the Administrator, DON, or assigned designee, and Physician, NP or designee. The administrator or assigned designee will report findings to the QAPI Committee for 3 months or until deemed no longer necessary. DON or designee will monitor daily 24-hour report to ensure that change of condition is followed up immediately and documented during shift change. DON or designee will monitor communication daily or as deemed necessary to ensure timely communication with physician, NP or designee and to escalate as required or D/C to ER. Verification of Plan of Removal: Record review of the Resident Roster dated 1/9/24 revealed Resident #1 no longer resided in the facility. During an interview on 1/9/24 at 3:00 pm the DON stated Resident #1 was deceased on 1/1/24, cause of death unknown. During an interview on 1/10/24 at 8:52 am, the DON stated change of conditions were determined every day by reviewing the 24-hour report. She checks that the MD and RP were notified of the change of condition and documented in the clinical chart. The DON stated she follows up on physician recommendations, if applicable. From the time 1/7/24 to 1/10/24 at 9:00 am, Resident #6 had a change of condition (1/8/24 in early morning). The DON stated Resident #6 had episodes of diarrhea. Interventions included: PRN anti-diarrhea medication, hydration at 125 cc per hour, and notified the RP; vitals taken and would be taken Q shift. During an interview on 1/10/24 at 9:10 am, the Administrator stated changes of condition were monitored and captured in the 24-hour report. The Administrator stated he follows-up by checking with the DON that the RP and MD were notified of the change of condition. The Administrator stated that he inquired at morning reports that physician recommendations were implemented, and documentation was made in the clinical chart. During an interview on 1/10/24 at 11:09 am, the ADON stated she attended the morning administrative and clinical meetings and one resident [Resident#7] had a change of condition on 1/9/24; sent to ER, positive of flu. Based on the facility's clinical procedures, assessment was completed and documented as a change of condition, MD and RP notified, and clinical record was documented. During a joint interview on 1/10/24 at 12:02 pm the Administrator and the DON stated changes of condition were discussed at morning meetings - administrative meeting at 9:00 am Monday to Friday and the clinical meeting at 9:30 am. Attendees at the administrative meetings were department heads, the DON, the ADON and the Administrator. Attendees at the clinical meeting usually included the DON, the ADON, the Administrator, the Wound Care Nurse, the Director of Rehab and the MDS Nurse. The Administrator stated two residents [Resident #6 and Resident #7] had changes of condition from the timeframe of 1/8/24 to the present 1/10/24. The Administrator stated that for Resident #6 and Resident #7, the MD and RP were notified of the changes of condition; and the clinical record was documented. The Administrator stated the next QAPI meeting was for 1/17/24 at 10:00 am and the required attendees would be the Administrator, the DON, the MD, and a Pharmacy Rep by telephone. The DON concurred that Resident #6 and Resident #7 had changes of condition and the facility followed its policy: assessment, vitals, notify RP and MD, documentation and continued monitoring for up to 72 hours. Interviews on 1/10/2024 from 8:28 am to 3:00 pm, with 5 day shift (6 am to 2 pm) nursing staff (2 LVNs, 3 CNAs, 2 MAs), 5 evening shift (2 pm to 10 pm) ( 2 LVNs, 2 CNAs, 1 MA), and 2 night shift (10 pm to 6 am) nursing staff (2 LVNs) they said they had been in-serviced on how to communicate changes of condition between shifts, documentation for 72 hours, and notification to MD and RP. Record review of the facility's sign-in sheets on of 1/10/24 revealed 65 nursing signatures for a completion rate of 96% (nursing staff=65). Record review of the facility's Acute Condition Changes-Clinical Protocol, dated revised March 2018, revealed one was present and in effect. Record review of the facility's Charting and Documentation policy, dated revised July 2017, revealed one was present and in effect. Record review of the facility's Resident Examination and Assessment policy, dated revised February 2014, revealed one was present and in effect. Record review of the facility's Change in a Resident's Condition or Status policy, dated revised February 2021, revealed one was present and in effect. Record review of the facility's Transfer or Discharge, Emergency policy, dated revised August 2018, revealed one was present and in effect. Record review of facility's Abuse and Neglect policy, dated revised March 2018, revealed one was present and in effect. On 1/10/24 at 5:00 pm, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to monitor Resident #1 following an episode during which he became unresponsive with low blood pressure on [DATE] and failed to notify the physician related to Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on [DATE]. Resident #1 expired at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:35 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy because due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1's diagnoses included: atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), cognitive communication deficit,?muscle weakness,?hyperlipidemia (high cholesterol),?hypertension (high blood pressure),?atherosclerotic heart disease (damage in the heart's major blood vessels), and?peripheral vascular disease (circulatory condition in which?narrowed blood vessels reduce blood flow to the limbs).? Record review of Resident #1's MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 3 (suggesting severe impairment) and active diagnoses of debility, cardiorespiratory conditions. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was at risk for complications related to atrial fibrillation/flutter with interventions of: Assess, document and report to physician as needed for the s/s of irregular heartrate (fast, slow, pounding), feelings of syncope (loss of consciousness for a short period of time) or collapse. Resident #1 had coronary artery disease (CAD) r/t atrial fibrillation, hyperlipidemia, and hypertension with interventions of: Monitor/document/report PRN any s/s of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating. Resident #1 had anemia with interventions of: Monitor/document/report PRN following s/s of anemia: pallor and syncope. Record review of Resident #1's orders included: Aspirin EC Tablet Delayed Release 81 MG; Give 1 tablet by mouth one time a day for Heart health, Clopidogrel Bisulfate Oral Tablet 75 MG; Give 1 tablet by mouth one time a day for CHF, Lisinopril Oral Tablet 10 MG; Give 1 tablet by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW 100/60 or 60, Maalox Max Oral Suspension 400-400-40 MG/5ML; Give 30 ml by mouth every 4 hours as needed for Indigestion; Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 MG; Give 12.5 mg by mouth one time a day for HTN; HOLD FOR BLOOD PRESSURE BELOW 100/60 OR PULSE BELOW 60. Record review of Resident #1's ER record, dated [DATE], revealed Resident #1 was seen by provider at 9:24 am, chief complaint was AMS. According to review of electronic health records, Resident #1 had a history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (damage or disease in the heart's major blood vessels with history of stent x3), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and congestive heart failure (condition in which the heart can't pump blood well enough to meet the body's needs). Resident #1 presented to the emergency department from nursing home by EMS due to shortness of breath and had become unresponsive. Initial vital signs at 9:38 am were T 97 F, P 48, R 4, BP 55/30. Resident #1's general appearance was lethargic (diminished energy, mental capacity, and motivation) with agonal (abnormal pattern) breathing, dazed look, and bradycardia (week pulse). Resident #1 was actively dying, and family confirmed no CPR. Time of death was 9:31 am. Record review of Resident #1's Blood Pressure Log revealed a blood pressure of 109/54 on [DATE] at 7:12 am. Record review of nurse progress note written by LVN B, dated [DATE] at 9:16 am, revealed: Note Text: this nurse called to shower room. resident noted to be unresponsive (what did they mean, how was it described) and noted stool on floor. resident placed back in bed legs elevated. 142/80 92%ra 70 stat cbc cmp ordered. res alert at this time. no distress noted. family aware. No further assessment was completed. Record review of Resident #1' EMR revealed there was no documentation of assessments/monitoring for [DATE] and [DATE]. During an interview on [DATE] at 1:18 pm the DON said that Resident #1 becoming unresponsive in the shower room on [DATE], he was taken back to his room and his feet were elevated. She said the physician ordered stat CBC and CMP. Record review of Resident #1's Clinical Laboratory Report, dated [DATE], revealed: Glucose 140, Total Protein 5.8, Albumin 2.8, RBC 3.09, and H/H 9.3/30.5, During an interview on [DATE] at 1:39 pm LVN B said she had notified the physician after Resident #1 became unresponsive on [DATE] and he ordered labs. She said she obtained a set of vital signs (BP 142/80, P 70, SpO2 (percentage of oxygen in the blood) 92% RA), put the resident back in bed and lifted his legs up, and Resident #1 returned to baseline (oriented x1). LVN B said she did not assess further because Resident #1 was not in distress and was at baseline (alert and oriented to self). She added there were no other issues during the rest of her shift. During an interview on [DATE] at 5:02 pm the physician said he did not see any communication to him from the facility on [DATE] regarding Resident #1's condition and added the facility might have reached out to the NP and the orders for the labs might have come from the NP. The physician said he did not recall being notified by the NP of Resident #1's condition. He added the facility knew that, if a resident was unresponsive, they needed to call 911 so that more definitive care could be provided. The physician said the vital signs documented on [DATE] at 9:16 am looked fine, but if the Resident #1 went unresponsive, he expected the facility to have called 911. The physician said he would have expected the facility to monitor Resident #1's status for 72 hours following the incident. During an interview on [DATE] at 5:53 pm CNA D said when they tried to get him up for a shower on [DATE] Resident #1 was not looking good but was awake, he was laid back down after the shower because he was not feeling well and was not himself. She added Resident #1 usually helped a little, but he was not doing that. CNA D said they were in the shower room when Resident #1 became unresponsive, adding he closed his eyes and was not responding to his name or rubbing of his chest. CNA D said the DON came into the shower room and said to get vital signs. She said it was decided to lay him back down and do an evaluation. CNA D said she remembered the nurse took his vitals and elevated his feet above his heart to see if that helped. CNA D said she then went on break and could not say if the interventions helped, but when she left the room approximately 5 minutes later, Resident #1 was still unresponsive. During an interview on [DATE] at 6:06 pm CNA C said she had walked into the shower room on [DATE] and her partner CNA D was trying to undress Resident #1 and she said hey, he doesn't look good. She went to get LVN B who wasn't available, so she grabbed the DON and was told by the DON to get vital signs. She said when she walked back to Resident #1's room, the nurse was already in there and was trying to get his BP but was unable to, so the DON tried and could not get it. They put Resident #1 in bed and the nurse was still doing the blood pressure. CNA C said she was in Resident #1's room approximately 10 minutes and Resident #1 was not doing anything. She added when she arrived at the shower room Resident #1's arms were limp and his eyes looked glazed over, she said he did not look good, he looked pale. CNA C said she was calling his name and there was no response. During an interview on [DATE] at 6:17 pm LVN B said Resident #1 was passed out in the shower chair and he was white. She said she called his name and shook him, but he did not respond. During an interview on [DATE] at 12:55 pm, the DON said training was not provided after Resident #1 became unresponsive on [DATE] because she felt the nurses assessed well. She added she did not see a need for further intervention because she felt that the interventions (lying him down, obtaining vital signs, notifying the NP and obtaining labs) were appropriate. The DON said Resident #1 was not sent out sooner because in her clinical opinion as soon as his feet were elevated, he went back to baseline. The DON said Resident #1 did have a BM while in the shower room that did not require struggle. During an interview on [DATE] at 6:24 pm the NP said Resident #1 fainted in the shower. He instructed staff to elevate the head of the bed, hydrate, obtain vital signs and labs. During an interview on [DATE] at 7:45 pm the DON said she was aware of Resident #1's hypotensive episode on [DATE] at 7:12 am and that he should have been ok to be showered because there was a 2-hour gap between when the BP was taken and when he was taken to the shower and the showers didn't get that hot. She added that Resident #1's BP fluctuated a lot. The DON said the physician was not notified of Resident #1's hypotensive episodes because he asked to be notified after 3 consecutive days, but this was not in writing. The DON said the facility process for monitoring included shift-to-shift communication and assessment of the situation that was reported by the previous shift. Record review of facility policy, dated February 2021, titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .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 . Record review of the facility clinical protocol, dated [DATE], titled Acute Condition Changes revealed Monitoring and Follow-Up . The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician, NP or designee will adjust treatment accordingly for 72 hours . The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:35 pm and were provided with the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 8:28 pm and reflected the following: 1. Corrective Action: Administrator and DON immediately ensured that changes in condition are monitored and assessed every shift for 72 hours. If a change in condition is noted staff is to report change in condition immediately to charge nurse, DON and physician, NP or designee and provide intervention as directed. 2. Resident with potential to be Affected: The alleged deficient practice had the potential to affect Resident #1 who may have had change of condition episode in shower on [DATE] with staff assistance in shower and all residents who have a change in condition. 3. Measures of Systemic Changes: RN, LVN, DON have been re- educated on [DATE], Completion of training [DATE] by DON and administrator included in-house staff and agency. For those unavailable to attend, a team's call was recorded discussing the topics and provided a link via text and respond stating they listened and understood the information provided. Staff will then sign a reeducation form stating they watched the meeting prior to start of shift. Reeducation provided on changes in condition and monitoring length of time for nursing staff to follow. Staff reeducation on procedure of reporting change in condition. As documented will continue to monitor change of condition and asses' residents with a change of condition. Monitoring: DON or designee will follow up on change of conditions using 24-hour report and medication parameter monitoring tool daily by DON or designee. Any change of condition will be reported to DON or designee and followed up with physician, NP or designee daily and between staff during shift change. If unable to get a response staff will reach out to the backup physician. If unable to get contact will send resident to ER. Changes in condition will be reviewed in Daily Stand-Up Meeting, and immediately correct any abnormal findings, and report those findings to the Administrator, DON, or assigned designee, and Physician, NP or designee. The administrator or assigned designee will report findings to the QAPI Committee for 3 months or until deemed no longer necessary. Verification of Plan of Removal: Record review of the Resident Roster dated [DATE] revealed Resident #1 no longer resided in the facility. During an interview on [DATE] at 3:00 pm the DON stated Resident #1 was deceased on [DATE], cause of death unknown. During an interview on [DATE] at 8:52 am the DON stated change of conditions were determined every day by reviewing the 24-hour report. She checks that the MD and RP were notified of the change of condition and documented in the clinical chart. The DON stated she follows up on physician recommendations, if applicable. From the time [DATE] to [DATE] at 9:00 am, Resident #6 had a change of condition ([DATE] in early morning). The DON stated Resident #6 had episodes of diarrhea. Interventions included: PRN anti-diarrhea medication, hydration at 125 cc per hour, and notified the RP; vitals taken and would be taken Q shift. During an interview on [DATE] at 9:10 am the Administrator stated changes of condition were monitored and captured in the 24-hour report. The Administrator stated he follows-up by checking with the DON that the RP and MD were notified of the change of condition. The Administrator stated that he inquired at morning reports that physician recommendations were implemented, and documentation was made in the clinical chart. During an interview on [DATE] at 11:09 am the ADON stated she attended the morning administrative and clinical meetings and one resident [Resident#7] had a change of condition on [DATE]; sent to ER, positive of flu. Based on the facility's clinical procedures, assessment was completed and documented as a change of condition, MD and RP notified, and clinical record was documented. During a joint interview on [DATE] at 12:02 pm the Administrator stated changes of condition were discussed at morning meetings - administrative meeting at 9:00 am Monday to Friday and the clinical meeting at 9:30 am. Attendees at the administrative meetings were department heads, the DON, the ADON and the Administrator. Attendees at the clinical meeting usually included the DON, the ADON, the Administrator, the Wound Care Nurse, the Director of Rehab and the MDS Nurse. The Administrator stated two residents [Resident #6 and Resident #7] had changes of condition from the timeframe of [DATE] to the present [DATE]. The Administrator stated that for Resident #6 and Resident #7, the MD and RP were notified of the changes of condition; and the clinical record was documented. The Administrator stated the next QAPI meeting was for [DATE] at 10:00 am and the required attendees would be the Administrator, the DON, the MD, and a Pharmacy Rep by telephone. The DON concurred that Resident #6 and Resident #7 had changes of condition and the facility followed its policy: assessment, vitals, notify RP and MD, documentation and continued monitoring for up to 72 hours. In interviews on [DATE] from 8:28 am to 3:00 pm, with 5 day shift (6 am to 2 pm) nursing staff (2 LVNs, 3 CNAs, 2 CMAs), 5 evening shift (2 pm to 10 pm) ( 2 LVNs, 2 CNAs, 1 CMAs), and 2 night shift (10 pm to 6 am) nursing staff (2 LVNs) they said they had been in-serviced on how to communicate changes of condition between shifts, documentation for 72 hours, and notification to MD and RP. Record review of facility's sign-in sheets on of [DATE] revealed 65 nursing signatures for a completion rate of 96% (nursing staff=65). Record review of facility's Acute Condition Changes-Clinical Protocol, dated revised [DATE], revealed one was present and in effect. Record review of facility's Charting and Documentation policy, dated revised [DATE], revealed one was present and in effect. Record review of facility's Resident Examination and Assessment policy, dated revised February 2014, revealed one was present and in effect. Record review of facility's Change in a Resident's Condition or Status policy, dated revised February 2021, revealed one was present and in effect. Record review of facility's Transfer or Discharge, Emergency policy, dated revised [DATE], revealed one was present and in effect. Record review of facility's Abuse and Neglect policy, dated revised [DATE], revealed one was present and in effect. On [DATE] at 5:00 pm, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal.