**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 as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 18 residents (Resident #91) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #91 on the secure unit, after he attempted to elope 20 minutes prior to eloping, out of the window on 12/31/23. An Immediate Jeopardy (IJ) was identified as past non-compliance on 11/21/24. The non-compliance began on 12/31/23 and ended on 1/2/24. The facility had corrected the non-compliance before the survey began on 11/19/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of Resident #91's undated face sheet revealed he was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. Record review of Resident #91's care plan revealed he was on a secure unit, was an elopement risk/wanderer and was at risk for possible injury related to his wandering and diagnosis of Alzheimer's Disease. The care plan also revealed Resident #91 eloped on 12/31/23 through his window in his room on the sercure unit. Record review of Resident #91's admission Wandering Assessment performed on 12/1/23 by LVN E at 8:04 p.m., revealed a score of 8 which indicating the resident was a high risk for wandering. Record review of Resident #91's Physician Orders by MD C, revealed an order for Memantine HCl Oral Tablet 5 mg, 1 tablet by mouth a day, for memory r/t Dementia. Ordered on 12/1/23. Record review of Resident #91's December 2023 MAR-TAR revealed, RN A documented the resident was having wandering behaviors on 12/31/23 during the day. Record review of the facility's provider report on 11/21/2024 revealed, the charge nurse was notified that the resident was found on 12/31/23 at 3:05 pm. The report said a complete search of the facility was performed for the resident and it appeared he left via the window. The report said three teams went to search for the resident via cars. It also said the alarm system was tested and was working properly. The report revealed the resident had set off the alarm about 20 minutes prior but did not elope. Per the report, maintenance staff tested the alarm system, and it was working properly. The alarm company also did a test of the system, and everything was working properly. The provider report also revealed the facility staffed dedicated a person to monitor the alarm and the resident for 72 hours after the elopement. Record review of Resident #91's nurses note dated on 12/31/23 at 3:00 pm from RN A stated, Resident set off the alarm, and he was redirected back to his room and staff reset the alarm. About 20 minutes later writer left the Hall to go pick up diagnostic results off the fax for another resident when writer came back to the Hall, one of the CNA's was standing in front of the last room on the right side of the hall, and she said one of the residents in that room is pointing at the window and it's open. Writer did head count and noticed that resident was missing. The note went on to say, RN A last saw the resident at about 2:45 pm, but CNA B was the last person to see him and that was in the dining room. The note said, [at 4:00pm] the police told [RN A] that he has been found that someone dropped him off at the Fire station on [street]. The note said the resident was back at the facility at 4:15 pm and Q15 minute checks were started. Record review of Resident #91's Wandering Assessment performed on 12/31/24 at 4:15 pm by RN A revealed a score of 7 which was a moderate risk for wandering. Record review of Resident #91's nurse's note from 12/31/23 at 6:31 pm by LVN D said, Resident sitting on the hallway in company of a CNA, resident pleasant and talking with staff, Q15 minutes round sheet on progress per facility protocol. CR Record review of Resident #91's history and physical performed by MD C on 1/2/24 revealed, Patient left facility, found at Vista and [NAME] Road. Found by [good Samaritan]. Fire Department brought him back. No new orders. In observation on 11/19/24 at 10:31am resident #91 is observed playing ball in the dining room with other residents with staff supervision. On 11/20/24 at 9:25am observed the alarm monitor screen which indicated it was on. Reviewed alarm company records. In an observation and interview on 11/20/24 at 9:30am resident stated he's doing good. He just took a shower. He states his hair is still wet and requests a towel. Did not observe resident wandering, messing with the windows, or trying to exit. During observations he in the dining room with other residents under staff supervision. In an interview with CNA B on 11/21/24 at 11:01 am, she said she was on her 1 hour break when the elopement happened. She said she left for break after they had given snacks to the residents and then came back around 3 pm. She said when she came back, the resident was gone, and they went outside looking for the resident, but could not find him. She said the police found him at a fire station and a citizen had picked him up and dropped him off there. She said the resident came back close to dinner time and the only complaint was that he wanted water. CNA B said herself, an agency CNA, and one nurse were working on the Secure Unit that day. She said her schedule was Saturday-Sunday from 6am-10pm. She said the windows did not have locks but had alarms that would go off and were loud enough to be heard all through the Secure Unit and outside of the unit by the door. She said to reset the alarm all the windows had to be closed and the alarm panel was at the nurse's station. The CNA stated they were trained on elopement and to notify the nurse as soon as a resident is missing. They search the whole building and perform head counts. In an interview with the Administrator on 11/21/24 at 1:04 pm, he said, he was at the facility for the incident with Resident #91. He said there was no exact answer on how the resident got out. He said the facility partnered with the VA and sent them all the information he had, and they were not concerned . He said the incident happened on a weekend, on a Sunday, and the alarm went off earlier in the day. He said RN A reset the alarm and he thought Resident #91 must have disarmed the alarm because it was working earlier in the day, and no one heard an alarm go off. He said the alarm system worked very well and he had the alarm company come out and check it and it was fine. He said some one found Resident #91 on and took him to the fire station. The Administrator said the Police Department brought Resident #91 back to the facility. He said they performed a Missing Resident in service on how to search for the resident and an in-service on Abuse and Neglect. The Administrator also said Resident #91 was placed on Q15min checks for multiple days. In an interview with RN A on 11/21/24 at 4:12 pm, she said, earlier in the day, the alarm went off in the Secure Unit, but she was not sure why. She said another nurse re-set the alarm. She said she left the Secure Unit to grab an order off the fax and left an agency CNA on the Secure Unit to watch the residents while she left. She said when she got back, the CNA and another resident were pointing into a resident's room. RN A said she went to the room and the window was open and it was Resident #91's room. She said she immediately performed a head count and realized Resident #91 was missing. She said she had performed a head count right before she left the unit to get the lab order off the fax and seen Resident #91 in the dining room. She said CNA B had just left for break and she had seen him before she left. RN A said the facility had not had any other issues with the alarms before that day. She said the alarm that went off earlier in the day could have been from Resident #91's window but she could not remember. Record review reveals resident has not eloped since 12/31/23. Record review of facility's policy and procedure on Elopement (no revision date) read in part: Nursing personnel must report and investigate all reports of missing residents. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. Determination of missing resident either by routine nursing rounds or door alarms: Note: A resident is determined missing when he/she leaves the facility without the staff knowledge .Should an employee observe a resident leaving the premises, he/she should: attempt to prevent the departure: obtain assistance from other staff members in the immediate vicinity, if necessary .Should an employee discover the resident is missing from the facility, he/she should: Report to the charge nurse, determine if the resident is out on an authorized leave or pass. If not; make a thorough search of the building(s) and premises .Provide search teams with resident identification information, Make an extensive search of the surrounding area . It was determined this failure placed Resident #91 in an IJ situation from 12/31/24 to 1/2/24. The Administrator was notified and provided with the IJ template on 11/21/24 at 5:34 p.m. The facility took the following action to correct the non-compliance on 1/2/24:. o The facility had Maintenance check the alarm system several times to ensure it was working properly. o The alarm company came out the next day on 1/2/24 at 9 a.m. - 11 a.m. and checked the whole alarm system and ensured it was working. o The alarm company replaced the sensor on Resident #91's window as a precaution. o An employee was placed on the unit who was dedicated to monitoring the alarm and the residents for 72 hrs from 12/31/23 to 1/3/24. o Maintenance tested the alarm system, daily, for 7 days after the incident . o In services on facility elopement, resetting the alarm system, and abuse/neglect were given on 1/2/24 and ongoing. o Rounds were done every 15-minute checks on Resident #91 on 12/31/23, 1/1/24, 1/2/24, 1/3/24. o The incident was brought to QAPI . unknown date. No other issues with elopement since 12/31/23. In an interview with RN A on 11/21/24 at 4:12 pm interviewee stated they had in services on elopement, which included performing a head count and searching the whole building for the resident. Then contacting the police as soon as possible. In an interview on 11/21/24 at 5:17 p.m. CNA B said they were trained on elopement and to notify the nurse as soon as a resident is missing. They search the whole building and perform head counts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 (CR #2) residents reviewed for notification of changes in that: The facility failed to notify the physician when CR #2 displayed a change in condition on 1/22/23. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. While the IJ was removed on 8/31/23 at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk for a decline in health, and possible death. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on 1/22/23 and expired on 1/28/23. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised 12/4/22, revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's lab results from 1/13/23 revealed potassium 5.2 (normal 3.5-5.2), BUN 31 (how well kidneys are functioning, normal 6-25%), Creatinine 1.79 (how well kidneys are functioning, normal 0.57-1.11), and eGFR 28 (how well kidneys are working, normal >60). Record review of CR #2's medical record revealed a progress note from 1/17/23 by MD #1 that stated the reason for the appointment was for a sick visit. CR #2's Labs reviewed creatinine 1.79, potassium 5.2. No significant leg swelling, no shortness of breath. Discontinue Spironolactone. Record review of CR #2's medical record revealed one blood pressure recorded for 1/22/23 at 7:32am, and it was 111/72. Record review of CR #2's MAR for 1/22/23 revealed an order to record the Side Effects to Hypnotic/Sedative Medication: (0)None, (1)Anxiety, (2)Blurred Vision, (3)Confusion, (4)Daytime Sedation, (5)Dizziness, (6)Fatigue, (7)Hallucinations, (8)Headache, (9)Mania, (10)Nightmares, (11)Syncope, (12)Urinary Retention, (13)Other, to be done Every day and night shift. The answer for Days on 1/22/23 by LVN #A was (0) or None. Record review of CR #2's medical record revealed she had the following medications ordered by MD A: - Amlodipine Besylate Tablet 5mg, 1 PO QD, started on 2/5/22 - Aspirin Tablet Chewable 81mg, 1 PO QD, started on 1/16/18 - Bupropion HCl ER Oral Tablet Extended Release 12 Hr 100mg, 1 PO QD, started on 1/13/23 - Lasix Tablet 20mg, 1 PO QD, started on 11/5/21 - Lisinopril Tablet 5mg, 1 PO QD, started on 2/6/21 - Multivitamin, 1 PO QD, started on 7/1/21 - Docusate Sodium 100mg, 1 PO BID, started on 10/21/20 - Memantine HCl Tablet 10mg, 1 PO BID, started on 10/2/17 - Depakote Sprinkles Capsule Delayed Release 125mg, 1 PO TID, started on 11/19/22 Record review of CR #2's medical record revealed she received the following medications on 1/22/23 by MA A: - amlodipine Besylate 5mg tab PO at 8:00am - aspirin 81mg chewable tab PO at 8:00am - bupropion HCL 100mg PO at 8:00am - Lasix 20mg PO at 8:00am - lisinopril 5mg PO at 8:00am - multivitamin PO at 8:00am - docusate sodium 100mg PO at 8:00am and 4:00pm - memantine 10mg PO at 8:00am and 4:00pm - Depakote sprinkles 125mg PO at 8:00am, 12:00pm, and 4:00pm. Record review of CR #2's medical record revealed a progress note from 1/22/23 at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs 114/92, HR-64, RR-20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for 1/22/23. Record review of CR #2's EMS report from 1/22/23 at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3 for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. Record review of CR #2's hospital record's from 1/22/23, revealed a patient registration form stating admit date was 1/22/23 at 10:16pm to ICU due to UTI, septic shock, and renal failure. Record review of CR #2's hospital records also revealed an H&P from 1/23/23 which indicated she had pyuria (infected urine), leukocytosis (elevated white blood cells) at 13.54, elevated lactic acid (indicator of systemic infection), and renal failure with BUN 79, creatinine 4.13, and GFR 10. According to the H&P, CR #2 was seen in room xxx and was obtunded (unconscious). The H&P also revealed CR #2 had a BP of 42/26 on 1/22/23 at 8:15pm, BP of 77/42 early in the morning of 1/23/23, and a BP of 60/39 on 1/23/23 at 1:00am. It was also revealed CR #2 had coarse rhonchi throughout her lungs and was on 2 L/min of O2 via NC. Her GCS was 7 with E(1), V(1), M(5). According to the assessment/plan from the H&P, CR #2 had a urinary tract infection with severe sepsis, aspiration pneumonia, acute renal failure with acute hyperkalemia, and acute metabolic encephalopathy. Record review of LVN A's statement from 6/27/23 at 2:30pm revealed on 1/21/23 CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on 1/22/23 that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on 7/26/23 at 11:01am she stated she remembered CR #2 and that she was sleepier on 1/22/23 then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on 7/26/23 at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on 1/22/23 because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on 1/22/23. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with the DON on 7/26/23 at 11:43am she stated she was not there the day the incident happened because it was a Sunday. She stated it was normal for CR #2 to sleep all day sometimes, if she stayed up all night, and was a heavy sleeper. She stated LVN A had worked with CR #2 for about 5yrs and knew the resident well. She also stated that she was told the family member left for about 3hrs, and if she was that concerned about CR #2, she would not have left. The DON stated the family member went to the facility more than any other family member and staff knew what the family wanted/expected and would not have left the resident like that. She also said if a family member wanted a resident to be sent to the hospital, there were no questions asked and they sent them right away. In an interview with CR #2's family member on 7/26/23 at 12:03pm, she revealed she arrived at the facility on 1/22/23 between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, 1/20/23 and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on 7/26/23 at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday 1/20/23 and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview with MD A on 9/1/23 at 12:pm revealed, he was CR #2's doctor for many years, and he knew she was declining. He stated she had been diagnosed with heart failure, kidney failure, COPD, as well as dementia. He said he had been fine tuning her medications to allow for all her chronic conditions. He said she was always friendly when she saw him, but lately he could tell she was not feeling well and was slowly declining. He stated he always monitored her lactic acid levels with her chronic kidney disease and liver disease, and there was a decline from her normal baseline. MD A confirmed he was not called on 1/22/23 when CR #2 first displayed a change of condition. Regarding the change of condition in a resident, he said the nurses at the facility were familiar with the residents, and knew their baseline. He revealed he would expect them to call him, call the family, and call 911 if an emergency. Record review of the facility's policy and procedure on Change in Resident Condition, with no date, read in part: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition . i. Instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) b. Impacts more than one area of the resident's health status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility Administrator received the IJ template on 8/30/23 at 2:44pm. The Plan of Removal (POR) was accepted on 8/31/23 at 2:50pm and reflected: Immediate Action Taken (Initiated (08/29/23) (Completion 08/29/23) 1. Resident #1 was discharged 911 to [Name of the Medical Center] on 01/22/2023 and did not return to the facility. On 08/29/2023 LVN A, B, and C on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in {EMR system]. This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated 08/29/23) (Completion 08/29/23) 2. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on 08/29/2023 and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses, on the following on 08/29/2023. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on 08/30/2023 and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in the EMR and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on 08/29/2023 were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. (Initiated (08/29/23) (Completion 08/29/23) 3. A Quality Assurance Performance Improvement meeting was held on 08/29/2023 at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on 08/29/2023. (Initiated 08/30/23) Completion 08/30/23) 4. The Medical Director was notified by phone of the additional IJ for Tag 580 - Notification to Physician. (Initiated 08/30/23) (Completion 09/01/23) 5. The Director of Nursing in-serviced all licensed nurses in the facility on 08/30/2023 on notification of the physician when a change of condition occurs. The charge nurse, LVN A, who was identified as CR#2 's charge nurse and both other nurses who worked that specific shift on 01/28/2023 received the in-service. All other licensed nurses in the facility, including two additional charge nurses, the ADON, wound care nurse, and two MDS nurses also received the training. All permanent nurses will be required to receive the same training prior to working any further shifts. Also, this in-service provision for any agency nurses or new hires will be on-going from 08/30/23. Any agency and new hires will be required to receive the training before they will be allowed to work a shift. On-Going Training (Initiated (08/29/23) (Completion 08/30/23) 1. While all staff present on 08/29/2023 completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated (08/29/23) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated (08/29/23) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated (08/30/23) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. They will also verify that the charge nurse notified the physician regarding that change of condition. From 8/31/23-9/1/23 a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On 8/29/31-8/31/23, the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on 8/29/23, including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on 8/29/23-8/31/23, revealed no concerns. Record review of in-services on 8/31/23 revealed nursing staff had a Change of Resident Condition in-service on 8/29/23 and 8/30/23, with a 5-question posttest. Record review of in-services on 8/31/23 also revealed nursing staff had a Notification of Physician, Family and Others in-service on 8/30/23 and 8/31/23. Record review on 8/31/23 revealed a QAPI meeting was conducted on 8/29/23 to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on 8/31/23 revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on 8/31/23 revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on 8/29/23-8/31/23. Interviews with CNA's on 8/31/23 revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on 8/31/23 revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on 8/31/23 revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on 8/31/23 at 3:46 PM. While the Immediate Jeopardy was removed on 8/31/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident (CR #2) reviewed for quality of care. -The facility failed to provide needed care and services resulting in a decline of CR #2's physical, mental, and psychosocial wellbeing on 1/22/23. -CR #2 was identified as unresponsive at 11:00am on 1/22/23 by the family, and only at the request of the family was CR #2 sent out to the hospital. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. While the IJ was removed on 8/31/23 at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk for a decrease in their physical, mental, and psychosocial wellbeing. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on 1/22/23 and expired on 1/28/23. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised 12/4/22, revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's medical record revealed a progress note from 1/22/23 at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs 114/92, 64, 20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for 1/22/23. Record review of CR #2's EMS report from 1/22/23 at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3, for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. On 1/28/23 at 9:26am the ICU progress note revealed CR #2 had an O2 saturation of 67%. A progress note from 1/28/23 at 4:50pm revealed CR #2's time of death was 4:50pm. Record review of CR #2's Certificate of Death issued 2/22/23, revealed the cause of death as aspiration pneumonia with severe sepsis. Record review of LVN As statement from 6/27/23 at 2:30pm revealed on 1/21/23 CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on 1/22/23 that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on 7/26/23 at 11:01am she stated she remembered CR #2 and that she was sleepier on 1/22/23 then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on 7/26/23 at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on 1/22/23 because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on 1/22/23. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with CR #2's family member on 7/26/23 at 12:03pm, she revealed she arrived at the facility on 1/22/23 between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. The MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, 1/20/23 and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on 7/26/23 at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday 1/20/23 and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview on 8/2/23 at 8:50am with the Activities Director she stated, the family member went to her office on 1/22/23 around lunch time and asked her to come look at CR #2. When the Activities Director got to the room and saw CR #2, she thought the resident was just sleeping. She said she saw the resident was not waking up when the family member was trying to wake her up. She stated that she whispered in the family member's ear to send her out to the hospital and was trying to convince her to call EMS. She said that she was only the Activity Director and did not want to step on anyone's shoes, so she stayed in her lane and could not tell the nurse's what to do. She said the incident happened before lunch and she did not see the family member anymore after that because she got busy with her activities, and she did not know what happened after that. In an interview with MD A on 9/1/23 at 12:pm revealed, he was CR #2's doctor for many years, and he knew she was declining. MD A confirmed he was not called on 1/22/23 when CR #2 first displayed a change of condition. Regarding the change of condition in a resident, he said the nurses at the facility were familiar with the residents, and knew their baseline. He revealed he would expect them to call him, call the family, and call 911 in an emergency if there was a decline from her baseline. The facility Administrator received the IJ template on 8/30/23 at 2:44pm. The Plan of Removal (POR) was accepted on 8/31/23 at 2:50pm and reflected: Immediate Action Taken (Initiated (08/29/23) (Completion 08/29/23) 1. Resident #1 was discharged 911 to (Name of Medical Center) on 01/22/2023 and did not return to the facility. On 08/29/2023 three charge nurses on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in (name of EMR). This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated 08/29/23) (Completion 08/29/23) 2. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on 08/29/2023 and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses, on the following on 08/29/2023. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on 08/30/2023 and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in (name of EMR) and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on 08/29/2023 were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. (Initiated (08/29/23) (Completion 08/29/23) 3. A Quality Assurance Performance Improvement meeting was held on 08/29/2023 at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on 08/29/2023. (Initiated 08/30/23) Completion 08/30/23) 4. The Medical Director was notified by phone of the additional IJ for Tag 684. On-Going Training (Initiated (08/29/23) (Completion 08/30/23) 1. While all staff present on 08/29/2023 completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated (08/29/23) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated (08/29/23) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated (08/30/23) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. They will also verify that any non-emergency physician orders are being administered and that any resident who experienced an emergency change in condition was transported to the nearest hospital via 911. From 8/31/23-9/1/23 a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On 8/29/31-8/31/23, the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on 8/29/23, including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on 8/29/23-8/31/23, revealed no concerns. Record review of in-services on 8/31/23 revealed nursing staff had a Change of Resident Condition in-service on 8/29/23 and 8/30/23, with a 5-question posttest. Record review of in-services on 8/31/23 also revealed nursing staff had a Notification of Physician, Family and Others in-service on 8/30/23 and 8/31/23. Record review on 8/31/23 revealed a QAPI meeting was conducted on 8/29/23 to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on 8/31/23 revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on 8/31/23 revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on 8/29/23-8/31/23. Interviews with CNA's on 8/31/23 revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on 8/31/23 revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on 8/31/23 revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on 8/31/23 at 3:46 PM. While the Immediate Jeopardy was removed on 8/31/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to identify CR #2 was unresponsive on 1/22/23. LVN A got CR #2 into her wheelchair and attempted to give her water to drink, when she was unresponsive. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. While the IJ was removed on 8/31/23 at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place all residents at risk for inadequate or delayed treatment and interventions, based on inaccurate assessments. Findings include: CR #2's undated face sheet revealed she was an [AGE] year-old female readmitted on [DATE], with diagnoses of Alzheimer's Disease, major depression (extreme sadness, tearfulness), hypertension (high blood pressure), heart failure (heart does not pump blood efficiently), and dysphagia (trouble swallowing). CR #2 was sent to the hospital on 1/22/23 and expired on 1/28/23. Record review of CR #2's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15, which indicated severely impaired cognition. CR #2 required extensive assistance with bed mobility, transferring, eating, and locomotion. CR #2 used a wheelchair and was always incontinent of bowel and bladder. No was answered to the question, Life expectancy of less than 6 months? According to the MDS, CR #2 required a mechanically altered diet (a change in texture of food or liquids like pureed foods, thickened liquids, Etc.). Record review of CR #2's care plan, revised 12/4/22, revealed Resident has DX of Alzheimer/Dementia. Resident has short- and long-term memory deficits. Needs moderate assistance with decisions-Resident will have no S/S of side effects to medications through next review date: Observe for change in mental status, increased behaviors, confusion, and notify MD. Observe for/document/report to MD and changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness .level of consciousness, mental status. The resident has ADL Self Care Performance deficits regarding .eating r/t cognitive deficits .and resisting care-The resident will remain clean, dry, odor free and appropriately dressed daily with interventions through next review date: Resident requires extensive assistance and verbal cue for eating. Provide physical assistance as needed. Encourage and assist as need to upright position for meals and PO intake. Record review of CR #2's lab results from 1/13/23 revealed potassium 5.2 (normal 3.5-5.2), BUN 31 (how well kidneys are functioning, normal 6-25%), Creatinine 1.79 (how well kidneys are functioning, normal 0.57-1.11), and eGFR 28 (how well kidneys are working, normal >60). Record review of CR #2's medical record revealed a progress note from 1/17/23 by MD A that stated the reason for the appointment was for a sick visit. CR #2's Labs reviewed creatinine 1.79, potassium 5.2. No significant leg swelling, no shortness of breath. Discontinue Spironolactone. Record review of CR #2's medical record revealed one blood pressure recorded for 1/22/23 at 7:32am, 111/72. Record review of CR #2's MAR for 1/22/23 revealed an order to record the Side Effects to Hypnotic/Sedative Medication: (0)None, (1)Anxiety, (2)Blurred Vision, (3)Confusion, (4)Daytime Sedation, (5)Dizziness, (6)Fatigue, (7)Hallucinations, (8)Headache, (9)Mania, (10)Nightmares, (11)Syncope, (12)Urinary Retention, (13)Other, to be done Every day and night shift. The answer for Days on 1/22/23 by LVN A was (0) or None. Record review of CR #2's medical record revealed she had the following medications ordered by MD A: - Amlodipine Besylate Tablet 5mg, 1 PO QD, started on 2/5/22 - Aspirin Tablet Chewable 81mg, 1 PO QD, started on 1/16/18 - Bupropion HCl ER Oral Tablet Extended Release 12 Hr 100mg, 1 PO QD, started on 1/13/23 - Lasix Tablet 20mg, 1 PO QD, started on 11/5/21 - Lisinopril Tablet 5mg, 1 PO QD, started on 2/6/21 - Multivitamin, 1 PO QD, started on 7/1/21 - Docusate Sodium 100mg, 1 PO BID, started on 10/21/20 - Memantine HCl Tablet 10mg, 1 PO BID, started on 10/2/17 - Depakote Sprinkles Capsule Delayed Release 125mg, 1 PO TID, started on 11/19/22 Record review of CR #2's medical record revealed she received the following medications on 1/22/23 by MA A: - amlodipine Besylate 5mg tab PO at 8:00am - aspirin 81mg chewable tab PO at 8:00am - bupropion HCL 100mg PO at 8:00am - Lasix 20mg PO at 8:00am - lisinopril 5mg PO at 8:00am - multivitamin PO at 8:00am - docusate sodium 100mg PO at 8:00am and 4:00pm - memantine 10mg PO at 8:00am and 4:00pm - Depakote sprinkles 125mg PO at 8:00am, 12:00pm, and 4:00pm. Record review of CR #2's medical record revealed a progress note from 1/22/23 at 5:20pm by LVN A that stated, [Family] in facility concerned about Resident not opening her eyes and not speaking throughout the day. Request for transfer to Patients ER for evaluation. On call Nurse notified of request. Called [name of EMS] and they stated they do not have units out today. On call notified and called 911. Upon arrival of EMS vs 114/92, 64, 20, 97%, glucose 74, 97.5 vs stable. Resident continues hard to arouse. [Family] request to continue with transfer to Patients ER. Resident leaves via stretcher and report called. No other notes were documented for 1/22/23. Record review of CR #2's EMS report from 1/22/23 at 5:42pm revealed she was unresponsive and had weakness to her left and ride side. At 5:50pm it revealed CR #2's GCS (used to objectively describe extent of impaired consciousness) was E (best eye response) 2, V (best verbal response) 1, M (best motor response) 3, for a total score of 6 out of 15 which indicated severely impaired consciousness. The E/V/M were scored from 1 (no response) to 4 (normal response). At 6:12pm CR #2 was intubated (a tube in the throat to breathe for you). According to the EMS narrative it revealed, Patient is unconscious and only responsive to pain. It also stated, Facility was unable to obtain vitals. EMS left the facility at 6:07pm and arrived at the hospital at 6:20pm. Record review of CR #2's hospital record's from 1/22/23, revealed a patient registration form stating admit date was 1/22/23 at 10:16pm to ICU. Record review of CR #2's hospital records revealed an H&P from 1/23/23 which revealed CR #2 had a BP of 42/26 on 1/22/23 at 8:15pm, BP of 77/42 early in the morning of 1/23/23, and a BP of 60/39 on 1/23/23 at 1:00am. It was also revealed CR #2 had coarse rhonchi throughout her lungs and was on 2 L/min of O2 via NC. According to the labs from 1/22/23 she had pyuria (infected urine), leukocytosis (elevated white blood cells) at 13.54, elevated lactic acid (indicator of systemic infection), and renal failure with BUN 79, creatinine 4.13, and GFR 10. Her GCS was 7 (severe) with E(1), V(1), M(5). According to the assessment/plan from the H&P, CR #2 had a urinary tract infection with severe sepsis, aspiration pneumonia, acute renal failure with acute hyperkalemia, and acute metabolic encephalopathy. Record review of CR #2's ICU progress notes from 1/24/23 revealed she was still unconscious, had a foley catheter, and was on 4 L/min of O2 via NC. The ICU progress note from 1/25/23 revealed CR #2's urine culture came back positive for an MDRO-E. Coli. It also revealed CR #2 had to be switched to a NRBM at 4 L/min of O2. It also stated CR #2's ABG revealed hypoxia and her chest x-ray was worse than the previous one. On 1/28/23 at 9:26am the ICU progress note revealed CR #2 had an O2 saturation of 67%. A progress note from 1/28/23 at 4:50pm revealed CR #2's time of death was 4:50pm. Record review of CR #2's Certificate of Death issued 2/22/23, revealed the cause of death as aspiration pneumonia with severe sepsis. Record review of LVN As statement from 6/27/23 at 2:30pm revealed on 1/21/23 CR #2 was fine and ate all 3 meals in her wheelchair. LVN A received in morning report on 1/22/23 that CR #2 did not sleep well through the night. LVN A got CR #2 out of bed for breakfast, into her wheelchair, and into the dining room. Per LVN A's statement, she did not wake up enough to eat breakfast, but she was able to wake her up to drink fluids. After breakfast, LVN A laid CR #2 back down in bed, changed her and took her vital signs, which were stable. LVN A's statement revealed before lunch, her and another staff member tried to get CR #2 up, but she was resisting and replied no when asked if she wanted to get up. The 2 staff members changed CR #2 and left her in bed with the HOB raised. Per the statement, when lunch came CR #2 did not wake up to eat, but LVN A checked her vitals, and they were stable (the only vital signs in the medical record were at 7:32am). LVN A's statement said, before dinner they changed CR #2, got her up into the wheelchair and took her to the dining room. Resident CR #2 still said no when asked if she wanted to get up, but since she did not eat lunch, LVN A got her up anyway. During dinner CR #2 did not eat, and her family member came and requested her to be sent to the hospital. LVN A stated her vital signs were stable (the only vital signs in the medical record were taken at 7:32am). EMS arrived and checked CR #2's vitals and they were stable. According to LVN A's statement, EMS asked what they wanted to do because the patient was ok with her eyes closed but was replying verbally very little and vitals were stable. EMS was told to take CR #2 to the hospital for further evaluation d/t sleeping throughout the day. In an interview with MA A on 7/26/23 at 11:01am she stated she remembered CR #2 and that she was sleepier on 1/22/23 then most days. She said it was normal for CR #2 be sleepy though, because sometimes she would stay up all night and then sleep during the day. She did not remember giving medications to CR #2, how awake she was when she took them, or how she took them because it was too long ago. She stated she made sure residents were awake enough before giving medications by ensuring they could open their eyes, say something, and take a sip of water first. In an interview with LVN A on 7/26/23 at 11:15am she stated it took 2 people to get CR #2 into a wheelchair on 1/22/23 because she was so sleepy, and she was not able to assist getting into the wheelchair. She also stated CR #2 resisted when they were changing her. LVN A stated CR #2 opened her mouth to drink when she asked her to, but never opened her eyes. She also said she did not feed CR #2 anything, and only gave her water to drink. LVN A stated she could not wake up CR #2 when tapping her shoulder or calling her name, but that was normal for her when she did not sleep at night. She stated she did not open her eyes, but she would say 1 word like no every now and then. When LVN A changed her, she said CR #2 pushed against them and resisted. LVN A stated her vital signs were normal so there was nothing wrong. She stated she did not feel the resident had a change in condition because she was sleepy like this sometimes during the day, when she stayed up all night. She stated she felt like it was okay for her to have gotten CR #2 into her wheelchair, even though she was sleepy, because she had the dining table in front of her so she could not have fallen. LVN A did not remember she documented 0 or none, for side effects to hypnotics/sedatives on 1/22/23. LVN A said she did not understand how EMS could have scored CR #2 as a GCS of 6, because she was not. In an interview with the DON on 7/26/23 at 11:43am she stated she was not there the day the incident happened because it was a Sunday. She stated it was normal for CR #2 to sleep all day sometimes, if she stayed up all night, and was a heavy sleeper. She stated LVN A had worked with CR #2 for about 5yrs and knew the resident well. She also stated that she was told the family member left for about 3hrs, and if she was that concerned about CR #2, she would not have left. The DON stated the family member went to the facility more than any other family member and staff knew what the family wanted/expected and would not have left the resident like that. She also said if a family member wanted a resident to be sent to the hospital, there were no questions asked and they sent them right away. In an interview with CR #2's family member on 7/26/23 at 12:03pm, she revealed she arrived at the facility on 1/22/23 between 11:00am and 11:30am and found CR #2 unresponsive in her bed. The family member called out CR #2's name, patted her on the shoulder, and gave her a hug and she still did not respond. The family member went and spoke to LVN A, who stated CR #2 was just really sleepy from staying up the night before. The family member asked MA A why CR #2's food tray was still on her bedside table because she always ate in the dining room. The MA A stated LVN A was unable to get CR #2 to eat, so she was going to try again later. The family member stated she told LVN A that CR #2 was not just sleepy and then went back to the resident's room. The family member stayed with CR #2 for a while and stated LVN A never came back into the room. The family member stated she left the facility for about 45min to get her phone charger and a change of clothes because she was going to send CR #2 to the hospital when she got back. The family member stated when she got back to the facility, LVN A told her she was able to get CR #2 to eat some cake and drink some water while she was gone. Then she saw CR #2 in the dining room in her wheelchair, slumped down in the chair with her head hanging back on the wheelchair. She tapped CR #2's arm and called her name, and she did not respond. The family member went back to LVN A and told her she wanted CR #2 transported to the hospital. The family member stated that LVN A said, You want her transported to the hospital? She is just sleepy. The family member said yes, and CR #2 was taken to her room to be changed. According to the family member, when EMS arrived LVN A told EMS She thought CR #2 was just sleepy, but the family member wanted her transferred. The family member stated CR #2 never opened her eyes the whole time she was there and never said one word. Also, the family member stated she last saw CR #2 on Friday, 1/20/23 and she was up in her wheelchair in the lobby, and they were laughing and having a good time. The family member also stated that CR #2 would be sleepy sometimes from staying up all night, but she could be woken up by calling her name or tapping her on the arm. She said she never had been in such a deep sleep that she could not have been woken up. In an interview with LVN B on 7/26/23 at 12:48pm she revealed she had worked with CR #2 for more than 5yrs and knew her and her family member well. She stated she worked with CR #2 on Friday 1/20/23 and she was awake, alert, and her usual self. She stated that CR #2 would sometimes be sleepy during the day but could be woken up by talking to her or tapping her shoulder. She also stated that it would be abnormal if CR #2 did not wake up or respond if she tried to wake her. LVN B stated she ensured residents were awake enough before giving them something to eat/drink by making sure their eyes were open, and they were talking first. She also stated on the days CR #2 was sleepy, she would not get her out of bed because she would be at risk of falling out of her wheelchair or hurting herself. She said she would not have gotten CR #2 out of bed, to her wheelchair, if she was that sleepy. She said she knew the family member really well and she did not feel that she was overreacting and would have believed that something was wrong. In an interview on 8/2/23 at 8:50am with the Activities Director she stated, the family member went to her office on 1/22/23 around lunch time and asked her to come look at CR #2. When the Activities Director got to the room and saw CR #2, she thought the resident was just sleeping. She said she saw the resident was not waking up when the family member was trying to wake her up. She stated that she whispered in the family member's ear to send her out to the hospital and was trying to convince her to call EMS. She said that she was only the Activity Director and did not want to step on anyone's shoes, so she stayed in her lane and could not tell the nurse's what to do. She said the incident happened before lunch and she did not see the family member anymore after that because she got busy with her activities, and she did not know what happened after that. Record review of the facility's policy and procedure on Change in Resident Condition, with no date, read in part: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition . i. Instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) b. Impacts more than one area of the resident's health status . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status . 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility Administrator received the IJ template on 8/30/23 at 2:44pm. The Plan of Removal (POR) was accepted on 8/31/23 at 2:50pm and reflected: Immediate Action Taken (Initiated (08/29/23) (Completion 08/29/23) Resident #1 was discharged 911 to (Name of Medical Center) on 01/22/2023 and did not return to the facility. On 08/29/2023 three charge nurses on duty, the Director of Nurses, the ADON, Wound Care Nurse, and two MDS nurses did an immediate assessment of all 101 residents in the building. All vital signs and any concerns regarding residents' physical, mental, and psychosocial conditions were documented in (name of EMR). This immediate action was initiated at 1:00PM by all 8 nurses and completed by 3:00PM. The medical director was also in the facility while 100% of residents were assessed. No residents were found exhibiting a change of condition of an emergency nature. All on-going concerns were already being addressed by the physician and staff (Initiated 08/29/23) (Completion 08/29/23) 1. The three charge nurses, LVN A, charge nurse #1 and identified as Resident #1's charge nurse, LVN B, charge nurse #2, and LVN C, charge nurse #3 were the three charge nurses who were in the facility on 08/29/2023 and helped conduct the initial assessments of 100 percent of the residents along with LVN D, wound care, RN A, ADON, LVN E, MDS and LVN F, MDS. All of the nurses on duty at that time were in-serviced by the Director Nurses on the following on 08/29/2023. RN B and RN C were the other two charge nurses working the shift that was identified in the immediate jeopardy. Both of them are being in-serviced on 08/30/2023 and are not scheduled to work for several days. a. Existing Change of Condition policy. No policy changes required. b. How to perform a complete resident assessment, including, vitals, other staff interviews, and concerns of a physical, mental, or psychosocial nature. c. How to properly document all findings in (name of EMR) and on the 24 hour report. d. Emergency Change of Condition requiring 911. In the event of a medical emergency regarding change of condition, the charge nurse shall immediately call 911 for transport to the nearest local hospital. The judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20 (b)(ii) shall be the guiding principle. e. Non-Emergencv Change of Condition requiring physician intervention, continued monitoring. The charge nurse shall notify the physician, nursing supervisor, and family (RP) of any significant change in the resident's physical, mental, and psychosocial status. The nurse will gather info on the resident and immediately contact the physician to obtain orders for the continued monitoring and treatment of the resident. All staff present on 08/29/2023 were required to take a five (5) question test following the in-service. Any staff not making a 100 were required to be in-serviced again by the DON. Then, they were required to take the test again. Anyone not passing after three (3) consecutive times were not allowed to work their assigned shift on that day, until all in-service requirements were met. All nursing staff present passed on their first try. Plan of Removal - 8/29/23 (Initiated (08/29/23) (Completion 08/29/23) 3. A Quality Assurance Performance Improvement meeting was held on 08/29/2023 at 12:00PM to review the allegations surrounding the Immediate Jeopardy and the plan moving forward related to the Plan of Removal. The Medical Director was notified and in attendance for the meeting on 08/29/2023 On-Going Training (Initiated (08/29/23) (Completion 08/30/23) 1. While all staff present on 08/29/2023 completed their in-service successfully, all other permanent, licensed nurses will be required to undergo the same in-service prior to working their assigned shift. (Initiated (08/29/23) (On-going) 2. If the facility requires the use of agency staff, they will be required to go through the same training as permanent staff. Each shift shall identify one charge nurse who has been properly trained in providing the in-service and training to the agency staff prior to their working their assigned shift. Agency staff [NAME] not be allowed to work unless they successfully pass the test per the above requirements. (Initiated (08/29/23) (On-going) 3. Newly hired staff will have this entire component of the same exact training and testing by the Director of Nurses built into their orientation process. No newly hired staff will be allowed to train on the floor until they successfully complete the training and pass the test in the same manner as all other staff. (Initiated (08/30/23) (On-going) 4. The DON and Administrator will review the 24 report daily for any changes in condition. From 8/31/23-9/1/23 a monitoring visit was conducted to ensure the facility was following it's POR. The visits revealed: On 8/29/31-8/31/23, the Director of Nursing began in-services with all nursing staff on change of condition and notification of physician. The Director of Nursing also had nurses perform assessments on all residents in the facility on 8/29/23, including vital signs. The DON also said she would monitor the 24hr report daily, for any change of condition reports. Record review of assessments performed by nurses on 8/29/23-8/31/23, revealed no concerns. Record review of in-services on 8/31/23 revealed nursing staff had a Change of Resident Condition in-service on 8/29/23 and 8/30/23, with a 5-question posttest. Record review of in-services on 8/31/23 also revealed nursing staff had a Notification of Physician, Family and Others in-service on 8/30/23 and 8/31/23. Record review on 8/31/23 revealed a QAPI meeting was conducted on 8/29/23 to review the Plan of Removal and the plan moving forward on trainings. Record review of the facility's policy and procedure on Notification to Physician, Family and Others on 8/31/23 revealed facility will inform the resident's physician, and resident's representative of any changes in the resident's physical, mental, or psychological status, including in emergency or non-emergency changes in condition. Interviews with nursing staff on 8/31/23 revealed they had training on changes of resident condition with a post-test. Nursing staff were able to describe what to do in an emergency and non-emergency changes of condition, including notifying the physician. Nursing staff also confirmed they assessed the residents on 8/29/23-8/31/23. Interviews with CNA's on 8/31/23 revealed they would let the charge nurse know about any change in condition in the resident, and they would stay with the resident. Observations and interviews with residents on 8/31/23 revealed they were satisfied with their care. They also confirmed that they had a nurse come and assess them in the last couple of days. Interview with the physician on 8/31/23 revealed he expected staff to call him, call the family, and call 911 if it was an emergency regarding change of condition. He stated the staff knew the resident's well and knew their baseline. The facility's ADM was notified the IJ was removed on 8/31/23 at 3:46 PM. While the Immediate Jeopardy was removed on 8/31/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.