**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 3 residents reviewed for radiology services. The facility failed to follow up on Resident #1's x-ray results in a timely manner. The facility failed to follow up on x-ray results that revealed a fracture of the right tibial plateau. Resident #1 was sent to hospital on [DATE] at 10:10 am. The noncompliance was identified at PNC. The Immediate Jeopardy (IJ) began on 05/12/2024 and ended on 05/15/2024. The facility had corrected the noncompliance before the survey began. These failures resulted in delayed diagnosis, medical treatment, and hospitalization. Findings included: Review of Resident #1's admission record, dated 06/05/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 05/13/2024, revealed the resident was at risk for falls - aimlessly wandering. Interventions included anticipate and meet the resident's needs, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in w/c, and keep needed items, water, etc. within reach. Review of Resident #1's nurse note dated 05/12/2024 at 1:15 pm, written by LVN A, reflected Resident c/o pain on right knee, upon assessment noted right knee slightly swollen and tender to touch, Clinician on call notified via phone call, assessment done via video call, new order received for right knee xray and ultrasound and both ordered. Awaiting on the xray and ultrasound. Review of Resident #1's nurse noted, dated 05/12/2024 at 4:55 pm, written by LVN A, reflected Xray of right knee done, RP notified via phone call. Review of Resident #1's nurse note dated 05/13/2024 at 10:42 am, written by the DON, reflected In the course of reviewing nursing documentation, the DON saw that the resident complained of right knee pain which was assessed and seen to be slightly swollen, MD notified, x-ray and ultrasound ordered. The xray results came in 5/13/24 indicating resident has a suspicious metadisphyseal longitudinal fracture of the medial tibial condyle extending into the intercondylar notch. This nurse notified the MD with the result and order received to sent the resident out to the hospital. Nurse administered Tylenol 650, notified RP, and Administrator of the fracture. Resident sent to the ER for evaluation and treatment related to suspicious fracture. Review of Resident #1's nurse note dated 05/13/2024 at 2:55 pm, written by LVN B, reflected Resident returned from Hospital with the Dx: of a closed fracture of the right tibial plateau. The Resident was transferred back into bed. The resident has a brace noted on the right leg. New Order to follow-up with an orthopedic MD given. The PCP aware of the resident's return. No medication changes at this time. Will continue with the plan of care. Review of facility's Provider Investigation report for Resident #1, dated 05/13/2024, revealed the following: Resident complained of pain to her right knee. Right knee swollen and slightly inflamed, no bruising. Physician notified, order for x-ray obtained. Nurse gave resident 2 tablets of Tylenol 325 mg for pain. No bruising around knee, slightly inflamed with some redness. X-ray showed fracture of the medial tibial condyle with extension into the intercondylar notch. When x-ray report was received resident sent to hospital. Hospital sent resident back with an immobilizer on her knee and an order to see orthopedic doctor. Nursing staff obtained orders from physician for pain medication, no weight bearing to right leg, pain assessment every shift, right leg to be in immobilizer at all times, and to keep leg elevated when in wheelchair. Physician, family, DON and Administrator notified of injury. Quality of Life Rounds done by Social Worker in the secure unit. [Resident #1] could not say how she received her fracture. Interviews with staff and residents on the secure unit did not reveal how resident obtained injury. Camera footage of the unit was reviewed for the unit and did not show how resident obtained her injury. Resident does not have a history of falls. In an interview on 06/05/2024 at 9:19 am, the DON stated Resident #1 complained of leg pain. They did an x-ray, the results were delayed, and when the results came in, she realized Resident #1 had a fracture. The DON stated the results were delayed probably 8 hours and she saw the results the next day around 9 am. When asked why the results were delayed, the DON stated communication with the x-ray company. She said they always fax results but did not this time. She said staff have access to the results (through a portal) but if they were critical, the x-ray company was supposed to fax, call, and if no answer from the facility they were supposed to call the DON's cell phone. In an interview on 06/05/2024 at 10:30 am, the DON stated she was in the process of getting a new imaging company after the incident with Resident #1. She stated in-services with the staff were completed on stat x-rays. She stated if the x-ray was not completed within 4-5 hours, the nurse was to notify the doctor who may send the resident out to the hospital. The DON stated the night nurse, RN F, did not call the x-ray company to follow up and communicated to follow up in the morning to the nurse. The DON stated she in-serviced RN F that she was supposed to call the x-ray company about the result or call the doctor to say she did not get any report. Observation on 06/05/2024 at 11:31 am in the secure unit revealed Resident #1 well groomed and dressed sitting up in her wheelchair in the hallway outside of her room. Resident #1's right leg had an immobilizer and was elevated. Resident #1 stated she was not in any pain and did not know how her knee was injured. In an interview on 06/05/2024 at 2:16 pm, the DON stated they did not have a written policy on x-ray services. She stated they follow the change of condition policy, and depending on what it was, if x-rays were needed, they followed the procedures based on the change of condition. Attempted interview on 06/05/2024 at 2:24 pm with RN F was unsuccessful, a voicemail was left. In an interview on 06/05/2024 at 2:53 pm, LVN B stated she was in-serviced on change of condition. She stated if a stat lab/x-ray was ordered, the time frame to check, and call them to follow up. She stated if a stat x-ray was ordered the company would usually come out in 1-4 hours and the results would be available within 1-2 hours. LVN B stated she was in-serviced because a resident on the secure unit had a fractured leg, and they did not know why the injury occurred. LVN B stated if x-rays were ordered on her shift and the x-ray company had not come out, or the x-ray was completed but no results were faxed or called in to the facility, she stated she would call the x-ray company to follow up and notify the MD and the DON. She stated especially if a resident continued to have a change of condition, they would be sent out. LVN B stated she had come in on Monday (05/13/2024) and was told that Resident #1's x-rays were done but results were not posted. She said the ADON had come back to the unit with the results around 9 am. LVN B said when she came in on Monday, Resident #1 just was not moving as much. She stated Resident #1 was normally very mobile, walked, bends over, and tried to clean things everywhere so it was weird for her to not move. She said Resident #1 was not able to verbalize her needs and was pretty depressed the first week or two [after the injury] but was perking back up now. In a telephone interview on 06/05/2024 at 3:34 pm, LVN C stated she was in-serviced on stat x-rays. She stated if they were not completed timely, she would call the x-ray company, let the next nurse know, and inform the doctor. LVN C stated if a resident's x-ray was completed on her shift she would check the fax, or the portal. She stated if results were not received timely, she would call the x-ray company to see what was going on, inform the DON, and let the doctor be aware. She stated the nurse on shift was responsible and the DON or anyone could follow up for the results. She stated the risk was the patient could have an injury. In an interview on 06/05/2024 at 3:49 pm, RN E stated if x-rays or labs were ordered on her shift and they were not done or no results were received she would contact her supervisor, and handover to the next shift. She stated if stat x-ray was done on a resident during her shift and no result was received, she would contact the doctor. RN E stated they could be in pain, or injury if not treated. In an interview on 06/05/2024 at 3:59 pm, LVN D stated she had been in-serviced on x-rays because someone that fell on the [secure] unit. LVN D stated she was in serviced on stat orders and said if it was an emergency like a suspected fracture, she would put in the order stat, and contact the x-ray company if they were not there timely. She stated she was supposed to contact the doctor if the stat x-ray was not done within 4 hours. LVN D stated the nurse checked the fax for results and notify the doctor if the x-ray was done on their shift. LVN D stated if the results were not received timely the resident could be in pain and it could delay treatment. In a telephone interview on 06/05/2024 at 4:49 pm, the Regional Director of Operations for the x-ray company stated the order came in for Resident #1 on 05/12/2024 at 1:08 pm as a routine study. She stated images were uploaded at 4:39 pm and results were read [by the radiologist] at 6:46 pm. She stated they did not get an answer when they called the facility that evening on 05/12/2024. She stated there was a timestamp on 05/13/2024 at 9:54 am where an agent spoke with a nurse (the ADON). She stated the results were faxed usually right when it was read by the radiologist. She stated the facility also had access to their database (where results can be retrieved). In an interview on 06/06/2024 at 9:43 am, LVN A stated she was in-serviced on stat x-rays and the timeframe to follow up. She stated if a stat x-ray was ordered, and the x-ray had not been done then contact the doctor and the DON. She said if the x-ray had been done and results were not received, she would call the x-ray company, and check the portal. LVN A stated if the resident had a broken bone, they would need to go to the hospital. She stated the nurse was responsible to check the results and all nurses have access to the portal. LVN A stated it there was an abnormal lab or x-ray, the company was supposed to call with a critical lab or critical anything. In an interview on 06/06/2024 at 10:08 am, when asked what the risk to the resident was, the DON stated Resident #1 was monitored and pain medicine was given. The DON stated pain was not severe like crying. When Resident #1 went to the hospital, she was not prescribed pain medicine, so they contacted the doctor after she returned, and Resident #1 was prescribed Tylenol 3 to manage pain for the injury. The DON stated nurses and herself were responsible but not one person it was the team. She said they had conversations of changing the x-ray company, and they already had a new lab company as of 06/03/2024. In an interview on 06/06/2024 at 10:08 am, the Regional Compliance Nurse stated they had put a plan in place and an issue could arise if not addressed. She stated they could have continued to have a timeliness issue and pain was not an issue since Resident #1's pain was addressed. She said they had to give a 30-day notice for the new x-ray company. Attempted interview on 06/06/2024 at 10:48 am with RN F was unsuccessful, a voicemail and text message were left. In a telephone interview on 06/06/2024 at 1:07 pm, RN F stated on her shift Resident #1's x-ray was already done, the result was pending, and she handed off to the oncoming nurse. She stated the x-ray company did not call her, and she was not informed of any results. She said the x-ray company was supposed to call if any problem. RN F stated LVN A already documented in [EHR name] and there was nothing new, so she did not document about the pending result, she just informed the oncoming nurse (LVN B). RN F stated she was in-serviced on 05/15/2024 on following up on x-ray and lab results. She stated if any abnormality the x-ray company was supposed to call her. She stated if she got the report that indicated a fracture, she was supposed to notify the MD, the DON, the RP and if any orders, to send to the hospital. RN F stated she knows to check the portal for any results and document the status in [EHR name]. Record review of in-services dated 05/13/2024, on the topic of Injuries of unknown origin imaging request reflected the following: All falls and injury related imaging request must be entered as STAT orders. Notify the MD if the stat orders have not been performed after 4 hrs and request if there can be a change of plan for example sending the resident to the hospital. Record review of in-services dated 05/13/2024, on the topic of Reviewing imaging and laboratory results reflected the following: Review imaging and laboratory results obtained during your shift and notify the MD, the DON, and the RP with the results. Follow up on labs and imaging ordered prior to your shift and during your shift for results and communicate with the next shift on all new orders received. Record review of in-services dated 05/13/2024, on the topic of Injuries of unknown origin and change of condition reflected the following: Notify the Administrator immediately if a resident is found with an injury of unknown origin. Notify the MD, the DON and the RPs of all injuries to a patient and any change of condition. Record review of in-service dated 05/13/2024, signed by RN F, on the topic of Following up and checking on imaging and labs results ordered reflected the following: Following up on imaging and labs results ordered during your shift and on the prior shift and notified the MD, the RP, and the DON of all abnormal results and document in [EHR Name]. Follow up on all new and prior laboratory imaging and medication orders and document in [EHR Name] the result status. Check the laboratory and imaging portal results that were performed prior to your shift and within your shift and notify the MD, the RP and the DON of the results and status documented in [EHR Name]. Notify the MD immediately and document recommendations in [EHR Name] of all abnormal results, during shift change always give report on the results or pending results, pending collection and those performed of all imaging laboratory orders to the oncoming nurse. Check the result tab in [EHR Name] for all residents within your shift and report abnormal results to the MD. Check the imaging portal for all outstanding results. Record review of policy titled Notifying the Physician of Change in Status revised March 11, 2023, reflected in part: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .9. Faxes should be following up by the end of the business day .11. Abnormal lab, x-ray and other diagnostic reports require physician notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from neglect when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. These failures could place residents at risk of abuse and neglect, serious injury, serious harm, serious impairment, pain, mental anguish, or death. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #1's face sheet dated 02/27/24 reflected he was a [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24 DX included: Traumatic Subdural Hemorrhage with loss of consciousness (brain injury) of unspecified duration, HX of Subsequent Encounter Conversion Disorder with seizures or convulsions (conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain seizures). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 0 indicating severely impaired cognition- nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected he has a resident is at risk for falls r/t traumatic subdural hemorrhage neuromuscular dysfunction and chronic respiratory failure. Record Review of PN dated 2/25/2024 at 7:07 AM by LVN A reflected '[company name]'was notified '[Resident #1's fall and injuries]' and will send a nurse down to assess pt . Record review of Resident #1's PN dated 02/26/24 at 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN/MD BY MD O note dated 02/26/24 12:55 AM, reflected Date of Service: 02/26/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in Chief Complaint / Nature of Presenting Problem: Review x-ray result .Neurology discussed MRI and EEG results with FM that since patient has not shown improvement clinically from a neurological standpoint. Patient will have to continue with current supportive care treatment .Reviewed. Nursing Staff: Reviewed x-ray result Patient: Limited by cognition. Patient had a fall over the weekend. X-ray reviewed and no fracture. Patient had a small skin tear. Wound care is already following. Observation of Resident #1 on 02/27/24 at 11:00 AM and 02/28/24 at 8:15 AM revealed resident to be lying in bed, head of bed raised, feeding tube operating, both bags were dated, eyes closed, and a fall mat on the floor. Resident was observed to have two healing stage skin injuries to the forehead. Resident was not interviewable. In an interview on 02/27/24 at 3:09 PM, with CNA J revealed on 02/25/24 at 6 PM she arrived to work and conducted rounds every 2 hours or less. CNA J stated that she sat adjacent to Resident #1's room due to his history of falls and seizures. CNA J stated she was familiar with Resident #1's care and knew he required bed in low position, call light near, and fall mat next to bed. CNA J stated she did not notify the head nurse that the fall mat was missing. CNA J had conducted rounds on resident 15 minutes prior him falling at 4:40 AM on 02/25/24. CNA J said at 5:00 AM she heard him hit the floor and entered immediately, called for nurse, and remained until nurse arrived. CNA J stated Resident #1 was bleeding from skin tears located on his bed. CNA J said Neglect of a Resident was failing to provide the Resident with care and identified and scheduled by MD. CNA J said the fall mat would have prevented the injuries that Resident #1 sustained from the fall. In an interview with the DON on 02/27/24 3:38 PM she stated that she was contacted by LVN A on 02/25/24 at 6:40 AM via video call to assess the resident. Reporting that Resident#1 fell out of the bed on the floor and had skin tears with blood on his forehead. The DON stated Resident #1 has fall prevention precautions in place to prevent falls, related to convulsing like seizures. The DON stated the cause of the fall was possibly due to him coughing and convulsing, like a seizure, resulting in falling on the floor and gaining injuries. She said the fall mat was not in place on the day of the incident. The DON said on 02/23/24 the day of re-entry, LVN I was working the 6 PM-6 AM shift and was not familiar with the resident's care and orders, and failed to ensure the fall mat was in place. The DON stated the rounding nurses and aides did not ensure the resident's fall mat was in place during shifts on 02/23/24, 02/24/24, and 02/25/24. The DON stated that the mat should have been in place, and she expects nursing to review MD orders, care plans, and assessments to ensure the residents are receiving care consistent with their needs and orders . DON said failing to provide Resident #1' fall mat per MD orders was neglect, and the staff working on that day confirmed observation of the missing fall mat, however, it was not implemented for his safety. In an interview on 02/28/24 at 9:33 AM RN J stated upon arriving and completing shift change reports on 02/25/24 at 6 AM she was notified by LVN E that Resident #1 had fallen and had injuries to the forehead. RN J said there were no other details provided. RN J proceeded to Resident #1's room and she observed injuries to his forehead. She then cleaned the blood off of his forehead, applied Tiple Antibiotic Ointment to his forehead, and took Resident #1's vital signs. RN J said the fall mat was not on the floor next to the bed. RN J called the MD, the DON, and his family to report the incident. RN J does not know the details of the fall, as it was not provided, and she did not ask additional questions. RN J said the DON arrived at the facility on 02/25/24 at 4:30 PM and the '[company name]'nurse arrived at 5:00 PM. Both assessed the resident and the DON ordered X-rays . RN J stated that she did not review Resident #1's orders the day of the incident. The DON and '[company name]' nurse placed a fall mat on the floor upon arrival. RN J said X-rays were negative for fractures. In an interview on 02/28/24 at 10:28 AM with LVN W revealed the readmission process included taking patient vital signs, skin assessment, review medications and orders to see if orders changed. Nurses should notify the MD and confirm resident orders upon readmission to assure notification of orders and to determine if there was a need to change or follow up on returned orders. In an interview with RN HN nurse on 02/28/24 at 10:55 AM revealed Resident #1 was admitted to '[company name]' at the hospital prior to discharge on [DATE]. RN HN stated that the facility nurse called '[company name]' on call line to report the incident, and the on-call nurse reported she would be out to assess. RN HN said the on-call report stated Resident #1's fall on 02/25/234 at 6:26 AM. LVN A called and stated he had fallen on the floor from his bed, sustaining injuries to his forehead, no discomfort or distress. RN HN said Resident # 1's first care encounter at the facility was on Monday (02/27/24). She ordered Bolster's (a long thick pillow that is placed under the pillow for support.) for his bed (when sitting up he aspirates/coughs during tube feeding and he moves forward.) She placed the fall mat on 02/25/24 after the fall. She was not aware of the fall mat orders prior to intake to '[company name]'. In an interview on 02/28/24 at 1:04 PM with LVN S, she stated that she arrived on 02/23/24 at 7:00 PM and Resident #1 had been readmitted . She conducted vital signs and completed a skin assessment. She was not familiar with his care. She reviewed his orders. However, she did not recall an order for a fall mat. LVN S stated the mat was present when she arrived, and Resident #1 had no injuries. LVN S said it was important to review orders and ensure the mat was down to prevent injuries from falls or lessen the injuries. LVN S was trained after the incident by the DON on admission assessment, orders, fall precautions, and reviewing of the MD orders. Record review of policy titled Abuse/Neglect dated 03/29/18 reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation This includes but is not limited situations that may constitute abuse or neglect to any resident in the facility. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly . Investigations will be reviewed by the facility administrator and/or Abuse Preventions within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will designate an Abuse Preventions to monitor tracking and trending data and completion of investigations as needed. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse will be investigated by the Abuse Preventions and/or designee and a comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventions All allegations of abuse, will be investigated. This was determined to be an Immediate Jeopardy (IJ) on 02/28/24 at 3:38 PM The ADM, DON, and CRN were notified. The ADM was provided with the IJ template on 02/28/24 at 3:43 PM. The following Plan of Removal submitted by the facility was accepted on 02/29/24 at 9:10 AM . Plan of Removal was accepted on 02/29/24 at 11:23 AM. Free from Neglect Statement: The facility failed to ensure Resident #1 was free from abuse and neglect in that: Resident #1 was found on the floor in his room on 2/25/24 at 6:47 am by CNA J. Interventions: 1. Resident # 1 was transferred to the hospital as of 2/28/24 for evaluation. 2. The Charge Nurse and CNA that cared for resident #1 on the shift he sustained the fall was in-serviced 1:1 by the DON and Regional Compliance Nurse on: a. Fall Prevention Strategies (ensuring fall mats are in use) b. Abuse and Neglect Policy to include ensuring safety devices are in place. c. [NAME]: how to use to determine if a fall mat is required for a resident. 3. An audit was performed by the Regional Compliance Nurse and the DON for all residents who require a fall mat on 2/28/24 to ensure that they are in place. 4. The medical director was notified of the immediate jeopardy citation on 2/28/24 by the Director of Nursing. 5. An ADHOC QAPI meeting was held on 2/28/24 with the IDT Team to include the medical director to discuss the immediate jeopardy and plan of removal. In-services: The following in-services were initiated by the Administrator, the DON, and Regional Compliance Nurse on 2/28/24 for all Charge Nurses. All Charge Nurses, not present on 2/28/24, will be in-serviced prior to the start of next shift. All new hires will be in-serviced during orientation. All agency staff will be in-serviced prior to the start of their shift. o Fall Prevention Strategies (ensuring fall mats are in use) o Abuse and Neglect Policy to include ensuring safety devices are in place. o [NAME]: how to use to determine if a fall mat is required for a resident. o Following MD orders (including the use of fall mats and ensuring bed in low in position). o Inservice provided on a list of residents that require a fall mat. Monitoring: The DON/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, by DON, CRN, and ADM dated 02/26/24, 02/27/24, 02/28/24, 02/29/24 reflected curriculum covered the facility's policy on abuse and neglect, fall precautions, interventions, [NAME] referencing, MD orders, and reporting abuse and neglect immediately to the Abuse Coordinator (the Administrator). Interviews were conducted on 02/29/24 starting at 1:01 PM and continued through 4:03 PM with the following staff from various shifts: CNA G (6 AM-6 PM), CNA J (6 PM-6 AM), CNA S (6 AM-6 PM), CNA D (6 AM-6 PM), CNA T (6 AM-6 PM), CNA P (6 AM-6 PM), CNA L (6 AM-6 AM), RN J (6 AM-6 PM) ), the CRN , the DM, the MD, the SW, the HKS, the DOR, the ADM, the DON, and the ADON were all able to communicate education attendance and knowledge of the in-service curriculum responding timely, reporting immediately, fall mats, [NAME] for care list, types of abuse, abuse coordinator, timing of reporting abuse and neglect, and identifying abuse and neglect. Observations and interviews on 02/29/24 from 1:00 PM to 3:30 PM with Residents#1, #3, #5, #21, #26, and #30 reflected all fall mats were in place, and their current care plans and assessments reflected that interventions were in place for effective and person-centered care. The Administrator and the DON were notified the IJ was removed on 02/29/24 at 4:30 PM. The facility remained out of compliance at a scope of isolated and at the severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. In an interview with the Administrator on 02/29/24 at 3:47 PM revealed his expectations of staff were to comply with facility policies and procedures, follow up with patients requiring specialized care, monitor and report to leadership (ADON, DON, and CRN) any inconsistencies, and compliance nursing services. He stated the DON will assign an overnight staff to follow through on the process in place such as following physician orders, accessing and reviewing [NAME] overnight system with aides to ensure familiarity with resident care. The ADM, the DON, and the ADON will monitor documentation of task off site electronically to ensure compliance. All staff will ensure the residents receive the best care possible. Expectation for nursing and aides to complete end of shift reports best practice expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents hazards. The facility failed to protect Residents #1 from accidents when they failed to provide the necessary care devices to prevent injury from a fall. Resident #1 had a history of subdural hemorrhage with brain injury and a previous order for a fall mat. The CNA was aware the fall mat was missing and Resident #1 experienced convulsions/seizures resulting in a fall. Resident #1 sustained a skin tear from the fall. This failure could affect 8 Residents at the facility that received fall precautions and interventions resulting in serious harm and injuries. On 02/28/24 at 3:38 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/29/24 at 3:52 PM, the facility remained in compliance at a severity level of no harm and a scope of' 'isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #1's face sheet dated 02/27/24 reflected he was a [AGE] year-old male admitted initially on 06/23/23 and again on 02/23/24 DX included: Traumatic Subdural Hemorrhage with loss of consciousness (brain injury) of unspecified duration, HX of Subsequent Encounter Conversion Disorder with seizures or convulsions (conversion disorder is a condition in which you have physical symptoms but no injury or illness to explain seizures). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 0 indicating severely impaired cognition- nonverbal, Section K feeding Tube, Section M stage 4 wound documented and being treated with ointments and medication, including diet, Section N Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), Section O no treatments. Pain unable to answer. Record Review of Resident #1's Care plan dated 12/01/23 reflected he has a resident is at risk for falls r/t traumatic subdural hemorrhage neuromuscular dysfunction and chronic respiratory failure. Record review of PN dated 2/25/24 at 06:47 AM reflected Progress Note: Resident was found on the floor face down. Has a skin tear on the forehead. No neurological deficits noted at this time. wife called no response, unable to leave a voicemail because the mailbox was full. neuro check in progress. DON and Dr. Notified.To continue with the plan of care. BP 120/71 P 78 T 98.7 02 96. Record review of Resident #1's incident report dated 02/25/24 at 6:55 AM by LVN A reflected resident was found on the floor face down. Has a skin tear on the forehead. No neurological deficits noted at this time. Unable to speak. MD notified. Record review of Resident #1's fall nurse note dated 02/25/24 at 7:05 AM by RN J reflected no injury, no decline, no appearance of pain, and fall interventions; fall mat, low bed, bed assist handle, ¼ rail. Record Review of PN dated 2/25/2024 at 7:07 AM by LVN A reflected '[company name]' was notified '[Resident #1s fall and injuries]' and will send a nurse down to assess pt . Record review of PN dated 02/25/24 at 7:10 AM by RN-EC reflected, Resident admitted to [company name] '[company name]' with the diagnosis of Traumatic Subdural Hemorrhage (a type of bleeding in the brain from a blow to the head) with loss of consciousness (awareness). No directions specified for order. Record review of Resident #1's X-ray dated 02/25/24 (time unknown) reflected order given by MD NK, conducted by technician LO .reviewed by MD PS . procedures (facial bones, less than 3 views .findings no obvious fractures or other significant abnormality seen in visualized facial bones .Impression: normal study electronically signed by MD S 02/26/24 at 5:10 PM Record review of Resident #1's PN dated 02/26/24 at 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN dated 02/26/24 08:47 AM by the DON reflected X ray to the forehead and facial bones shows no obvious fracture. Nursing will continue to treat skin per standing orders. Record review of Resident #1's PN/MD BY MD O note dated 02/26/24 12:55 PM, reflected Date of Service: 02/26/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in Chief Complaint / Nature of Presenting Problem: Review x-ray result .Neurology discussed MRI and EEG results with FM that since patient has not shown improvement clinically from a neurological standpoint. Patient will have to continue with current supportive care treatment .Reviewed. Nursing Staff: Reviewed x-ray result Patient: Limited by cognition. Patient had a fall over the weekend. X-ray reviewed and no fracture. Patient had a small skin tear. Wound care is already following. Record review of Resident #1's PN dated 02/26/24 at 2:47 PM by the DON reflected Resident admitted to '[company name]' with diagnosis of Traumatic Subdural Hemorrhage with loss of Consciousness .'[company name]' nurse in house to assess resident and new orders received for pain, anxiety, increased secretions and nausea and vomiting, scoop mattress, morphine sulfate Q 3 h for pain or SOB, Lorazepam for anxiety Q 6 h. Record review of Resident #1's PN dated 02/26/24 3:55 AM BY RN AR reflected bump noted on forehead. neuro checks continue to be done; no S/S of infection noted. nurses will continue with ordered wound treatment and monitor for any S/S of infection. LVN I. Record review of Resident #1's fall nursing note dated 02/27/24 at 12:24 AM by LVN DO reflect injury: skin tear forehead .size 8.8 cm X 0.1, 1.2 cm X 0.1, no S/S of infection, no decline since fall no appearance of pain, no changes that required MD notification, all interventions fall mat, low bed. Record review of Resident #1's fall nurse note dated 02/27/24 at 7:04 AM by LVN DO indicate no injury, fall mat and low bed. Fall note assessment dated [DATE] indicated skin tear or laceration on forehead 0.8cm x o.1, 1.2cm x o.1. Record review of neuro assessment dated [DATE] at 07:04 AM and 02/28/24 at 10:10 AM by RN J reflected Eyes were spontaneously opening, sounds only-moans/groans .abnormal flexion-stimulus causes abnormal flection of limbs (adduction of arm, internal rotation of shoulder, pronation of forearm, with flexion-decorticate posture no new observations. Observation of Resident #1 on 02/27/24 at 11:00 AM and 02/28/24 at 8:15 AM revealed resident to be lying in bed, head of bed raised, feeding tube operating, both bags were dated, eyes closed, and a fall mat on the floor. Resident was observed to have two healing stage skin injuries to the forehead. Resident was not interviewable. In an interview on 02/27/24 at 3:09 PM, with CNA J revealed on 02/25/24 at 6PM she arrived at her shift, and conducted rounds every 2 hours or less. CNA J stated she was familiar with Resident #1's care. CNA J stated Resident #1 was a fall risk and required his bed in low position and fall mat next to bed. CNA J heard Resident #1 fall on the floor, and she immediately responded and observed Resident #1 lying fac down on the floor, and bleeding skin tears to his forehead. CNA J, called for the nurse, and remained with Resident #1. CNA J said it was important to ensure fall prevention devices were applied for residents to prevent injurie. CNA J said Resident #1's fall mat was not applied next his bed, and he sustained injures. CNA J said the fall mat could have decreased impact and prevented Resident #1's injures from occurring. In an interview with the DON on 02/27/24 3:38 PM she stated that she was contacted by LVN A on 02/25/24 at 6:40 AM via video call to assess the resident. Reporting that Resident#1 fell out of the bed on the floor and had skin tears with blood on his forehead. The DON stated Resident #1 has fall prevention precautions were ordered to prevent resident injuries from accidents and falls. DON said she was notified immediately. DON stated resident was immediately assessed by nurses per facility protocol and notification to '[company name]', MD, and FM. DON stated the rounding nurses and aides did not ensure the resident's fall mat was in place during shifts on the day of the fall, 02/25/24. DON stated that she expects all nursing staff to ensure resident orders, preventions, and care needs are followed. She further expects the nursing staff to review residents' orders, implement as written, and monitor during rounds to prevent accidents from occurring. DON said she initiated in service with her nursing staff on MD orders, resident monitoring, and care needs, including but limited to fall mats, low beds, new and re-admission orders and precautions to prevent accidents. In an interview on 02/28/24 at 9:33 AM RN J stated upon arriving and completing shift change reports on 02/25/24 at 6AM she was notified by LVN E that Resident #1 had fallen and had injuries to the forehead. RN J notified the MD, the DON, and his family to report Resident #1's fall. RN J was not provided the details of the fall, nor did she did not ask additional questions. RN J said the DON and '[company name]' on call nursed arrived to assess Resident #1's incident, applied fall mat, and additional prevention devices for safety. RN J said failing to follow MD orders could result in resident's receiving injuries when falling. or prevention could prevent accidents from occurring. In an interview on 02/28/24 at 10:28 AM with LVN W revealed nurses are expected to review and follow MD orders, ensure fall prevention devices are implemented and monitored every shift to prevent injuries. Additional tasks include, monitoring devices, following up on orders, and reporting immediately any changes with the orders. LVN W stated that fall mats are a prevention device that can prevent accident injuries if a resident fall. In an interview with RN HN nurse on 02/28/24 at 10:55 AM revealed Resident #1 was admitted to '[company name]' at the hospital prior to discharge on [DATE]. RN HN stated that the facility nurse called '[company name]' on call line to report the incident, and the on-call nurse reported she would be out to assess. RN HN said the on-call report stated Resident #1's fall on 02/25/234 at 6:26 AM. LVN A called and stated he had fallen on the floor from his bed, sustaining injuries to his forehead, no discomfort or distress. RN HN said Resident # 1's first care encounter at the facility was on Monday (02/27/24). She ordered Bolster's (a long thick pillow that is placed under the pillow for support.) for his bed (when sitting up he aspirates/coughs during tube feeding and he moves forward.) She placed the fall mat on 02/25/24 after the fall. She was not aware of the fall mat orders prior to intake to '[company name]'. In an interview on 02/28/24 at 1:04 PM with LVN S, Resident #1 had been readmitted on [DATE], and she observed his fall mat positioned next to his bed during rounds. LVNS stated Resident #1 had no falls during her shift on 02/23/24 from 7P-6A. LVN S said it was important to review MD orders and ensure they are being followed so the resident does sustain injuries. Record review of the facility policy dated October 5, 2016, titled Preventive Strategies to Reduce Fall Risk reflected Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualized nursing care plans will be implemented to prevent falls. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). Environment: Keep bed in low position. This was determined to be an Immediate Jeopardy (IJ) on 02/28/24 at 3:38 PM]. The ADM, CRN and DON were notified. The ADM was provided with the IJ template on 02/28/24 at 3:52 AM The following Plan of Removal submitted by the facility was accepted on 02/29/24 at 11:23 AM Plan of Removal Free of Accidents Hazards/Supervision/Devices Statement: The facility failed to supervise Resident #1 and abuse and neglect in that: Resident #1 was found on the floor in his room on 2/25/24 at 6:47a by CNA. Interventions: 1. Resident # 1 was transferred to the hospital as of 2/28/24 for evaluation. 2. The Charge Nurse and CNA that cared for resident #1 on the shift he sustained the fall was in-serviced 1:1 by the DON and Regional Compliance Nurse on: a. Fall Prevention Strategies (ensuring fall mats are in use) b. Abuse and Neglect Policy to include ensuring safety devices are in place. c. [NAME]: how to use to determine if a fall mat is required for a resident. 3. An audit was performed by the Regional Compliance Nurse and DON for all residents who require a fall mat on 2/28/24 to ensure that they are in place. 4. The medical director was notified of the immediate jeopardy citation on 2/28/24 by the Director of Nursing. 5 An ADHOC QAPI meeting was held on 2/28/24 with the IDT Team to include the medical director to discuss the immediate eopardy and plan of removal. In-services: The following in-services were initiated by the Administrator, DON, and Regional Compliance Nurse on 2/28/24 for all direct care staff. All direct care staff not present on 2/28/24 will be in-serviced prior to the start of next shift. All new hires will in-serviced during orientation. All agency staff will in-serviced prior to the start of their shift.Fall Prevention Strategies (ensuring fall mats are in use); Abuse and Neglect Policy to include ensuring safety devices are in place; [NAME]: how to use to determine if a fall mat is required for a resident .Inservice provided on a list of residents that require Monitoring: The DON/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, by DON, CRN, and ADM dated 02/26/24, 02/27/24, 02/28/24, 02/29/24 reflected curriculum covered the facility's policy on abuse and neglect, fall precautions, interventions, [NAME] referencing, MD orders, intervention and reporting abuse neglect immediately to the Abuse Coordinator (Administrator). Interviews were conducted on 02/29/24 starting at 1:30 PM and continued through 4:30 PM with the following staff from various shifts: CNA A, CNA D, CNA L, CNA J, CNA S, CNA T, CNA P, LVN A, LVN C, LVN D, LVN P, LVN S, RN E, RN J, RN R, AD, DM, MAD, SW, HKS, DOR were interviewed and confirmed in-service trainings: Fall Prevention Strategies (ensuring fall mats are in use), Abuse and Neglect Policy to include ensuring safety devices are in place. [NAME]: how to use to determine if a fall mat is required for a resident. Following MD orders (including the use of fall mats and ensuring bed in low in position. Inservice provided on a list of residents that require a fall mat. Interviews with the following licensed nurses on 02/29/24 at 2:30 PM LVN A, LVN C, LVN D, LVN P, LVN S, RN E, RN J, RN R, were interviewed and confirmed attendance at in-services training on the types of abuse, Fall Prevention Strategies (ensuring fall mats are in use), Abuse and Neglect Policy to include ensuring safety devices are in place. [NAME]: how to use to determine if a fall mat is required for a resident. Following MD orders (including the use of fall mats and ensuring bed in low in position). Interviews with completed on 02/29/24 at 3:20 PM with ADON, DON, and CRN confirming additional in-service training and information for nurse managers to audit and monitor The Don/ADON/Designee will review 3 residents per day x 5 days a week to ensure fall mats are in place x 4 weeks. In an interview with the Administrator on 02/29/24 at 3:47 PM revealed his expectations of staff were to comply with facility policies and procedures, follow up with patients requiring specialized care, monitor and report to leadership (ADON, DON, and CRN) any inconsistencies, and compliance nursing services. He stated the DON will assign an overnight staff to follow through on the process in place such as following physician orders, accessing and reviewing [NAME] overnight system with aides to ensure familiarity with resident care. The ADM, the DON, and the ADON will monitor documentation of task off site electronically to ensure compliance. All staff will ensure the residents receive the best care possible. Expectation for nursing and aides to complete end of shift reports best practice expectations. The Administrator and the DON were notified the IJ was removed on 02/29/24 at 4:30 PM. The facility remained out of compliance at a scope of isolated and at the severity level of no harm, due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that each resident received treatment and care in accordance professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to place an oxygen cannula and monitor the vital signs for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. An Immediate Jeopardy (IJ) situation was identified on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk for respiratory distress (potentially leading to cardiac arrest), sedation, or a drop in blood pressure. Findings included: Review of Resident #1's face sheet, dated 07/21/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (a lack of sufficient oxygen in body tissues), and diagnoses of COPD (chronic obstructive pulmonary disease- a disease which causes breathing problems, leading to low oxygen levels in the blood), heart failure, and traumatic brain injury. Review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had impaired vision, was able to be understood, and understood others. Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. She had no psychosis or behaviors. Resident #1 required limited assistance from one person to transfer and bathe, but was able to walk, locomote using her wheelchair, eat, and perform hygiene on her own. She required extensive assistance from one person to get dressed. She was noted to have debility and/or cardiorespiratory (affecting heart function and breathing) conditions, which included heart disease, high blood pressure, history of pneumonia, respiratory failure, and COPD. Resident #1 used oxygen therapy and bi-pap or c-pap (a machine to help with breathing while sleeping.) Review of Resident #1's physician orders for July 2023 revealed the order started on 06/04/23 and stated Resident #1 may use oxygen at 3L/m via nasal canula during the day one time related to COPD but was discontinued and changed on 7/20/23 once readmitted from the hospital to represent the correct order that sated Resident #1 may use oxygen at 2-4 L/m via nasal cannula for oxygen <92% every shift related to COPD. Review of Resident #1's care plans reflected a care plan for oxygen use, revised 06/20/23. [Resident #1] has Oxygen Therapy. Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 06/12/2023 Revision on: 06/20/2023 Target Date: 06/19/2023- For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Date Initiated: 06/15/2023 Created by: [ADON] - Monitor for s/sx of respiratory distress and report to MD PRN : Respirations, Pulse oximetry, Increased heart rate (Tachycardia), restlessness, Diaphoresis [excessive sweating], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lung], Hemoptysis [coughing blood from lungs], Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 06/15/2023 Created by: (ADON)- Oxygen per nasal canula as ordered Date Initiated: 06/05/2023 Created by: (ADON) Revision on: 06/12/2023 oxygen as ordered Date Initiated: 06/15/2023 Created by: (ADON) Revision on: 06/19/2023 - Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 06/15/2023 Created by: (ADON) Also reflected were careplans for asthma (revised 06/20/23), congestive heart failure (revised 06/20/23), shortness of breath (Revised 06/20/23), hypertension (revised 06/20/23), altered respiratory status/ difficulty breathing/ shortness of breath re: Bi-pap (revised 06/20/23). Review of the facility transfer progress note, effective 07/18/23 at 8:02 AM reflected Resident #1 was transferred to the hospital for a change in condition. Review of Resident #1's progress note dated 07/18/23 at 7:43 AM, written by LVN A reflected Note Text: Resident observed in lying in bed unable to get to get self up. noted something was wrong, resident speech unclear, stating ' I dont know what is wrong with me, but I'm sorry' Resident was noted to have pills in a bag with no prescription bottle with medications. Resident was so confused that it was unclear many pills she had taken. MD was in the facility, assessed resident, and gave order to send resident out to hospital for further evaluation. ADMN , DON notified. Review of Resident #1's Transfer Form, effective 07/18/23 at 8:02 AM, reflected Resident #1 was being sent to the hospital, and her oxygen was 98% via oxygen mask. Under treatments and devices currently required oxygen was not selected. Review of Resident #1's Physician Progress note, written by Physician E, dated 07/18/23 (did not include time of assessment) reflected Chief Complaint / Nature of Presenting Problem: Pill bag found in patient's room, patient not acting like herself . History Of Present Illness: [AGE] year-old lady admitted to [Facility Name] on 6/3/2023 for rehabilitation or status post hospitalization for acute on chronic respiratory failure with hypoxemia and COPD exacerbation The patient has a medical history significant for COPD, methamphetamine use, memory loss, acute respiratory failure with hypoxia traumatic brain injury in 1982. She presented to the hospital with shortness of breath .Patient: Patient seen and examined in room. Patient was not acting like herself. Unable to provide an answer for any question. Asked patient about the pill bag and she said her friend has brought it for her. And patient is build back following gabapentin 300 mg and 600 mg. Also found hydroxyzine 50 mg pills. Patient kept on repeating I am sorry I will not do this again. Patient unable to tell how many pills she has taken. Sending patient to ER . Physical Exam General .Excessive sedation. Unable to keep eyes open. Unable to have full conversation. Review of Resident #1's blood pressure readings from the facility EMR reflected her blood pressure on 07/18/23 at 7:35 AM (when LVN A found resident with a change in condition), and 8:22 AM (four minutes before EMS walked into the facility) the readings for both were 142/72. Review of Resident #1's oxygen readings from the facility EMR reflected her oxygen saturation on 07/18/23 at 8:23 AM (three minutes before EMS walked into the building) was 98% via oxygen mask. No data for her oxygen level was entered at the time the nurse found her with a change in condition. All oxygen readings from 07/08/23 to 07/18/23 t 7:35 AM reading reflected it to be the only reading for via oxygen mask. All other readings were for room air (six) or oxygen via nasal cannula (19). Review of the EMS company's patient care report, dated 07/18/23, stated the O2 sats on 7/18/23 between 8:34 AM and 9:28 AM ranged from 66-82 O2%. The report included notes which indicated Resident #1 did not have oxygen on when they arrived. During this the pt had been moved over to the cot, secured, and vitals obtained. Pt was then found to be severely hypoxic on room air and a nasal cannula was then noticed on the pt's wheelchair. Pt was asked if on O2 and the pt. said she was. Pt was promptly placed on O2 via nasal cannula and the pt's O2 saturations began to improve .Pt was then moved out to the MICU for further treatment of hypoxia. In the MICU pt O2 saturations showed to have stalled at approximately 83% on O2 via nasal cannula. Pt was then placed on a NRB mask and then transported to [hospital]. En route pt showed to become more altered and appeared sedated. Pt was able to aroused [sic] with gentle physical stimulation and was still able to answer questions but had a hard time staying awake. Pt report was called into the hospital to notify of the pt's condition and given an ETA. Pt continued to be monitored and no further interventions were made en route. Upon arrival at the hospital ( .) Pt's RN was made aware of the situation around the pt's condition and how the pt had not been on her o2 prior to EMS arrival for unknown reasons. Review of the Emergency Department admission Sheet, dated 07/20/23, reflected Resident #1 arrived at the hospital on 7/18/23 at 9:31 AM complaining of dyspnea (shortness of breath). Per EMS Resident #1 was sent by nursing home staff for acute hypoxia (absence of enough oxygen in blood tissues) related to accidental drug overdose (Seroquel, Gabapentin and hydroxyzine.) Her primary admitting diagnosis was respiratory failure. Per the history of present illness documentation Resident #1's oxygen saturation percentage was in the 20s when EMS found her. They then placed her on a non-rebreather and her oxygen level improved rapidly. The ( .) vitals taken on 7/18/23 at 9:50 AM were blood pressure 148/70 , pulse 79, respirations 18 breaths per minute and oxygen blood saturation 100% on non-rebreather mask. According to the Physical exam Resident #1's appearance was somnolent, attention diminished, awakened to sternal rub, and moved all four extremities. Lab work collected on 7/18/23 at 9:58 AM revealed Resident #1's blood carbon dioxide levels to be over 100 (the normal range being 35-45), and a blood test of her oxygen reflected a result of 37 (the normal range being 80-105.) According to the ED deposition, due to an extensive history, physical exam and cardiopulmonary workup, Resident #1's presentation was consistent with COPD (lung disease) exacerbation. Despite typical ED treatment the resident did not improve to the point that which she would be able to return to the nursing facility safely and was admitted to the hospital for further treatment. An interview on 07/21/23 at 12:43 PM with the Administrator revealed he had not reported the incident with Resident #1 taking outside medications, because she stable, in no distress, and talking to him and other staff while she was in the facility. He stated they had investigated the issue with the family member bringing medications in, and the family member stated she had brought them, and given them directly to the resident. Observation of video footage reflected: On 07/18/23 at 8:08 AM, CNA B wheeled Resident #1 to the nurses station, and placed her next to the front side of the nurses station. When enlarging the video on the State Surveyor's computer screen, Resident #1 did not appear to be wearing an oxygen cannula. No tubing was visible around her upper body/shoulders or on her face, and there was no indentation on her skin visible from the tubing. The back of her wheelchair was not visible due to the angle of the video, and the nurses station wall blocked the view. Resident #1's upper body was visible. She spoke and laughed with LVN A, who was inside the nurses station, already seated at the computer, and was on the phone. Other staff could be seen walking past the station, and into the nurses station, while the resident was seated next to it. LVN A could be seen turning her head frequently to look directly at Resident #1. The resident did not appear to be distressed, and sometimes appeared sleepy, but for a majority of the video was awake and looking around. At 8:13 AM, the Administrator entered the front door of the facility and approached Resident #1, greeted her, placed his hand on her shoulder and turned into the hall where his office was located. He immediately turned and walked back to the nurses' station, and talked with LVN A, and they both looked at Resident #1 while they talked. At 8:14 AM CNA B returned with a can of soda, inserted a straw, and handed the can to Resident #1. Resident #1 was able to hold the can, manipulate the straw, drink, and set the can down on the nurses' station counter, with no apparent problems. Also at 8:14 AM the Administrator approached the resident, and leaned on the counter to talk with her. The resident appeared to be speaking during most of this conversation, appeared alert, and did not appear distressed. During their conversation LVN A left her seat to use another computer at the nurses' station, and returned to her seat, and continued to use the computer and hold the phone to her ear. At 8:21 AM the Administrator pulled his phone out of his pocket and made a call. He ended the call approximately a minute and a half later. At 8:23 AM the Administrator walked away from the resident and entered the hall leading to his office. At the same time, LVN A exited the nurses' station, and followed him down the hall. At this time a woman in a white lab coat (identity unknown) briefly addressed Resident #1 and walked away, exiting the facility front door. Various other staff were present in the area of the nurses' station during the time LVN A was gone, but none appeared to address the resident, or directly observe her at this time. At 8:24 AM the last one of the staff (identify unknown by surveyor) who was near the nurses' station exited the facility front door, and LVN A returned to her computer near the resident. At 8:26 AM three EMS personnel could be seen entering the front door with a gurney. They approached LVN A and Resident #1. LVN D approached and had a conversation with them. LVN A was still on the phone and using the computer. EMS staff leaned on the counter and the gurney and conversed with Resident #1 while she drank her coke, and LVN D, walked away at 8:28 AM. At 8:28 AM a police officer entered the front door. EMS personnel addressed the officer, and gestured to Resident #1. At 8:30 AM the police officer approached Resident #1. LVN D addressed Resident #1, and they had a brief conversation, while EMS stood in the doorway of the lobby with their arms folded, watching. Resident #1 had a brief conversation with the police officer, and at 8:31 AM, EMS personnel lowered the gurney and removed bags from it (to make room for the resident.) At 8:32 AM Resident #1 unsteadily stood up, and placed herself on the gurney, while one EMS worker had his hand on her back, and held one of her hands. He assisted her getting her legs onto the gurney. The resident was lying on the gurney for approximately three minutes while EMS staff appeared to be arguing with LVN D and LVN A, two of the EMS personnel gestured emphatically with their hands as they spoke. One of them walked away from the conversation and applied the blood pressure cuff to Resident #1 at 8:33 AM. The LVN D left the video and returned shortly, and her facial expression appeared strained, and walked away again. At 8:36 AM one EMS worker placed an oxygen cannula on Resident #1's face. At this time the other two EMS turned their attention to the resident, and appeared to be having a conversation with her. They stood, as if waiting, until 8:38 AM, when one of the three EMS personnel entered the hallway to the Administrator's office. At 8:42 AM the EMS personnel walked toward the front door of the facility with Resident #1 on the gurney. The resident appeared to be awake and not in any distress when they rolled her away from the nurses' station. They stood at the door, and LVN A walked to the door and entered the code to exit at 8:43 AM. An interview with the complainant on 07/18/23 at 4:21 PM revealed Resident #1 went to the hospital after taking pills at the facility from a bag a family member provided her, and the resident was not wearing her oxygen when EMS arrived. The resident was placed on oxygen by the EMS personnel, and when they checked her O2 SATS (oxygen saturation levels), she was at 29%, which was an indication she had been off her oxygen for some time. The complainant stated the documentation showed the nurse had taken the resident's vitals just before EMS arrived, and her oxygen level was at a normal level, but the resident was hypoxic when they arrived, and could not have become so that quickly. The complainant stated the resident was pleasant and cooperative, and a little altered and sedated and had a TBI (traumatic brain injury) but was still able to talk to them. An interview on 07/19/23 at 1:15 AM with LVN A revealed when she was waiting for EMS to come get a resident , she would monitor all the vital signs, which included oxygen, and document the time of the assessment, at that time. She said she found Resident #1 in her room, in bed, when she would normally be up, and when she spoke, she did not sound right. She said she took Resident #1's blood pressure, and the resident was apologetic and said she wouldn't do it again. When she asked her what she did, she found pills in a bag. The physician came into the room, and the vitals recorded at 8:22 AM were the ones she took at an earlier time, when the physician saw the resident. They figured out that the pills were gabapentin and hydralazine. The physician told LVN A to send Resident #1 to the hospital to be assessed. She said Resident #1 had COPD and always wore oxygen and only took it off to go to the bathroom. She said she took the vitals right when the situation occurred, when she discovered the resident with a change in condition, but did not take them again before EMS arrived, because the times were close enough together that she did not need to. She said the resident was at risk of passing out, but she was right at the nurse station, asking for soda, and talking, and in no distress, and did not need to have her vital signs monitored. An interview on 07/19/23 at 1:25 PM with CNA B revealed he was a PRN CNA and had been the one to get Resident #1 dressed and ready to go to the hospital. He said she did not have oxygen on when he saw her. An interview on 07/20/23 at 9:14 AM with Resident #1's family member revealed Resident #1 had to be held at the hospital because of her oxygen levels, and she was requiring too much oxygen. She said they needed to get her back to a level where she would be safe at the facility. She said when she was in the hospital, her oxygen requirement was seven liters, and they had her down three, and would be discharging her soon. An interview on 07/20/23 at 9:09 AM with the DON revealed she felt LVN A did a good job monitoring Resident #1. She said she would expect visual monitoring was appropriate in this case, and she had the resident in her line of vision, so she could notice whether she showed any changes, and could reassess her. She said she was not aware Resident #1 was not wearing her oxygen, but she barely wore oxygen, and she definitely did not recall her being on oxygen all the time. She said the resident was often up, walking around the facility, and not wearing her oxygen. She said she thought the resident told EMS as they were leaving she had taken Seroquel and gabapentin from the bag of pills her sister brought. She said she was alert, and talking, and drinking her coke without fumbling, and did not seem to be in any sort of distress, and was just twitching a little, and groggy, from the medication. She said she did not have any residents with continuous oxygen orders, including Resident #1. An interview on 07/20/23 at 9:33 AM with CNA B revealed saw Resident #1 trying to get up and staggering when he was passing breakfast trays on 07/18/23, so he went in to help her. He said she had her oxygen on then, but he had to help her change clothes and get ready for EMS, so he was not sure if the oxygen was on her when he took her to the front. He said she mostly used the oxygen in her room, but he did not see her using it often when she left her room. He said he saw her several times while she waited for EMS, and she did not appear to be in any sort of distress. An interview and observation on 07/20/23 at 10:33 AM in the hospital with Resident #1 revealed her to be alert, sitting up in bed, with four liters of oxygen running. She said a family member brought her some pills from the pharmacy that she had been taking for a long time. She said she did not feel the nurse was giving her what she needed , so she asked her sister to pick them up from the pharmacy. She said she took some out of the bottles, and gave the rest to a nurse , and she should not have done that. She said she had taken Seroquel and hydralazine. She said she was always on oxygen, and only took it off to use the restroom. She said she felt great at the time of the interview, and it was not the pills that got her to the hospital, it was the oxygen. An interview on 07/20/23 at 10:14 AM with LVN C revealed if a resident with respiratory diagnoses was being sent out to the hospital, she would put their oxygen on them, and keep the monitor on their finger, and monitor their vitals. She said she would have oxygen on the resident, and would stay with them, or have someone else stay with them who could monitor their vital signs while she got the paperwork ready for EMS. She said Resident #1 often left her room without wearing oxygen, and it might have been ok to just visually monitor her , but she was not there when it happened, and was not sure of her condition when she was sent out. An interview on 07/20/23 at 11:02 AM with LVN D revealed the nurses had a class by a Respiratory Therapist a few months prior to this visit, because they were getting a resident who had a trach. She said they trained them on how to recognize respiratory distress, and what to do. She said if she was sending a resident out, who had COPD, she would monitor their oxygen by keeping the monitor on their finger, and keeping them by her, and checking their vitals every few minutes. She said she would not just use visual monitoring for oxygen , because you could not tell when someone's oxygen started to drop and by the time you saw signs it could already be very low. She said someone would need to be checking their vital signs, and keeping them on oxygen. LVN D said it did not make any difference whether the change in condition was due to their respiratory diagnoses, and they had those diagnoses all the time, and their respiratory status could be challenged by other issues, as well. An interview on 07/20/23 at 12:55 PM with the DON and Administrator revealed the DON did not know if Resident #1 was on oxygen when the physician saw her, but she was normally not when she saw her, and was at 97-98 percent on room air. She said they did not have anyone on orders for continuous oxygen, and that the orders in place (which had not included the parameters for O2 SATs) were a standard set of orders, and the nurses added how many liters. She said they had audited their O2 orders, and clarified them, and the nurses should clarify them when they received the physician orders. She said the physician and the ADON were responsible for making sure the orders entered were correct. She said one of the State Surveyors had said the resident was supposed to be on continuous oxygen, and they had called corporate to check, and there were notes where she was on room air, and was only on O2 in some of the notes. The Administrator said when the resident was waiting, she was stable, and was talking to him, and even got up to get on the gurney herself, and the EMS personnel took nine minutes to touch the resident, and it took them two minutes to leave with her because they were too busy arguing with his staff. He said the staff wanted them to take the resident to get checked out and were about to leave without taking the resident with them. An interview on 07/20/23 at 11:28 AM with Physician E revealed LVN A told her Resident #1 was not acting like herself, and was dizzy and sedated. She looked at the bag with the pills in it, the nurse found in the resident's room, and it had a lot of pills, hydralazine 300 mg and Neurontin 600 mg. She said Resident #1 did not look like herself, and started crying, and said she did not know what she took, because they did not know how much she took, of which pills, she told the nurse to send her to the hospital. When asked if she felt the resident needed to be monitored closely since one of the pills she might have taken (Seroquel) could cause respiratory distress, she answered EMS was there soon after and the resident was talking, so they were closely monitoring her. She said she was in the room with the resident around 7:30 AM to 7:45 AM. Physician E said the resident was on oxygen, but in the time between seeing Resident #1 and EMS arriving she saw other patients. She said Resident #1 was on continuous oxygen at her baseline and was always on continuous oxygen when she saw her, and was oxygen dependent. She said if someone who needed oxygen did not receive it for a long period, it could cause their CO2 to increase, and cause respiratory distress. She did not elaborate on what a long time meant. An interview on 07/20/23 at 3:54 PM with the Medical Director revealed Resident #1 was on oxygen the majority of the time due to her congestive heart failure diagnosis. She said Resident #1 was very non-compliant and had been refusing things, including her bi-pap. She said she was able to go to the restroom without her oxygen, but usually needed it. When asked by the surveyor if a nurse could tell a resident's vital signs by looking at them, she acknowledged that they could not. and stated Resident #1 should have had hers monitored during the situation, with an unknown amount of medication in her system. She said she had tried to instill in staff at the facility to assess, perform interventions appropriately, and notify her. When asked by the surveyor if being off oxygen could cause high carbon dioxide levels, she said it could. An interview with the DON on 07/21/23 at 1:50 PM revealed the was resident was stable, and being closely visually monitored by LVN A, the resident very often was non-compliant with her oxygen. She said the resident was observed by multiple staff, and the Administrator spoke with her for several minutes and she was not showing any signs of respiratory distress, and she even got up herself to get on the gurney. When asked by the surveyor if visual observation would allow someone to see a resident's vital signs, the DON acknowledged that it could not, and stated said that even so, visual observation was a crucial factor in monitoring conditions, and the nurses were educated to know signs of someone's oxygen levels dropping. She said Resident #1 returned on the previous evening (07/20/23), and she was doing well, and very happy to get back to the facility. An interview on 07/21/23 at 2:30 PM with the Administrator revealed EMS staff did not look concerned about Resident #1, and took a long time to arrive at the facility and a long time to get her to the hospital. He said he felt there was some retaliation going on against his staff, because the EMS staff had been argumentative with his staff, and not wanted to take Resident #1 because she initially said she did not want to go, and that one of them had probably called in a complaint. He said the documentation the EMS company provided them, and the numbers the State Surveyors had asked them about did not match up, and there were details in the documentation by the company that their camera footage showed to not be accurate, which included nowhere was her oxygen documented even close to the low percentages inquired about during this survey. He said they had set up a meeting with the company to discuss their concerns about the behavior of their company's staff, and he did not think this situation rose to the level of an IJ Record review of staff training records reflected the facility nursing staff attended a training given by a Respiratory therapist throughout the month of November in 2021. LVN A signed in and earned a certificate for the training on 11/10/21. The training was focused on patients with a trach and also appeared to cover general respiratory emergencies. LVN A attended the training and received a continuing education certificate. Record review of the facility policy for Notifying the Physician of Change in Status, revised 03/11/13, reflected The nurse will monitor and reassess the resident' s status and response to interventions. The facility failed to place an oxygen cannula and monitor the vital signs for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. This was determined to be an Immediate Jeopardy (IJ) on 07/20/23 at 1:06 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 07/20/23 at 1:06 PM. The following Plan of Removal submitted by the facility was accepted on 07/21/23 at 8:57 AM. Plan of Removal: 07/20/23 Plan of Removal Problem: F684 Quality of Care All residents have the potential to be affected by this deficient practice. Interventions: o As of 7/20/23, the resident remains in the hospital for evaluation. o All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of 7/20/23. No additional issues were found. o All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of 7/20/23 by the DON/ADON. No additional issues were found. o On 7/20/2023, the DON obtained clarification orders from the physician to ensure that accurate orders were in place in PCC. o LVN A was immediately suspended pending investigation on 7/20/2023. o LVN A will not be permitted to provide care to residents until the following 1:1 in-services have been completed. o Providing care to residents who are experiencing a change in condition or respiratory distress. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. In-services: o All charge nurses will be in-serviced by 7/21/23 by the DON/ADON regarding the following and all nurses not in-serviced by 7/21/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. o [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #1) of five residents reviewed for respiratory care. The facility failed to place an oxygen cannula for Resident #1 while she waited for EMS to arrive, after she ingested an unknown combination of prescription pills. This deficient practice resulted in actual harm, when Resident #1's oxygen levels dropped, resulting in her carbon dioxide levels being very high when she arrived at the hospital. In addition, oxygen orders for Resident #1 were incomplete, missing parameters for when oxygen was to be administered. An Immediate Jeopardy (IJ) situation was identified, regarding Resident #1 not having oxygen applied, on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk for respiratory distress, which could potentially lead to cardiac arrest. Findings included: Review of Resident #1's face sheet, dated 07/21/23, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (a lack of sufficient oxygen in body tissues), and diagnoses of COPD (chronic obstructive pulmonary disease- a disease which causes breathing problems, leading to low oxygen levels in the blood), heart failure, and traumatic brain injury. Review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had impaired vision, was able to be understood, and understood others. Resident #1 had a BIMS score of 11, which indicated moderate cognitive impairment. She had no psychosis or behaviors. Resident #1 required limited assistance from one person to transfer and bathe, but was able to walk, locomote using her wheelchair, eat, and perform hygiene on her own. She required extensive assistance from one person to get dressed. She was noted to have debility and/or cardiorespiratory (affecting heart function and breathing) conditions, which included heart disease, high blood pressure, history of pneumonia, respiratory failure, and COPD. Resident #1 used oxygen therapy and bi-pap or c-pap (a machine to help with breathing while sleeping.) Review of Resident #1's oxygen orders on 07/19/23 reflected an order with a start date of 06/04/23, May use oxygen @ 3 l/m via nasal canula during the day one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. Review of Resident #1's care plans reflected a care plan for oxygen use, revised 06/20/23. [Resident #1] has Oxygen Therapy. Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date. Date Initiated: 06/12/2023 Revision on: 06/20/2023 Target Date: 06/19/2023- For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Date Initiated: 06/15/2023 Created by: [ADON] - Monitor for s/sx of respiratory distress and report to MD PRN : Respirations, Pulse oximetry, Increased heart rate (Tachycardia), restlessness, Diaphoresis [excessive sweating], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lung], Hemoptysis [coughing blood from lungs], Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 06/15/2023 Created by: (ADON)- Oxygen per nasal canula as ordered Date Initiated: 06/05/2023 Created by: (ADON) Revision on: 06/12/2023 oxygen as ordered Date Initiated: 06/15/2023 Created by: (ADON) Revision on: 06/19/2023 - Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head of bed at 45 degrees). Date Initiated: 06/15/2023 Created by: (ADON) Also reflected were careplans for asthma (revised 06/20/23), congestive heart failure (revised 06/20/23), shortness of breath (Revised 06/20/23), hypertension (revised 06/20/23), altered respiratory status/ difficulty breathing/ shortness of breath re: Bi-pap (revised 06/20/23). Review of the facility transfer progress note, effective 07/18/23 at 8:02 AM reflected Resident #1 was transferred to the hospital for a change in condition. Review of Resident #1's progress note dated 07/18/23 at 7:43 AM, written by LVN A reflected Note Text: Resident observed in lying in bed unable to get to get self up. noted something was wrong, resident speech unclear, stating ' I dont know what is wrong with me, but I'm sorry' Resident was noted to have pills in a bag with no prescription bottle with medications. Resident was so confused that it was unclear many pills she had taken. MD was in the facility, assessed resident, and gave order to send resident out to hospital for further evaluation. ADMN , DON notified. Review of Resident #1's Transfer Form, effective 07/18/23 at 8:02 AM, reflected Resident #1 was being sent to the hospital, and her oxygen was 98% via oxygen mask. Under treatments and devices currently required oxygen was not selected. Review of Resident #1's Physician Progress note, written by Physician E, dated 07/18/23 (did not include time of assessment) reflected Chief Complaint / Nature of Presenting Problem: Pill bag found in patient's room, patient not acting like herself . History Of Present Illness: [AGE] year-old lady admitted to [Facility Name] on 6/3/2023 for rehabilitation or status post hospitalization for acute on chronic respiratory failure with hypoxemia and COPD exacerbation The patient has a medical history significant for COPD, methamphetamine use, memory loss, acute respiratory failure with hypoxia traumatic brain injury in 1982. She presented to the hospital with shortness of breath, Patient: Patient seen and examined in room. Patient was not acting like herself. Unable to provide an answer for any question. Asked patient about the pill bag and she said her friend has brought it for her. And patient is build back following gabapentin 300 mg and 600 mg. Also found hydroxyzine 50 mg pills. Patient kept on repeating I am sorry I will not do this again. Patient unable to tell how many pills she has taken. Sending patient to ER . Physical Exam General .Excessive sedation. Unable to keep eyes open. Unable to have full conversation. Review of Resident #1's blood pressure readings from the facility EMR reflected her blood pressure on 07/18/23 at 7:35 AM (when LVN A found resident with a change in condition), and 8:22 AM (four minutes before EMS walked into the facility) the readings for both were 142/72. Record review of Resident #1's oxygen readings from the facility EMR reflected her oxygen saturation on 07/18/23 at 8:23 AM (three minutes before EMS walked into the building) was 98% via oxygen mask. No data for her oxygen level was entered at the time the nurse found her with a change in condition. All oxygen readings from 07/08/23 to 07/18/23 t 7:35 AM reading reflected it to be the only reading for via oxygen mask. All other readings were for room air (six) or oxygen via nasal cannula (19). Record review of the EMS company's patient care report, dated 07/18/23, stated the O2 sats on 7/18/23 between 8:34 AM and 9:28 AM ranged from 66-82 O2%. The report included notes which indicated Resident #1 did not have oxygen on when they arrived. During this the pt had been moved over to the cot, secured, and vitals obtained. Pt was then found to be severely hypoxic on room air and a nasal cannula was then noticed on the pt's wheelchair. Pt was asked if on O2 and the pt. said she was. Pt was promptly placed on O2 via nasal cannula and the pt's O2 saturations began to improve .Pt was then moved out to the MICU for further treatment of hypoxia. In the MICU pt O2 saturations showed to have stalled at approximately 83% on O2 via nasal cannula. Pt was then placed on a NRB mask and then transported to [hospital]. En route pt showed to become more altered and appeared sedated. Pt was able to aroused [sic] with gentle physical stimulation and was still able to answer questions but had a hard time staying awake. Pt report was called into the hospital to notify of the pt's condition and given an ETA. Pt continued to be monitored and no further interventions were made en route. Upon arrival at the hospital ( .) Pt's RN was made aware of the situation around the pt's condition and how the pt had not been on her o2 prior to EMS arrival for unknown reasons. Review of the Emergency Department admission Sheet, dated 07/20/23, reflected Resident #1 arrived at the hospital on 7/18/23 at 9:31 AM complaining of dyspnea (shortness of breath). Per EMS Resident #1 was sent by nursing home staff for acute hypoxia (absence of enough oxygen in blood tissues) related to accidental drug overdose (Seroquel, Gabapentin and hydroxyzine.) Her primary admitting diagnosis was respiratory failure. Per the history of present illness documentation Resident #1's oxygen saturation percentage was in the 20s when EMS found her. They then placed her on a non-rebreather and her oxygen level improved rapidly. The ( .) vitals taken on 7/18/23 at 9:50 AM were blood pressure 148/70 , pulse 79, respirations 18 breaths per minute and oxygen blood saturation 100% on non-rebreather mask. According to the Physical exam Resident #1's appearance was somnolent, attention diminished, awakened to sternal rub, and moved all four extremities. Lab work collected on 7/18/23 at 9:58 AM revealed Resident #1's blood carbon dioxide levels to be over 100 (the normal range being 35-45), and a blood test of her oxygen reflected a result of 37 (the normal range being 80-105.) According to the ED deposition, due to an extensive history, physical exam and cardiopulmonary workup, Resident #1's presentation was consistent with COPD (lung disease) exacerbation. Despite typical ED treatment the resident did not improve to the point that which she would be able to return to the nursing facility safely and was admitted to the hospital for further treatment. An interview on 07/21/23 at 12:43 PM with the Administrator revealed he had not reported the incident with Resident #1 taking outside medications, because she stable, in no distress, and talking to him and other staff while she was in the facility. He stated they had investigated the issue with the family member bringing medications in, and the family member stated she had brought them, and given them directly to the resident. Observation of video sent to surveyor on 07/22/2023, by secure link, reviewed by surveyor on 07/24/2023 reflected: 07/18/23 at 8:08 AM, CNA B wheeled Resident #1 to nurses station, and placed her next to the front side of the station. When enlarging the video on the investigator's computer screen, Resident #1 did not appear to be wearing an oxygen cannula. No tubing was visible around her upper body/shoulders or on her face, and there was no indentation on her skin visible from the tubing. The back of her wheelchair was not visible due to the angle of the video, and the nurses station wall blocking the view. Resident #1's upper body was visible. She spoke and laughed with LVN A, who was inside the station, already seated at the computer, and was on the phone, the surveyor estimated a little more than arms-length away from the resident. LVN A could be seen turning her head frequently to look directly at Resident #1. The resident did not appear to be distressed, and sometimes appeared sleepy, but for a majority of the video was obviously awake and looking around. At 8:13 AM, the Administrator entered the front door of the facility and approached Resident #1, greeted her, placed his hand on her shoulder and turned into the hall where his office was located. He immediately turned and walked back to the station, and talked with LVN A, and they both looked at Resident #1 while they were talking. 8:14 AM CNA B returned with a can of soda, inserted a straw, and handed the can to Resident #1. Resident #1 was able to hold the can, manipulate the straw, drink, and set the can down on the station counter, with no apparent problems. Also at 8:14 AM the Administrator approached the resident, and leaned on the counter to talk with her. The resident appeared to be speaking during most of this conversation, appeared alert, and did not appear distressed. At 8:23 the Administrator walked away from the resident and entered the hall leading to his office. At 8:26 AM three EMS personnel could be seen entering the front door with a gurney. They approached LVN A and Resident #1. LVN D approached and had a conversation with them. LVN A was still on the phone and using the computer. EMS staff leaned on the counter and the gurney and conversed with Resident #1 while she drank her coke, and LVN D, walked away at 8:28 AM. At 8:32 Resident #1 unsteadily stood up, and placed herself on the gurney, while one EMS worker had his hand on her back, and held one of her hands. He assisted her getting her legs onto the gurney. The resident was lying on the gurney for approximately three minutes while EMS staff appeared to be arguing with LVN D and LVN A, two of the EMS personnel gestured emphatically with their hands as they spoke. One of them walked away from the conversation and applied the blood pressure cuff to Resident #1 at 8:33 AM. At 8:36 AM one EMS worker placed an oxygen cannula on Resident #1's face. At this time the other two EMS turned their attention to the resident, and appeared to be having a conversation with her. At 8:42 AM the EMS personnel walked toward the front door of the facility with Resident #1 on the gurney. The resident appeared to be awake and not in any distress when they rolled her away from the station. They stood at the door, and LVN A walked to the door and entered the code to exit at 8:43 AM. An interview with the complainant on 07/18/23 at 4:21 PM revealed Resident #1 went to the hospital after taking pills at the facility, from a bag a family member provided her, and the resident was not wearing her oxygen when EMS arrived. The resident was placed on oxygen by the EMS personnel, and when they checked her O2 SATS (oxygen saturation levels), she was at 29%, which was an indication she had been off her oxygen for some time. The complainant stated the documentation showed the nurse had taken the resident's vitals just before EMS arrived, and her oxygen level was at a normal level, but the resident was hypoxic when they arrived, and could not have become so that quickly. The complainant stated the resident was pleasant and cooperative, and a little altered and sedated and had a TBI (traumatic brain injury) but was still able to talk to them. An interview on 07/19/23 at 1:15 AM with LVN A revealed when she was waiting for EMS to come get a resident, she would monitor all the vital signs, which included oxygen, and document the time of the assessment, at that time. She said she found Resident #1 in her room, in bed, when she would normally be up, and when she spoke, she did not sound right. She said she took Resident #1's blood pressure, and the resident was apologetic and said she wouldn't do it again. When she asked her what she did, she found pills in a bag. The physician came into the room, and the vitals recorded at 8:22 AM were the ones she took at an earlier time, when the physician saw the resident. They figured out that the pills were gabapentin and hydralazine. The physician told LVN A to send Resident #1 to the hospital to be assessed. She said Resident #1 had COPD and always wore oxygen and only took it off to go to the bathroom. She said she took the vitals right when the situation occurred, when she discovered the resident with a change in condition, but did not take them again before EMS arrived, because the times were close enough together that she did not need to. She said the resident was at risk of passing out, but she was right at the nurse station, asking for soda, and talking, and in no distress, and did not need to have her vital signs monitored. An interview on 07/19/23 at 1:25 PM with CNA B revealed he was a PRN CNA and had been the one to get Resident #1 dressed and ready to go to the hospital. He said she did not have oxygen on when he saw her. An interview on 07/20/23 at 9:14 AM with Resident #1's family member revealed Resident #1 had to be held at the hospital because of her oxygen levels, and she was requiring too much oxygen. She said they needed to get her back to a level where she would be safe at the facility. She said when she was in the hospital, her oxygen requirement was seven liters, and they had her down three, and would be discharging her soon. An interview on 07/20/23 at 9:09 AM with the DON revealed she felt LVN A did a good job monitoring Resident #1. She said she would expect visual monitoring was appropriate in this case, and she had the resident in her line of vision, so she could notice whether she showed any changes, and could reassess her. She said she was not aware Resident #1 was not wearing her oxygen, but she barely wore oxygen, and she definitely did not recall her being on oxygen all the time. She said the resident was often up, walking around the facility, and not wearing her oxygen. She said she thought the resident told EMS as they were leaving she had taken Seroquel and gabapentin from the bag of pills her sister brought. She said she was alert, and talking, and drinking her coke without fumbling, and did not seem to be in any sort of distress, and was just twitching a little, and groggy, from the medication. She said she did not have any residents with continuous oxygen orders, including Resident #1. An interview on 07/20/23 at 9:33 AM with CNA B revealed saw Resident #1 trying to get up and staggering when he was passing breakfast trays on 07/18/23, so he went in to help her. He said she had her oxygen on then, but he had to help her change clothes and get ready for EMS, so he was not sure if the oxygen was on her when he took her to the front. He said she mostly used the oxygen in her room, but he did not see her using it often when she left her room. He said he saw her several times while she waited for EMS, and she did not appear to be in any sort of distress. An interview and observation on 07/20/23 at 10:33 AM in the hospital with Resident #1 revealed her to be alert, sitting up in bed, with four liters of oxygen running. She said she was always on oxygen, and only took it off to use the restroom. She said she felt great at the time of the interview, and it was not the pills that got her to the hospital, it was the oxygen. An interview on 07/20/23 at 10:14 AM with LVN C revealed if a resident with respiratory diagnoses was being sent out to the hospital, she would put their oxygen on them, and keep the monitor on their finger, and monitor their vitals. She said she would have oxygen on the resident, and would stay with them, or have someone else stay with them who could monitor their vital signs while she got the paperwork ready for EMS. She said Resident #1 often left her room without wearing oxygen, and it might have been ok to just visually monitor her , but she was not there when it happened, and was not sure of her condition when she was sent out. An interview on 07/20/23 at 11:02 AM with LVN D revealed the nurses had a class by a Respiratory Therapist a few months prior to this visit, because they were getting a resident who had a trach. She said they trained them on how to recognize respiratory distress, and what to do. She said if she was sending a resident out, who had COPD, she would monitor their oxygen by keeping the monitor on their finger, and keeping them by her, and checking their vitals every few minutes. She said she would not just use visual monitoring for oxygen , because you could not tell when someone's oxygen started to drop and by the time you saw signs it could already be very low. She said someone would need to be checking their vital signs, and keeping them on oxygen. LVN D said it did not make any difference whether the change in condition was due to their respiratory diagnoses, and they had those diagnoses all the time, and their respiratory status could be challenged by other issues, as well. An interview on 07/20/23 at 11:28 AM with Physician E revealed LVN A told her Resident #1 was not acting like herself, and was dizzy and sedated. She looked at the bag with the pills in it, the nurse found in the resident's room, and it had a lot of pills, hydralazine 300 mg and Neurontin 600 mg. She said Resident #1 did not look like herself, and started crying, and said she did not know what she took, because they did not know how much she took, of which pills, she told the nurse to send her to the hospital. When asked if she felt the resident needed to be monitored closely since one of the pills she might have taken (Seroquel) could cause respiratory distress, she answered EMS was there soon after and the resident was talking, so they were closely monitoring her. She said she was in the room with the resident around 7:30 AM to 7:45 AM. Physician E said the resident was on oxygen, but in the time between seeing Resident #1 and EMS arriving she saw other patients. She said Resident #1 was on continuous oxygen at her baseline and was always on continuous oxygen when she saw her, and was oxygen dependent. She said if someone who needed oxygen did not receive it for a long period, it could cause their CO2 to increase, and cause respiratory distress. She did not elaborate on what a long time meant. An interview on 07/20/23 at 12:51 PM with the DON and Administrator revealed the DON did not know if Resident #1 was on oxygen when the physician saw her, but she was normally not when she saw her, and was at 97-98 percent on room air. She said one of the State Surveyors said the resident was supposed to be on continuous oxygen, and they called corporate to check, and there were notes where she was on room air and was only on O2 in some of the notes. The Administrator said when the resident was waiting , she was stable, and was talking to him, and even got up to get on the gurney herself. The DON said orders were inputted by the nursing staff and sometimes the ADON would have to do it. The DON stated oxygen was a set order. She stated oxygen order set verbiage said something along the lines of 'may use oxygen via nasal cannula 2-3min/day.' The DON stated corporate was contacted to change the oxygen orders because the State Survey Agency questioned the facility about oxygen orders, so it made them go back and look at all the oxygen orders in the system since Resident #1's orders didn't specify continuous oxygen. She said the ADON was responsible for making sure the orders were correct in the system, but the former ADON was no longer with the facility about two weeks ago and now she only had one ADON. The administrator also stated the former ADON was the one responsible for making sure orders were inputted into the EMR correctly, since the residents' orders didn't display the correct orders. She explained since there was no one to fill the former ADON'S position no one had taken over the role of checking orders in the system to make sure they were correct. The Administrator stated he wasn't sure how often orders were assessed and monitored to know if a resident was on the correct medications, but he thought maybe every two months. An interview on 07/20/23 at 3:54 PM with the Medical Director revealed Resident #1 was on oxygen a majority of the time due to her congestive heart failure diagnosis. She said Resident #1 was very non-compliant and had been refusing things, including her bi-pap. She said she was able to go to the restroom without her oxygen, but usually needed it. She agreed that nurses could not tell what a resident's vital signs were by looking at them, and Resident #1 should have had hers monitored during the situation, with an unknown amount of medication in her system. She said she had tried to instill in staff at the facility to assess, perform interventions appropriately, and notify her. An interview with the DON on 07/21/23 at 1:50 PM revealed she did not believe the incident was an IJ, due to the resident being stable, and being closely visually monitored by LVN A, and because the resident very often was non-compliant with her oxygen. She said the resident was observed by multiple staff, and the Administrator spoke with her for several minutes and she was not showing any signs of respiratory distress, and she even got up herself to get on the gurney. She acknowledged during the interview that visual observation would not necessarily allow someone to see someone's vital signs, but said that visual observation was a crucial factor in monitoring condition, and that the nurses were educated to know signs of someone's oxygen levels dropping. She said that Resident #1 had returned on the previous evening (07/20/23), and she was doing well, and very happy to get back to the facility. An interview on 07/21/23 at 2:30 PM with the Administrator revealed he would share some additional information with the surveyors to consider, including the video footage, which showed the EMS staff arguing with his staff, and not assessing the resident immediately. He said they did not look concerned about her, and took a long time to arrive at the facility and a long time to get her to the hospital. He said he felt there was some retaliation going on, and that one of them had probably called in a complaint. He said the documentation the EMS company provided them, and the numbers the surveyors had asked them about did not match up, and there were details in the documentation by the company that their camera footage showed to not be accurate, including nowhere was her oxygen documented even close to the low percentages inquired about during this investigation. He said they had set up a meeting with the company to discuss their concerns about the behavior of their company's staff. Review of staff training records reflected the facility nursing staff attended a training given by a Respiratory therapist throughout the month of November in 2021. LVN signed in and earned a certificate for the training on 11/10/21. The training was focused on patients with a trach, but from the limited training materials available to the surveyor, also appeared to cover general respiratory emergencies. LVN A attended the training, and received a continuing education certificate. This was determined to be an Immediate Jeopardy (IJ) on 07/20/23 at 1:06 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 07/20/23 at 1:06 PM. An Immediate Jeopardy (IJ) situation was identified, regarding Resident #1 not having oxygen applied, on 07/20/23 at 1:06 PM. While the IJ was removed on 07/21/23, the facility remained out of compliance at a scope of isolated with a potential for actual harm, due to the facility's need to evaluate effectiveness of their corrective systems. The following Plan of Removal submitted by the facility was accepted on 07/21/23 at 8:57 AM: Problem: F689 Respiratory Care All residents have the potential to be affected by this deficient practice. Interventions: o As of 7/20/23, the resident remains in the hospital for evaluation. o All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of 7/20/23. No additional issues were found. o All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of 7/20/23 by the DON/ADON. No additional issues were found. o On 7/20/2023, the DON obtained clarification orders from the physician to ensure that accurate orders were in place in PCC, o LVN A was immediately suspended pending investigation on 7/20/2023. o LVN A will not be permitted to provide care to residents until the following 1:1 in-services have been completed. o Providing care to residents who are experiencing a change in condition or respiratory distress. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. In-services: o All charge nurses will be in-serviced by 7/21/23 by the DON/ADON regarding the following and all nurses not in-serviced by 7/21/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately. o Monitoring a resident for a change of condition until emergency services arrive which include vital signs and the need for oxygen supplementation every 15 minutes or sooner if a further decline is noted. o Charge nurses to follow physician orders to include oxygen orders. o Staff will educate residents and families to give all medications to the charge nurse if it is found that family or resident bring outside medications. o The medical director was notified by the administrator of this plan on 7/20/2023. An Ad Hoc QAPI meeting was held 7/20/2023. Monitoring: o Monitoring of this plan began on 7/20/2023 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from PCC at least 5 times per week to determine if vital signs including oxygen saturation remain within parameters and if not, the physician/NP will be notified. Monitoring began 7/20/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened shortness of breath is communicated to the physician/NP and follow up as needed. Monitoring began 7/20/23 and will continue x 4 weeks. o DON and/or designee will review the order listing report in PCC and monitor accuracy of all orders for oxygen 5 x a week during morning meeting for 4 weeks. Monitoring began 7/20/23 and will continue x 4 weeks. Monitoring of POR included the following: Interviews on 07/20/23, and 07/21/23 with charge nurses covering all shifts (LVN A, LVN C, RN E, LVN F, LVN G, LVN H) revealed they had been trained on all aspects of the incident with Resident #1, which included placing oxygen on a resident while they waited for EMS, and checking the resident's vital signs at least every 15 minutes, and as needed. They also had been trained and were able to answer questions regarding procedures for entering orders into the EMR, including oxygen parameters. All nurses were able to state why it was crucial to monitor vitals and not only observe a resident visually when