**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Residents #1) reviewed for accidents hazards and supervision: The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility near the access road near the expressway on Saturday, 5/10/25. The facility did not have a plan in place for monitoring the front door to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. An IJ was identified on 5/28/25. The IJ template was provided to the facility on 5/28/25 at 5:04 p.m. While the IJ was removed on 5/30/25, the facility remained out of compliance at a scope of isolated and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of its corrective systems This failure could place residents at risk of experiencing accidents, injuries, and/or death. The findings included: Record review of Resident #1's face sheet dated 5/28/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 5/10/25 with diagnoses that included unspecified dementia unspecified severity (general term used to describe a decline in cognitive function that is severe enough to interfere with daily life and activities)-without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's MDS discharge assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and was independent with mobility. Resident #1's MDS did not indicate any behaviors. Record review of Resident #1's baseline care plan, undated, was blank. Record review of Resident #1's physician's telephone orders, dated 5/8/25 revealed to admit to respite for 5-day period from 5/8/25-5/13/25. There was no order for monitoring the resident. Record review of Resident #1's Clinical admission document, dated 5/8/25 revealed the resident was: - Alert and oriented x 3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Further review revealed the following areas were left blank: - the Mood and Behavior section, under the Wandering category - the Special Care section used to determine the reason Resident #1 was in the facility (Hospice, Respite Care, Palliative Care, Source of discharge goal) - the Care Planning section, page 20 to page 38 Record review of Resident #1's admission Function Abilities and Goals document, dated 5/8/25 revealed he had no functional limitations in range of motion, was independent with mobility, and did not require a mobility device. Record review of Resident #1's progress note dated 5/10/25, time stamped 4:18 p.m., and authored by the Administrator revealed: Resident (#1) has been observed with increased wandering throughout the facility. Hospice notified and stated the family had called earlier letting them know they would be back in town around 8:00pm and intended to pick resident up from respite today. Resident (#1) to DC home with all medication and personal belonging 5/10/2025. Record review of the facility Incidents/Accidents reports reviewed from March 2025 to May 2025 revealed there was no incident report regarding Resident #1's wandering/elopement. Observation on 5/28/25 at 8:15 a.m. revealed the front door to the facility was unlocked, no code was needed to enter the front door, and the front receptionist desk was unattended. During an interview on 5/28/25 at 10:05 a.m., the Activities Director stated she was familiar with Resident #1 and described the resident as very confused but easily re-directable. The Activities Director stated the front door to the facility had a day mode sound that triggered when the door opened and there was a receptionist scheduled day and night. The Activities Director stated, if the receptionist was not stationed at the front desk, the Executive Assistant would be able to see the desk from the glass door in the office. During a telephone interview on 5/28/25 at 10:33 a.m., Resident #1's family member stated the resident stayed at the facility for two nights and had never stayed there before. The family member further stated Resident #1 returned home (5/10/25) at baseline and did not have any concerns with the care except the facility could not find the residents clothes or shoes. The family member stated Resident #1 had further declined since the resident admitted to the facility on [DATE] and was not talking too much these days and was not interviewable. Resident #1's family representative stated she received notification on 5/10/25 about Resident #1 trying to leave the facility. Resident #1's family representative stated, I believe I was told about him (Resident #1) trying to leave the building. It was not the facility; it was the hospice company that called or texted me and told me he (Resident #1) tried to leave the building. During an interview on 5/28/25 at 10:49 a.m., CNA A stated she recalled Resident #1 leaving the building on a weekend, maybe a Saturday at the end of the shift, some time before 2:30 p.m. CNA A stated the code (Code Pink) was announced by an unidentified nurse and CNA B told her to start searching all the rooms. CNA A stated she and CNA C searched together and further stated CNA C was assigned on the hall Resident #1 resided on. CNA A stated two unidentified staff went driving looking for the resident. CNA A stated Resident #1 was found across the street by the highway and an unidentified staff stated, he's (Resident #1) there by the expressway. CNA A stated, CNA D and CNA B escorted Resident #1 back to the facility. CNA A stated she believed the event may have occurred between 1:00 p.m. and 2:00 p.m. CNA A stated she recalled an unidentified receptionist was on duty at the time. CNA A stated, there were times the receptionist would leave the reception area to deliver packages to the residents or to deliver messages to residents. CNA A stated, I'm sure the alarm was on when Resident #1 left, they are always on. It happened quickly. I'm glad we found him, but he made it across the street. CNA A stated Resident #1 was asked where he was going and said he was going home and had gone out the back door. CNA A stated the back door was locked and all of the doors have alarms and believed the alarms to all of the doors were working. During an interview on 5/28/25 at 11:12 a.m., CNA C stated she was assigned on Resident #1's hall and described the resident as confused. CNA C stated she recalled Resident #1 had left the facility and recalled assisting the resident with his meal while the resident was in his room on the day of the event. CNA C stated she picked up Resident #1's food tray after assisting him, could not recall the time, and could not recall if it was breakfast or lunch, and left the resident in his room. CNA C stated she returned to Resident #1's room, less than 15 minutes later, and the resident was gone. CNA C stated she asked staff if they had seen the resident, and CNA E told her Resident #1 was seen walking around the hallways. CNA C stated she continued her search and when she could not locate the resident she informed the nurses. CNA C stated, an unidentified nurse said Resident #1 was outside but could not recall where the resident was found. CNA C stated CNA D brought the resident back into the facility. CNA C further stated, I know some staff walked around to try to find him (Resident #1) outside and people drove in their cars to try to find him. CNA C then stated she believed the event happened after lunch. CNA C stated she believed the door alarms were working at the time and asked the receptionist, could not recall the name, if she had seen Resident #1 leave and the Receptionist said no. During an interview on 5/28/25 at 11:38 a.m., CNA E stated she was in the facility when it was reported Resident #1 went missing. CNA E stated she believed the event happened around lunchtime and was asked by CNA C if she had seen Resident #1. CNA E stated she saw Resident #1 across the street by the barricade that led to the highway. CNA C stated Resident #1 had crossed the access road and was brought back to the facility by CNA D. CNA E stated the Weekend Receptionist, name unknown, stepped away to go to the bathroom, and I guess that's when he (Resident #1) got out. CNA E further stated all the doors were locked and if you try to open them the alarm goes off. CNA E stated she believed Resident #1 went out the front door. During an interview on 5/28/25 at 1:29 p.m., the ADON stated RN F notified him Resident #1 was missing and the ADON in turn notified the Administrator. The ADON stated he arrived at the facility between 2:15 p.m. and 2:30 p.m. and Resident #1 was already at the nurse's station. The ADON stated RN F called the Code Pink, which indicated a resident was missing, and was told Resident #1 was found up front. The ADON stated all of the doors have alarms on them. During an interview on 5/28/25 at 1:49 p.m., the Administrator stated she was notified by the ADON about Resident #1 missing but could not recall what time she received the message. The Administrator stated she was approximately 4 to 5 minutes away from the facility and when she arrived Resident #1 was already at the nurse's station getting assessed by RN F. The Administrator stated she was told by RN F that the resident was found at the front of the building. The Administrator then stated, Resident #1 was gone for no more than 4 minutes. During a telephone interview on 5/28/25 at 2:17 p.m., RN F acknowledged she was informed by an unknown CNA that Resident #1 was not in his room and asked the CNA when she had seen the resident last. RN F stated the CNA told her about 5 - 10 minutes ago. RN F stated she had staff start a search and an unidentified CNA she described as a tall, thin African American male who worked the 2:00 p.m. to 10:00 p.m. shift found Resident #1 in the front of the building. RN F stated the Administrator and the ADON were in the building at the time she assessed Resident #1. RN F stated she believed the event occurred after lunch, before my 4:00 p.m. scheduled accu checks. During an interview on 5/28/25 at 3:01 p.m., CNA D stated he was about to start his shift, which began at 2:30 p.m. and was approached by an unknown nurse who informed him they were looking for a patient. CNA D stated he and CNA B went outside the front door and found Resident #1 in the parking lot in an area with bushes just inside the street. CNA D stated he was familiar with Resident #1 and described him as not really alert, not aware, and always looked lost. During an interview on 5/28/25 at 3:20 p.m., CNA B stated she heard an unidentified CNA saying somebody was missing on the day of the event at approximately 1:30 pm to 2:00 p.m. CNA B stated she was approaching the end of her shift at 2:30 p.m., when she and CNA D retrieved Resident #1 where the resident was found in the parking lot by the bushes. CNA B stated the resident appeared confused. During an interview on 5/28/25 at 3:40 p.m., the Maintenance Director stated he did random rounds of the door alarms and further stated he had installed additional alarms on the 100 and 200 unit. The Maintenance Director stated he was not sure when the door alarm for the front door was activated as there was a daytime mode and a nighttime mode. During a telephone interview on 5/28/25 at 4:24 p.m., LVN G acknowledged she recalled the event that occurred when Resident #1 went missing. LVN G stated, after it was determined Resident #1 was missing, LVN G went next door to the local gas station to search for the resident. LVN G stated she then spotted Resident #1 by the grass, not in the street, and the tall, African American male CNA went to get the resident. LVN G stated she had only worked for the facility for close to a month, the event happened so fast, and did not know about the alarm system. During a follow-up telephone interview on 5/28/25 at 5:33 p.m., Resident #1's family member stated the resident's hospice representative informed her about Resident #1 attempting to leave the facility. Resident #1's family member stated she was never told Resident #1 made it outside the facility. Resident #1's family member stated she could not always believe what Resident #1 said and stated the resident had significantly declined since his discharge from the facility on 5/10/25 and was no longer interviewable. Resident #1's family member stated, at the time the resident was discharged , and when she picked him up, Resident #1 told her he had gone out the back door and then went to the highway and was picked up. Resident #1's family member stated, there's no way he (Resident #1) could have gone to the highway, he would have been killed. I didn't question the facility about it. During an interview on 5/30/25 at 8:20 a.m., LVN H stated there was always a staff sitting at the receptionist desk during business hours. LVN H stated there was a receptionist at the front entry until 10:30 p.m. but the doors were locked after 5:00 p.m., and then the receptionist would have to get up and open the door. LVN H stated the Maintenance Director was in charge of checking the door alarms and if there was a problem with an alarm not working, the Maintenance Director would have to be notified. LVN H stated, if the receptionist who worked during their scheduled hours had to leave their post, we have somebody watch the doors for them until they return. LVN H stated the front reception area was not supposed to be left unattended. During an interview on 5/30/25 at 8:40 a.m., the Floor Technician stated there was supposed to be a person at the front reception desk at all times and they have somebody come in during the evening up until 10:30 p.m. The Floor Technician stated he sometimes checked the door alarms, but when there was a problem, he would report it to the Maintenance Director. The Floor Technician stated, when the doors were locked, the door alarm goes off if somebody was trying to leave or get in. An attempt at a telephone interview on 5/30/25 at 3:16 p.m., with Receptionist I was unsuccessful; the voicemail box was full and was unable to leave a message. During an interview on 5/30/25 at 3:31 p.m., the Executive Assistant stated she monitored the front door as part of her duties. The Executive Assistant stated she had other job duties, and if she was unable to monitor the front door, she would get somebody to cover the front door. The Executive Assistant stated she usually arrived at the facility between 6:30 a.m., and 6:45 a.m., and the doors were usually unlocked. The Executive Assistant stated she could monitor the front door from her desk until Receptionist clocked in at 4:00 p.m. The Executive Assistant stated the Receptionist worked until about 10:30 p.m., or 11:00 p.m., but the doors were locked at 5:00 p.m. The Executive Director stated if the front door alarm did not engage when it was opened, then the Maintenance Director had to be notified. During an interview on 5/30/25 at 3:52 p.m., the Weekend Receptionist stated she often worked the weekends from 11:00 a.m. to 11:00 p.m. and the Manager on Duty covered monitoring of the front door until she arrived at her shift. The Weekend Receptionist stated, if she had to leave her post, such as to take a bathroom break, she would go really quick, but I can still hear the door/chime/ringer. The Weekend Receptionist stated it was the responsibility of the Maintenance Director to ensure the door alarms were working. The Weekend Receptionist did not have recollection of the event when Resident #1 went missing. During an interview on 5/30/25 at 4:41 p.m., Receptionist J stated she worked the evening shift from 4:00 p.m. to 10:30 p.m., and the front doors were locked at 5:00 p.m. Receptionist J stated the front door had a ring/chime that activated each time the door was opened. Receptionist J stated if she had to leave her post, she had to get somebody to cover for her. Receptionist J stated she had to report to nursing at the end of her shift to inform them she was leaving, and the doors stayed locked. Record review of the facility document titled, Safety and Supervision of Residents, with revision date December 2007 revealed in part, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our facility-oriented approach to safety addresses risks for groups of residents .Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .Employees shall be trained and inserviced on potential hazards and how to identify and report accident hazards, and try to prevent avoidable accidents .Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .Resident Risks and Environmental Hazards .Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include .Unsafe Wandering . Record review of the facility document titled, Wandering, Resident, undated, revealed in part, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated .If the resident is not located, notify the Administrator, and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident .Complete and file an incident report . An Immediate Jeopardy was identified on 5/28/25 and the Administrator was notified of the Immediate Jeopardy on 5/28/25 at 5:04 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 5/29/25 at 4:12 p.m. and reflected the following: Nursing Facility F689 - Free of Accident Hazards/Supervision Devices - Resident (#1) was immediately placed on 1:1 (5/10/2025) - Hospice company notified of resident (#1) exit seeking (5/10/2025) - Resident had scheduled discharge planned (5/10/2025) - Medical Director Notified (5/28/2025) - Elopement assessments completed on all residents residing in facility (5/28/2025) - Any resident that scores at risk of elopement will be further evaluated to determine risk level for actual elopement. - The facility elopement policy was reviewed with all staff (5/28/2025) Actions to Prevent Occurrence/Reoccurrence: The Facility took the following actions to prevent an adverse outcome from reoccurring. - Facility exit points checked. (5/10/2025) - Front door monitoring is assigned to HR manager from 8:00am to 5:00pm and by the night receptionist from 4:00pm - 10:30pm on weekdays and on weekends by the manager on duty from 7:00am - 11:00am and then by the receptionist from 11:00am - 10:30pm. Door is alarmed to ring at various locations after 10:30pm to alert staff is [sic] someone is attempting to exit the facility. - Administrator ordered (2) door alarms to be added to two exit doors. One for a side exit door, and one for the back service exit. (5/13/2025) door alarms arrived and installed in facility (5/14/2025) - Maintenance Director checked all door alarms to ensure working condition (5/15/2025) - In the event of an elopement the facility will follow our elopement policy. - The Administrator or designee is responsible for ensuring the elopement policy education is being provided to all staff members and for providing oversight to ensure it is followed. In-servicing on policy on elopement to continue monthly for 3 months. - Beginning 5/28/2025 door alarm checks will be completed 3x per day per shift for 2 weeks. - Staff members responsible for front door monitoring were in serviced on ensuring front door monitoring goes uninterrupted, how to redirect residents and calling for help when needed. - An elopement in service was initiated within our learning management system and assigned to all staff members. This educational material includes our policy and procedure for an elopement to include a pre and posttest. (5/28/2025) - The admission process in service was initiated within our learning management system and assigned to all licensed nursing staff to include completing an elopement assessment and a baseline care plan. - Staff will acknowledge residents who are at risk of elopement by checking off the POC alert created. - Careplans were reviewed and updated for residents deemed to be at risk of elopement. (5/28/2025) The facility's POR Verification was as follows: Record review of the POR binder included: - Door alarm receipt of purchase dated 5/13/25 - Bell alarm receipt of purchase dated 5/29/25 - MD notification letter informing the physician of the IJ deficiency related to an elopement authored by the Administrator and dated 5/28/25 - Communication record of voicemail/text to families regarding signing out residents dated 5/28/25 - Elopement assessments and care plan updates of 65 residents completed by the ADON, MDS nurse and LVN Treatment Nurse K dated 5/28/25 -Management of the security of the front door in-service training of 16 department head staff presented by the Administrator/Designee with start date 5/29/25 and ongoing until completed - Elopement training records of 74 staff with completion dates from 5/28/25-5/30/25 - Incident/Accidents Training records of 48 staff with completion dates ranging from 3/25/25-5/29/25 - Registration Document for Staff Training indicating there were 79 staff registered to take the training on Elopement dated 5/30/25 Record review of the in-service titled Management of the security of the front door, dated 5/29/25 listed the following objectives: 1) The front door needs to be monitored at all times, if you need to leave the front reception or office area you must find someone to relieve you. 2) If any situation occurs calls for assistance via overhead paging or directly to the nurse's station. 3) Training on how to redirect residents who may express a desire to exit the facility. Interviews conducted on 5/30/25 from 7:29 a.m. to 4:46 p.m. with 31 staff from various shifts (LVN L, Director of Staff Development, LVN M, CNA N, LVN H, Floor Technician, Medical Records, RN Instructor, Housekeeping, CNA O, MDS Coordinator, RN P, CNA Q, Medication Aide R, Maintenance Director, CNA S, CNA D, ADON, RN Corporate Nurse (acting as interim DON), Executive Assistant, Weekend Receptionist, CNA T, Medication Aide U, LVN V, LVN W, CNA X, RN Y, Dietary Z, Receptionist J, Night Shift Cook, and the Dietary Supervisor) revealed facility staff stated they had been in-serviced on front door monitoring to ensure monitoring was uninterrupted, how to re-direct residents, how to call for help when needed, and how to follow the elopement policy which included educational training material with a pre and posttest. Record review of the in-service materials including the pre and posttest provided by the RN Corporate Nurse revealed training on identification of residents at risk of elopement, the process for continuity of assessments for those residents at risk of elopement, and a guideline to search for a resident who was missing or had eloped. Record review of the POR binder revealed the management of the security of the front door in-service training was signed by 16 department head staff and presented by the Administrator with start date 5/29/25. During an interview on 5/30/25 at 3:07 p.m., the RN Corporate Nurse stated she had created the in-service training materials and had assisted with in-service training. The RN Corporate Nurse stated there should be notification to the family, the physician, and the Administrator in the case of an elopement and the staff were supposed to follow the Code Pink protocol for a missing resident. During an observation with the Maintenance Director on 5/30/25 at 3:20 p.m. revealed all facility exit doors including the front door and all doors on the 100/200/300 Resident hallways alarms were tested for working efficiency with no concerns noted. Observation of the outside property gates for security locks were observed in place. During an interview on 5/30/25 at 5:30 p.m., the Administrator stated there were 79 staff employed at the facility and 77 out of 79 completed the Elopement training. The Administrator stated the two staff who did not complete the Elopement training was a new hire who had not yet started working on the floor and the other staff was out on emergency leave and could not be contacted. The Administrator stated the two staff who had not completed the Elopement training would be in-serviced prior to working on the floor. The Administrator further stated in-service training for completing incident/accident reports were completed with licensed nursing staff. On 5/30/25 at 5:41 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on 5/30/25, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, for 30 of 75 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 11 additional residents with rooms on the 200/100 hallways (all residents of 300 affected), 3 of 3 halls (halls 300, 200 and 100) and affected residents who utilized the facilities hallways, and main living area reviewed in that: 1. The facility failed to ensure Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29) had a warm and comfortable environment on 2/18/2025-2/27/2025 when the local weather temperatures were as low as 21 and the inside facility temperatures were as low as 51 degrees Fahrenheit (F). The facility temperatures affected all three hallways of the facility, the common living room area, and all rooms on the 300-hallway. This resulted from a known issue where the heater motor had been out since 1/22/2025 on the 300-hallway and the 200-hallways heaters did not function at a capacity to heat all of the resident rooms. In addition, the motor on the 100-hallway heater had not been operational affecting the hallways for an unknown period of time. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 2/21/2025 at 8:52 p.m. The IJ template was provided to the facility on 2/21/2025 at 8:52 p.m. While the IJ was removed on 2/28/2025 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor the implementation of the plan of removal. 2. The facility failed to ensure a hole in the ceiling of Resident #3 and #26's room was repaired in a timely manner. 3. The facility failed to ensure the cord to Resident #30's room over bed light cord was repaired timely. 4. The facility failed to ensure the toilet in Resident #20's room was repaired timely. These failures could affect residents result in discomfort, hypothermia, a decline in health and/or death. The findings included: 300-hallway Residents Resident #2 Record review of Resident #2's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: central cord syndrome level of cervical spinal cord (incomplete traumatic injury to the cervical (neck) spinal cord which results in weakness in the arms more than the legs), peripheral venous insufficiency (inadequate blood flow to extremities) and polyosteoarthritis (arthritis which affects 5 or more joints). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMs score of 13 which indicated he was cognitively intact. The MDS indicated he required touch assistance or supervision with transfers and bed mobility. Record review of Resident #2's care plan initiated on 12/03/2024 revealed his resident rights would be respected and maintained with interventions which included: he had the right to complain about care or treatment and receipt prompt response to resolve the complaint without fear of reprisal or discrimination. During an interview on 2/21/2025 at 4:20 p.m. Resident #2 stated it was awful cold in the days and the nights for several days. He stated he had on a winter hat, sweatpants, socks, shoes, and a vest. He stated his feet would not get warm even with socks. He stated he had 4 blankets of his bed. He stated there were a whole lot of people who were cold at the facility. He stated his room was on the 300-hallway. He stated during the night he heard several people crying out because they were cold. He stated he heard Resident #25 crying and would not stop, so he went to see if she was okay. (He stated she was laying on the floor and she had taken all of her clothes off. He stated she was crying because she was cold. He stated he put a blanket on her the best he could and told the nurse (unknown name). Resident #2 stated the nurse did come and get the lady dressed and covered her with blankets, but the lady kept taking the blankets off. Resident #2 stated every staff member in the building knew how cold the residents were. He stated he was going out of a limb by talking to the surveyor. He stated he did not want to make it hard on himself at the facility. He stated he was going out on a limb in hopes something could be done about it and in hopes there would not be retaliation. Resident #4 Record review of Resident #4's face sheet dated 2/23/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, spinal stenosis and hypertensive heart disease without heart failure. Record review of Resident #4's MDS revealed no assessment was completed due to new admission status. Record review of Resident #4's Progress notes dated 2/22/2025 revealed: family notified of room change due to in climate weather documented by the BOM. During an observation and interview on 2/21/2025 at 3:21 p.m., Resident #4 was in bed covered by multiple blankets. He stated he was cold even with extra blankets. He stated he was unsure how long it had been going on just that he was cold. During an interview on 2/21/2025 at 6:41 p.m. Resident #4 stated Of course it's cold in here. That's a silly question. Can't you see? when asked how the cold was affecting him. He stated when his whole body was under the covers, he felt warm. He stated when even the edge of his arms came out of the covers, he was cold. He stated he had not refused therapy or showers. He stated he was still going to therapy, but he did have to wear a hoodie or a jacket and hat to go to therapy because it was cold. He stated yes, he had told the staff he was cold (unknown name) and they provided blankets. Resident #5 Record review of Resident #5's face sheet dated 2/23/2025 revealed a 91-yo-female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: hypothyroidism, hypertensive heart disease without heart failure and chest pain. The face sheet indicated Resident #5 was discharged to another nursing facility on 2/21/2025 (at family request). Record review of Resident #5's BIMs evaluation dated 2/21/2025 revealed a score of 12 which indicated a moderate cognitive impairment. (MDS not completed due to new admission status). Record review of Resident #5's Care Plan revealed she was dependent on staff for ADL care. During an observation and interview on 2/21/2025 at 3:23 p.m. Resident #5 was observed in bed with multiple blankets including a large thick comforter. A portable mini heater was observed on in the room and the room felt warmer than some of the other rooms. Resident #5 stated she had been very cold. She stated it was very bad during the past night. She stated many of the residents could be heard during the night crying and screaming that it was cold. She stated last night she heard a man saying over and over that he was cold. She stated he was screaming he was cold. Resident #5 stated she also heard another person, right next to her room crying and saying it was cold. Resident #5 stated she was very worried about the other residents. She stated she had her family to help her, and they brought her extra blankets from home. Resident #5 appeared concerned and stated, Will you please help them? During an interview on 2/21/2025 at 3:26 p.m. two family members at Resident #5's bedside stated Resident #5 had only been at the facility for one day and that was enough. They stated the facility was freezing. They stated the facility had originally supplied a small portable heater, but it was not doing much to warm the room. They stated they brought supplies from home including the bedspread/comforter from the resident's home, extra blankets, and a larger portable heater. They stated this afternoon, after lunch a staff member came by to try to take away the portable heaters. They stated they told her no heaters but no explanation. They stated they would not remove their portable heater from the room because it was just too cold without it. They stated Resident #5 had told them about hearing other residents cry and scream out from cold during the night. They stated Resident #5 had refused therapy services today because she said she was too cold. They stated they had already arranged for Resident #5 to transfer to another facility. They stated they were just waiting on transportation and the transfer would occur this same evening. They stated an EMT who had transported Resident #5 to the facility the prior day had told them they should be ashamed of leaving their family member at the facility because it was freezing. One of the family members stated they felt very ashamed for not removing her at that very moment. Resident #5's family members stated the staff was very aware there was no heater, and the residents were suffering, and they were aware of why they were removing their family from the facility. Resident #19 Record review of Resident #19's face sheet dated 2/27/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus, protein-calorie malnutrition, and anemia. Record review of Resident #19's 5-day admission MDS dated [DATE] revealed a BIMs score of 8 which indicated a moderate cognitive impairment. Record review of Resident #19's progress note dated 2/20/2024 at 10:57 a.m. documented by RN U revealed: Resident refused lab draw x 2. Resident moved his own bed next to wall last night due to being so cold he could get warm by laying (sic) closer to wall. Resident redirected and refuse (sic) for bed to be moved . During an observation and interview on 3:13 p.m., Resident #19 was observed self-propelling his wheelchair in the hallway towards the front of the building. He was observed wearing two large extra think blankets and a knit winter hat. Resident #19 stated he was cold and wanted to go where it was warm. He stated they (staff) wanted him to stay at the nurses station but he did not want to because it was cold. He stated the heaters were not working and he stated again he was cold. At 3:17 p.m. of the hallway near Resident #19 by the Maintenance Director with his laser thermometer revealed the hallway temperature was 59 degrees. Resident #20 Record review of Resident #20's face sheet dated 2/23/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: hypothyroidism, type 2 diabetes mellitus without complications, morbid (severe) obesity. Record review of Resident #20's MDS revealed no assessment completed due to new admission status. Record review of Resident #20's progress notes dated 2/22/2025 at 11:11 am revealed Resident/family notified of room change due to inclement weather, documented by BOM. Record review of Resident #20's skilled nursing observation documented on 2/22/2025 revealed the resident was alert and oriented x 3, speech clear, able to understand and be understood. During an observation and interview on 2/21/2025 from 3:17 p.m. to 3:18 p.m. Resident #20 stated he was chilly even with extra blankets. He stated he had a little portable heater until a few minutes ago when a staff member came by and put the portable heater in his closet. He stated the room was warmer with the portable heater. An observation in Resident #20's closet revealed a small portable heater was in the closet. The Maintenance Director stated he did not know about Resident #20's portable heater or why it was taken away. He stated the 300-hallway had been having heater issues and had been that way since the (outdoor) temperatures had dropped. During an interview on 2/21/2025 at 6:37 p.m. Resident #20 stated he had refused some showers before because it was pretty cold at the facility. He stated he reported the cold facility temperatures to the BOM. He stated the BOM stated the facility had a contract and they would be putting mini-splits in the rooms. He stated while under the blankets he felt okay, it was when he got up to go to the bathroom when he was cold. He stated he was still getting up but tried not to be up for long. Resident #21 Record review of Resident #21's face sheet dated 2/24/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, protein-calorie malnutrition, atherosclerosis of native arteries of extremities with rest pain. Record Review of 5-day admission MDS dated [DATE] revealed a BIMS of 8 which indicated a moderate cognitive impairment. Dependent on staff for ADL care. Record review of Resident #21's weights revealed he weighed Standing 122 lbs. on 2/19/25. Record review of Resident #21's shower sheet dated 2/20/2025 revealed the resident refused a shower and an unknown staff documented to (sic) cold. During an observation and interview on 2/21/2025 at 3:29 p.m. in the 300 hallway with the Maintenance Director, Resident #21 was lying in bed in a thick sweater and a blanket. He stated he was okay right now. During an observation and interview on 2/21/2025 at 6:46 p.m., Resident #21 was visibly shivering while lying in his bed with one fleece blanket. Resident #21 stated, the cold made him shiver even with blankets. He stated he was shivering now. He stated he had refused showers all week because he was just too cold. He stated he had not refused therapy. He stated the staff knew he was cold, but he did not want to complain. During an interview on 2/21/2025 at 6:48 p.m. a family member #1 of Resident #21 was in the room for a visit. He stated there used to be a portable space heater in the room but for some reason the staff had pulled it. He stated the whole week had been cold at the facility. He stated he was cold just visiting. He stated he has talked to staff and facility management but did not remember the date. He stated he has heard residents tell staff and management they are cold, and everyone was just ignoring them. The family member stated, What are my options? He stated his other family member had talked to the Administrator about the conditions. He offered the phone number for the other family member and stated, she had a lot to say. During a telephone interview on 2/21/2025 at 8:28 p.m., a family member #2 of Resident #21 stated the local weather had been extreme and most of the residents at the facility were elderly. She stated the resident rooms were so cold. She stated she was informed by staff if she kept the resident room closed (on 300-hallway) with a space heater it would keep the room warm. She stated she visited at night and heard a man near her family members room crying and screaming that he was cold. She stated she gave the man her hat and saw him shaking but she did not know his name. She stated her family member had been complaining every day of the cold. She stated he had been tossing and turning because it was too cold for him to sleep. She stated her family member was so fragile and did not deserve to be treated like this. She stated she brought her family member extra blankets from home to cover him, but because he was so thick, he complained that the blankets felt heavy on him. She stated she complained to the nurses, and they offered blankets and the portable space heater. Resident #22 Record review of Resident #22's face sheet dated 2/27/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus without complications, emphysema, and major depressive disorder. Record review of Resident #22's 5-day admission MDS dated [DATE] revealed a BIMs score of 15 which indicated he was cognitively intact. The assessment indicated he required supervision or touch assistance for ADL care. During an interview on 2/21/2025 at 3:39 p.m. Resident #22 and a family member in the room, both dressed in layers stated they were not warm. They declined further interview at this time. Resident #23 Record review of Resident #23's face sheet dated 2/23/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnoses which included: fracture of unspecified part of neck of right femur, encounter for closed fracture, metabolic encephalopathy and type 2 diabetes mellitus. Record R review of Resident #23's progress notes revealed she had a history of removing clothing and behaviors. Record Review of Resident #23's MDS revealed one was not completed due to new admission status. Record Review of Resident #23's care plan revealed she was reliant on staff for ADL care. During an observation and interview on 2/21/2025 at 3:40 p.m. Resident #23 was wearing long sleeved layered clothes and a knit hat and wearing a blanket on her lap. She stated she was cold and did not know how to turn the heater. She was unable to answer further interview questions due to cognitive status. Resident #25 Record review of Resident #25's face sheet dated 2/23/2025 revealed a [AGE] year-old female with admission date of 1/27/2025 with diagnoses which included: cerebral infarction, vascular dementia moderate and hypertensive heart disease without heart failure. Record Review of Resident #25's 5-day admission MDS dated [DATE] revealed a BIMs score of 6 which indicated a severe cognitive impairment. Record review of Resident #25's shower sheet dated 2/19/2025 revealed the resident refused the shower at 9:00 a.m. and an unknown staff member wrote refused building to (sic) cold. During an observation and interview on 2/21/2025 at 6:55 p.m. Resident #25 was observed lying in bed in a fetal position with a hat and two blankets covering her. She stated she was trying to stay warm under the covers. She stated she still felt cold and was very uncomfortable. She stated she had not told anyone she was cold or uncomfortable because she did not know who to tell. During an observation and interview on 2/21/2025 at 7:05 p.m., Resident #25 was brought in her wheelchair to the nurse's station on 300-hallway. She stated she did not want to sit there because it was too cold. Resident #25 was observed wearing a winter knit hat, layered clothing, and had one fleece blanket draped across her legs. She stated she was not comfortable and hollered NO, it's fucking cold that's a stupid question. The interview was ended because the resident was agitated. 200-hallway Residents Resident #1 Record review of Resident #1's face sheet dated 2/24/2025 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: hydrocephalus, seizures, and generalized muscle weakness. Record Review of Resident #1's modification of quarterly MDS dated [DATE] revealed a BIMS of 4 which indicated a severe cognitive impairment and total dependence on staff for ADL care. Record review of Resident #1's shower sheet dated 2/21/2025 revealed an unknown staff member documented the resident refused the shower and documented refused to (sic) cold. Resident #6 Record review of Resident #6's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: cerebral infarction due to thrombosis of basilar artery (stroke), severe protein-calorie malnutrition, and hypertensive heart disease without heart failure. Record review of Resident #6's modified quarterly MDS dated [DATE] revealed a BIMs of 2 which indicated a severe cognitive impairment. The assessment revealed the resident was dependent on staff for ADL care. During an observation and interview on 2/21/2025 at 1:34 p.m. Resident #1 was observed in the 200 hallway while in bed wearing layered clothing which consisted of a shirt made of soft knit material, a flannel shirt which he had on backwards, socks on his feet and multiple thick blankets. Resident #1 stated it had been cold in the building for the last 3 days. He stated yes when asked if he had told a staff member if he was cold (unknown staff). Resident #6, also in the room was in bed wearing a jacket with hood which was pulled up on his head, 3 fleeces blankets and a sheet. Resident #6 did not respond verbally to questions. Resident #3 Record review of Resident #3's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: congestive heart failure, moderate protein-calorie malnutrition, and chronic pain syndrome. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMs of 13 which indicated he was cognitively intact. The assessment indicated the resident required moderate assistance with ADL care and was non ambulatory. Record review of Resident #3's Care Plan initiated on 9/18/2024 revealed his resident rights will be respected and maintained with interventions which included the right to complain about care and treatment and receive a prompt response to resolve the complaint without fear of reprisal or discrimination. Record review of Resident #3's shower sheet dated 2/20/2025 it was documented the resident refused a shower with a note that read Too cold. I will not take a bath or shower documented by CNA W. And Resident refused shower x 3 attempts. Too cold documented by LVN R. During an observation of room on the 200 hallway and interview on 2/21/2025 at 2:27 p.m. Resident #3 stated the room was really cold especially early in the morning. He stated he had asked for extra blankets. He stated he was not okay because it was still cold in the room, and nothing was being done. He stated he had told multiple people including the CNAs and nurses that he was cold, but he did not know the name of the staff he told. He stated the staff did not really say anything, but they did bring him another blanket. Resident #7 Record review of Resident #7's face sheet dated 2/27/2025 revealed an [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: secondary parkinsonism, schizoaffective disorder, type 2 diabetes mellitus, epilepsy, and hypothyroidism. Record review of Resident #7's annual MDS dated [DATE] revealed a BIMs score could not be obtained because the resident was rarely/never understood and had both short term and long-term memory problems. The assessment indicated the resident was able to recall with accuracy the location of his own room and had some difficulty with decisions in new situations only. The assessment indicated the resident needed supervision or touch assistance with mobility and transfers and moderate assistance for ADL care. Record review of Resident #7's care plan last revised on 2/17/2025 revealed he had diabetes mellitus with interventions which included avoid exposure to extreme heat or cold. During an observation and interview on 2/21/2025 at 1:33 p.m. Resident #7 was observed in a room on the 200 hallway seated in a recliner wearing layered clothing including a sweatshirt and hat with arms cross over his chest. Resident #7 did not respond verbally to questions due to cognitive status. Resident #8 Record review of Resident #8's face sheet dated 2/27/2025 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: iron deficiency anemia, cerebral infarction (stroke), and major depressive disorder. Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMs score of 11 which indicated a moderate cognitive impairment. The assessment indicated the resident required substantial maximal assistance for bed mobility and transfers and ADL care and was non-ambulatory. Record review of Resident #8's care plan last revised on 2/20/2025 revealed her resident rights would be respected and maintained with interventions which included the right to complain about care or treatment and receive prompt response to resolve the complaint without fear of reprisal or discrimination. Resident #9 Record review of Resident #9's face sheet dated 2/27/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: type 2 diabetes mellitus, bilateral osteoarthritis of knee and anorexia. Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMs score of 4 which indicated a severe cognitive impairment. The assessment revealed she was required moderate assistance with ADL care and transfers. Record review of Resident #9's care plan last revised on 1/09/2025 revealed she had a potential to be underweight due to anorexia and she was a fall risk in which staff should anticipate her needs. During an observation and interview on 2/21/2025 at 1:38 p.m. in a room on the 200 hallway, Resident #8 was observed wearing layered clothes, socks a sweater and had on two blankets. She stated she was cold. Further information was unable to be obtained due to cognitive status. Resident #9, who was not interviewable due to cognitive status was laying on her left side facing the door curled in a fetal position with multiple blankets covering her. Resident #10 Record review of Resident #10's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: type 2 diabetes mellitus, generalized anxiety disorder and protein-calorie malnutrition. Record review of Resident #10's quarterly MDS dated [DATE] revealed a BIMs score of 15 which indicated he was cognitively intact. The assessment indicated the resident needed supervision or touch assistance with ADL care and transfers. Record review of Resident #10's care plan last revised on 12/19/2024 revealed her resident rights would be respected and maintained with interventions which included the right to complain about care or treatment and receive prompt response to resolve the complaint without fear of reprisal or discrimination. Resident #11 Record review of Resident #11's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral palsy, type 2 diabetes mellitus, and Duchenne or [NAME] muscular dystrophy (progressive muscular and neurological disease that results in wasting and muscle atrophy and eventual death). Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. The assessment revealed the resident required supervision for ADL care and mobility. Record review of Resident #11's care plan revealed he was PASRR positive for developmental disability. Resident #8's care plan last revised on 11/27/2024 revealed her resident rights would be respected and maintained with interventions which included the right to complain about care or treatment and receive prompt response to resolve the complaint without fear of reprisal or discrimination. During an observation and interview on 2/21/2025 at 1:41 p.m. of a room on the 200 hallway, Resident #10 and Resident #11 were both wearing a sweatshirt over clothing. Resident #10 stated they were warm in the room as long as they stayed under the blankets, but at night it was too cold. He stated even in the daytime if he got out of the blankets, he was cold. He stated this had been going on for a few days. Resident #11 was unable to answer interview questions due to cognitive status. Resident #12 Record review of Resident #12's face sheet dated 2/27/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: moderate protein-calorie malnutrition, Alzheimer's disease with late onset, and generalized anxiety disorder. Record review of Resident #12's quarterly MDS dated [DATE] revealed a BIMs score could not be obtained because the resident was rarely/never understood and had both long term and short-term memory problems. The assessment revealed the resident required partial assistance with ADL care. Record review of Resident #12's Care Plan last revised 2/20/2025 revealed she had a history of weight loss with interventions to monitor weight loss. Resident #13 Record review of Resident #13's face sheet dated 2/27/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: malignant neoplasm of pancreas (cancer), generalized anxiety disorder and vitamin deficiency unspecified. Record review of Resident #13's 5-day admission MDS dated [DATE] revealed a BIMs of 6 which indicated a severe cognitive impairment. The assessment revealed she needed moderate assistance with ADL's. Record review of Resident #13's shower sheet dated 2/20/2025 revealed CNA A documented a shower refusal and wrote resident states that it is too cold. During an observation of a room on the 200 hallway and interview on 2/21/2025 at 1:43 p.m., Resident #13 was wearing long pajamas, a sweater and a thick robe over her clothes while lying under a fleece blanket. She had socks on her feet. She stated she was okay, but the room was cold, and her feet were staying cold despite the blankets and layers. Resident #12 was lying in a fetal position under multiple blankets and was not interviewable due to cognitive status. Resident #14 Record review of Resident #14's face sheet dated 2/27/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral infarction (stroke), mild protein-calorie malnutrition, and nutritional deficiency. Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMs score could not be obtained because the resident was rarely or never understood and had both long-term and short-term memory problems. The assessment revealed she was totally dependent on staff for all care. Resident #15 Record review of Resident #15's face sheet dated 2/23/2025 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: multiple sclerosis, Parkinson's disease, and protein-calorie malnutrition. Record review of Resident #15's 5-day admission MDS revealed a BIMs of 13 which indicated the resident was cognitively intact. Record review of Resident #15's Care Plan revealed she was dependent on staff for care. During an interview and observation of a room on the 200 hallway, on 2/21/2025 at 1:46 p.m. Resident #14 was observed lying in bed covered with multiple fleece blankets. She was not interviewable due to cognitive status. Resident #15 was lying in her bed which was underneath a large window. She was visibly shaking from head to toe. She was wearing layered clothing, socks with slippers and was covered with a fleece blanket. She stated she was very cold and stated she always shakes when she was cold. Resident #15 was unable to state how long this had been occurring or answer any detailed interview questions. Resident #16 Record review of Resident #16's face sheet dated 2/27/2025 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses which included: type 2 diabetes mellitus with diabetic neuropathy, protein-calorie malnutrition and dependence on renal dialysis. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMs score of 8 which indicated a moderate cognitive impairment. The assessment revealed he required moderate assistance with ADLs. Record review of Resident #16's Care Plan last revised on 2/20/2025 revealed the resident rights would be respected and maintained with interventions which included the right to complain about care or treatment and receive a prompt response to resolve the complaint without fear of reprisal

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 17 residents (Resident #63) reviewed for physician notification of changes. The facility failed to consult with Resident #63's physician and provide all necessary details to the DON when Resident #63 had a significant change in condition on [DATE], that included pain, vomiting, diarrhea, and low oxygenation and subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. The findings included: Record review of the admission Record reflected Resident #63 was a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of encephalopathy [group of disorders referring to brain disease, damage, or malfunction], noninfective gastroenteritis [inflammation in stomach or intestine] and colitis [inflammation in the colon], rhabdomyolysis [condition that causes muscles to disintegrate leading to muscle tissue death], and acute kidney failure. [admission Record did not reflect presence of gastrostomy tube, or advanced directive code status.] Record review of the comprehensive MDS assessment dated [DATE], reflected that Resident #63 entered the facility from a short-term general hospital. Resident #63 had unclear speech, but usually was able to make self-understood, and sometimes had the ability to understand others. Further in the document contained conflicting data indicating that a BIMS should not be conducted due to the resident was rarely/never understood. Resident #63 was coded as having both short-term, and long-term memory problems, and had some difficulty only in new situations requiring modified independence for daily decision making. Resident #63 was coded as partial/moderate assistance with eating at admission. Resident #63 was coded as not rated for both urinary and bowel continence as resident had a urinary catheter and had an ostomy [surgical procedure that creates an opening in the abdominal wall] or did not have a bowel movement. Resident #63 had health conditions noted of vomiting. Nutritional approaches included feeding tube with 25% or less total calories received thru the feeding tube; 500 CC [milliliters] per day by tube feeding. Record review of the Order Summary Report, printed [DATE] at 4:05 PM, reflected Resident #63 had physician's orders for CPR/Full Code status, dated [DATE]. Resident #63 had physician's orders for enteral feeding orders: two times a day 70 milliliters per hour [did not reflect formula type, total volume, time of administration, or contraindications]. Record review of Resident #63's Progress Note, effective date [DATE] at 5:45 PM and written by RN B reflected, Resident arrived via [redacted] Ambulance. EMS stated that nothing significant happened during transfer. [Medical Director] was informed of patients arrival. Stated to continue orders and medications from hospital as well as lab orders of CBC, CMP, Prealbumin, and Ammonia level. Orders to continue Osmolite [complete balanced nutritional formula for tube-fed individuals] at 70mL/hour and to check residuals on PEG tube [percutaneous endoscopic gastrostomy tube, or g-tube] every shift. Patient's emergency contact [Emergency Contact Name] was called at [Emergency Contact Phone Number] to inform her patient arrived. Patient resting comfortably. Record review of Resident #63's Progress Note, effective date [DATE] at 8:09 AM and written by LVN A reflected, Resident was restless throughout the night especially after midnight. He was receiving Osmolite 1.5 @ 70 ml/hr via g tube. Resident complained of stomach discomfort and started having emesis [vomiting] episodes x3. After the first emesis the feeding was turned off and the DON was called. I really wanted to see if we could send this resident out to the emergency room for eval[uation]. Vital 96/57 [blood pressure; according to the American Heart Association, a normal blood pressure for adults is less than 120/80, and low blood pressure is less than 90/60], o2 stat [sic] was 90 [normal oxygen saturation is between 95% and 100%]. I immediately got O2 and applied it when notice his sat[uration] had increased with the oxygen. She [the DON] stated that I should call the doctor and see what he wanted to do and that was done. Doctor did not return my call. Bed was changed at 0200 [2:00 AM] with stool and emesis. Changed again at 0315 [3:15 AM], 0400 [4:00 AM]. I decided to go back in the room to check on him with some fresh sheets just in case they were needed, and he was looking straight up to the ceiling, his eyes wide open and that alerted me to assess him pulled him off the bed onto the floor and get the Crash cart Started CPR at 0445 [4:45 AM] called EMS. they came and took charge. Record review of Resident #63's Progress Note, effective date [DATE] at 9:00 AM and written by LVN A reflected, 1800 [6:00 PM] Initial head to toe assessment was completed, Observed and assessed the g-tube and the feeding, Osmolite 1.5@ 70 ml per hour. @ being set up by the off going nurse. Family came in to visit and to sit with the resident. They introduced themselves and were very pleasant and attentive of [Resident #63's] care. They left after 2 hours at around 2200 [10:00 PM]. Re-evaluated residents g-tube area due to his complaint of pain. The stomach area was slightly red, but it was not an open area or a rash, g-tube site was not red or draining, abdomen was slightly distended and firm to touch. Resident had his first small BM which was soft around 2300 [11:00 PM]. Cleaned resident and changed his bed linen. He ask [sic] me to place something at his bedside because he was feeling nauseated and he thought he had to throw up. He did throw up brownish color secretion, 150 ml. Assisted resident to clean his mouth and placed a pad on the side of the bed so if he had another vomiting episode, he would have some type of covering over his bedding. He had another episode of nausea and vomiting and also he had medium size BM around 0000. Resident became restless and voiced general discomfort. Vital signs were B[lood]/P[ressure] 95/57, Heart Rate 99, O2 sat was 90% on RA [room air]. At this time O2 [oxygen] was applied at 4 lpm via face mask and it brought his O2 sat up to 97% on 4 lpm. Resident continued to be restless and complaining of discomfort to abdomen. Around 0445 [4:45 AM] DON was called and notified of residents change of condition, DON instructed me to call the Doctor. Dr. was called around 0445 [4:445 AM] and message left. Resident continues to be restless and vomits again with another BM around 0500 [5:00 AM]. Changed the bed linen and provided peri care to the resident and placed clean gown on the patient. I checked resident around 0530 [5:30 AM] and noted restlessness, nausea and vomiting, I emptied out his container at his bedside 200 ml brownish colored vomit. As I assessed the resident, noted he had another bowel movement, abdomen remained firm and slightly distended at this time, no change noted. Cleaned up the resident's area with fresh clean linen after peri care applied. I took the soiled linen to the soiled linen area, went to the nurses' station, and then returned to check on resident and noted he was staring straight up to the ceiling with his eyes wide open. I immediately assessed him for his response by calling his name, assessed him breathing and heart rate. They were absent, no heart rate or respiration, immediately I pulled resident off the bed onto the floor started CPR, I had to go and get crash cart came back and called EMS at 0647 [6:47 AM] and started CPR again. Checked for pulse again and initiated CPR. The EMS dispatcher stayed on the line with me until EMS arrived person and was giving instructions and gathering information on the resident while I continue CPR. EMS arrived and assessed the resident and pronounced him @06:56 [6:56 AM]. Record review of Resident #63's Progress Note, effective date [DATE] at 9:15 AM and written by the Treatment Nurse reflected, Contacted Medical Examiner to obtain release of body. Writer was advised additional information is needed. Contacted [family member]. Per [family member] resident was living with [family member] in an apartment prior to hospital admission. The [family member] stated that resident had been losing weight, and stopped eating and began rapidly declining after [family member] received dx [diagnosis] of metastatic breast cancer that had spread to her lungs. Per [family member], resident was admitted for malnutrition. The [family member] advised resident was not previously following with a PCP and was last evaluated by [Physician] 2-3 years ago. Per hospital records resident was found on floor with altered mental status and admitted . Imaging done in hospital and PEG tube placed. Per hospital records no suspicion of abuse. SNF Medical director to sign death certificate. ME notified. Advised by ME per resident age, and no suspicion of abuse/neglect/APS case resident does not meet criteria for autopsy. Resident body ok to release to funeral home. ME #[number], case #[number]. Called [funeral home] and notified them of TOD: 0656AM and that ME released the body. [Funeral Home] advised they would arrive for p/u in 30 min to 2 hours. Record review of Resident #63's Progress Note, effective date [DATE] at 11:00 AM and written by the DON reflected, Time of death was pronounced by EMS at 0656 [6:56 AM]. Record review of Resident #63's Progress Note, effective date [DATE] at 11:25 AM and written by the Treatment Nurse reflected, 2 staff from [Funeral Home] picked up resident body. Family aware. Interview on [DATE] at 6:59 PM, LVN A stated that on [DATE], he arrived for his first shift at 6:00 PM after completing training [new hire orientation] at the facility and was assigned to Station 3. LVN A stated that throughout the course of the night Resident #63 seemed very antsy, the skin of his stomach was red, and he would use his call light to call LVN A every 30 to 45 minutes and LVN A would attempt to comfort the resident. LVN A stated that at one point, Resident #63's oxygen saturation was lower than 90%, and he provided Resident #63 with supplemental oxygen, which raised Resident #63's oxygen saturation back up to 97%. LVN A stated that he changed Resident #63's bed linens multiple times that night due to the linens being soiled from Resident #63's dark brown vomit and bowel movement, and after answering a different resident's call light, he went to check on Resident #63. LVN A stated that he then found Resident #63 staring straight up at the ceiling and called Resident #63's name. After Resident #63 did not answer, LVN A walked to the resident, attempted to rouse him, said his name again, and noticed his eyes were fixed and dilated and Resident #63 had no respirations or pulse. LVN A stated that at that time, he lowered the resident from his bed onto the floor to initiate CPR and noticed emesis in Resident #63's mouth. LVN A stated that he attempted to clear the emesis from the resident's mouth by turning him on his side and continued CPR. LVN A stated that he left Resident #63 during CPR to obtain Station 3's Crash Cart and AED. LVN A stated that during CPR, he called the DON who instructed him to call 911 and the MD. LVN A stated that, according to the EMT's, when EMT's arrived at the facility, they made their way to Station 1 instead of Station 3, and it took a while for them to get to Station 3. LVN A stated once the EMT's arrived to Resident #63's room, they took over CPR on Resident #63. LVN A stated that there was no way for him to have contacted anyone at Nurses' Station 1 or Nurses' Station 2 because he did not know the phone numbers to Station 1 [100-hallway] or 2 [200-hallway] and instead used his personal phone to call the DON and 911. LVN A stated that since there were only 3 residents on Station 3 [300-hallway], there were no CNAs assigned to assist him that night on Station 3. LVN A stated that he did not think to call the MD or DON when Resident #63's oxygen saturation became low due to the resident's oxygen saturation going back up after LVN A had administered oxygen, and the color of the vomit was not concerning to him. LVN A stated the time line of events was as follows: around 11:00 PM Resident #63 complained of pain, had vomiting and fecal incontinence that soiled his linens; Resident #63 had another bout of emesis and fecal incontinence around midnight but also noted his oxygen saturation dropped and LVN A put supplemental oxygen on Resident #63 at 4 liters per minute which raised his oxygen saturation to acceptable levels; Resident #63 had emesis and fecal incontinence three more times at 2:00 AM, 3:15 AM, and 4:00 AM. LVN A stated he returned to check on the resident shortly after the 4:00 AM bout of emesis, around 5:30 AM, when LVN A realized that Resident #63 required CPR. LVN A started CPR immediately, called the DON and 911, and attempted to notify the MD, but did not receive a call back from the MD prior to EMS arriving at approximately 5:45 AM, at which time EMS took over CPR and ultimately pronounced Resident #63 as deceased . LVN A stated that at the time of the incident he did not have any co-workers phone numbers saved in his personal phone and only had the contact information for the DON. Interview on [DATE] at 7:33 PM, RN B stated that she assisted in the admission of Resident #63 and set up his peg tube before leaving the facility after completing her shift. RN B stated that when Resident #63 came in, he seemed depressed and had told her he did not want his PEG tube. RN B stated that her interaction with Resident #63 was brief, and the resident did not appear to be feeling ill before she left for the evening. RN B stated that with 3 residents on Station 3 [300-hallway], there was only one nurse per shift scheduled. RN B stated that a resident suddenly needing and being provided with supplemental oxygen was a change in condition and that the MD and DON should be notified immediately if that occurred. RN B stated that if staff need help, they usually called or texted from their personal cell phones to other staff on duty. RN B stated that other staff have always been very good about responding and assisting when need. RN B stated that, in her experience on day shift, staff would promptly respond or show up to provide hands on assistance as needed. RN B stated she was unsure if the other staff on duty had shared their personal cell phone numbers with LVN A at the time of the incident. Record review of the facility schedule and timecards for [DATE] and [DATE], dated [DATE], reflected that CNA M, CNA P, and NA U worked overnight. The facility schedule reflected that CNA M worked from 2:30 PM on [DATE] until 6:30 AM on [DATE], CNA P worked from 10:30 PM on [DATE] until 6:30 AM on [DATE], and NA U worked from 10:30 PM on [DATE] until 6:30 AM on [DATE]. In an interview on [DATE] at 7:09 AM, CNA M stated that she was the float CNA on her shift on [DATE]-[DATE]. CNA M stated she did not recall Resident #63. CNA M stated she did not recall any problems on the 300-hallway. CNA M stated that when she was assigned the responsibility to be the float CNA for her shift, the expectation was that she would go between the 100-hallway and the 200-hallway. CNA M stated the 300-hallway was not a part of the responsibility for the person assigned as a float CNA. CNA M stated she was not asked to assist with the 300-hallway, or to float to the 300-hallway, as the census was too low. CNA M stated the nurse was expected to perform all care tasks on the 300-hallway, due to extremely low census on that hallway. CNA M stated the 300-hallway reopened around [DATE]. A phone interview was attempted on [DATE] at 8:58 AM with CNA U that was unsuccessful. A phone interview was attempted on [DATE] at 9:24 AM with CNA P that was unsuccessful. Interview on [DATE] at 12:27 PM, the DON stated that on [DATE] around the 4:00 AM hour, LVN A called her and told her that he had put oxygen on Resident #63 and that Resident #63 did not feel good and had a distended stomach, and the DON informed LVN A to call the physician. The DON stated that she did not receive another call until after 6:00 AM when she was informed that Resident #63 had expired. The DON stated she did not receive any calls informing her that LVN A was conducting CPR. The DON stated that she was not on site while the resident was in the building and never met the resident. When asked if, in this incident, there was a change of condition that should have been reported to the MD, the DON stated that a resident who needed supplemental oxygen was a change in condition and that it was her expectation that staff call her and the MD if a resident was put on supplemental oxygen. The DON stated that while there was no CNA assigned to Station 3, there was generally a floating CNA who would assist where necessary. The DON stated that the MD had an after-hours phone number, and it was in a notebook at every nurses' station. The DON stated that the incident was brought to QAPI. The DON stated that if staff knew the phone number to the nurses' station, they would call from any resident room, but if they do not know the phone number, they would have to use the phone at the nurse's station. The DON stated that her expectation was that if CPR was being performed, the staff would call for assistance to another hall if necessary . The DON stated she was not aware that EMS went to the incorrect hallway, and believed LVN A called another hall for assistance but was not sure who LVN A called. The DON stated she did not receive a call from LVN A while he was performing CPR, and Resident #63 was stable when LVN A called her. The DON stated LVN A an experienced LVN but was new to the facility at the time of the incident. The DON stated this was LVN A's first shift after new hire orientation. The DON stated there was not a curriculum or training manual; but that she was in the process of developing one to include a check list of items all nurses needed to know. The DON stated new hires were trained on what to do, when to do it, and what forms were necessary in the EHR for change of conditions or emergency situations, or accidents and incidents. A phone interview was attempted on [DATE] at 1:38 PM with the MD that was unsuccessful. In an interview on [DATE] at 1:45 PM the DON stated the MD was on vacation. In an interview on [DATE] at 9:05 AM, LVN V stated she did not work with Resident #63 and was not aware of any issues on the 300-hallway until later. LVN V stated she was not aware of EMS being called until she saw the ambulance in the parking lot as she was exiting at the end of her shift at approximate 6:30 AM to 7:00 AM on [DATE]. LVN V stated prior to that she was not told there were any problems on the 300-hallway, was not asked for her assistance and was not directed by anyone to help out on that hallway. LVN V stated she normally worked on the 100-hallway. LVN V stated typically staff called or texted each other on their personal cell phones, but one could also call the facility's main phone number and it would ring at each of the nurses' station. LVN V stated she later heard that EMS went to 200-hallway first and that was how staff found out there was something happening on the 300-hallway. LVN V could not recall when or who told her that information. Record review of facility policy titled, Change in a Resident's Condition or Status, dated [DATE], reflected, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . significant change in the resident's physical/emotional/mental condition, and A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:28 PM and the ADM, VP RN, and DON were notified at 5:28 PM and was provided with the IJ Template on [DATE]. The following Plan of Removal (POR) was accepted on [DATE] at 3:59 PM: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) - Facility Medical Director was notified of the incident. Completed [DATE]. Physical assessments were completed by ADON and Charge Nurses on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were not identified. Completed [DATE] Licensed nurse who was aware of significant change was suspended pending 1:1 education by the Director of Nursing. Completed [DATE] 2. Actions to Prevent Occurrence/Recurrence: - The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]). - All licensed nurses were educated by DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure. Including notification of MD and DON after you have identified a change of condition, implementation of new orders received from doctor and completion of the eInteract Assessment in Point Click Care . [EHR form utilized to streamline communications among providers and staff.] Completed [DATE] Nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. The nurse aides have been educated that for emergent changes in a resident condition they are to immediately notify the charge nurse verbally. For non-emergent changes the nurse aides were educated on the Stop and Watch alert in Point Click Care that they can complete. The alerts trigger to the nursing dashboard for the Charge Nurses to evaluate the resident upon alert and proceed as clinically appropriate to address the change. The DON or Designee will review the alert trigger dashboard and run the alert trigger report in morning meeting to ensure all alert triggers have been reviewed and addressed. Completed [DATE] Staff members were not permitted to work a shift until education was completed. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented with a focus on physician notification of significant changes. Completed [DATE] The PIP resulted in implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition. The DON/designee will also complete chart audits/health document assessment using a paper chart audit tool on the following schedule: - Three resident charts weekly for four weeks then; - Two resident charts weekly for two weeks then; - Two resident charts a months for two months. The VP RN will visit the facility frequently for 30 days to provide general oversight and monitoring of the PIP. POR verification: Record review of the email to Medical Director reflected the Medical Director was informed of the incident on [DATE] at 6:17 PM. Interview on [DATE] at 2:00 PM, the DON stated she informed the Medical Director of the incident. Record review of 100% of residents change in condition assessments were reviewed with no concerns or changes in condition noted. Interview on [DATE] at 1:43 PM, the DON stated that all residents had a change in condition assessment and no changes in condition were noted. Record review of the 1:1 In-Service Record dated [DATE] at 7:30 AM reflected LVN A's training topics included: initiated CPR and location of Code Status for each resident in EHR; Identifying factors that would constitute a Change in Condition; who and how to notify when a Change of Condition has been identified; and Completion of the Change of Condition Evaluation form in the EHR. Training was conducted by the DON. Interview on [DATE] at 1:35 PM, the ADM stated 1:1 training was completed with LVN A on [DATE] at 7:30 AM. Record review of staff training reflected 37 of 47 nursing staff across all shifts had been in-serviced. Record review reflected 37 of 37 staff who worked on [DATE] and [DATE] were in-serviced on change in condition to include notifying the Medical Director and DON after identifying change in condition, implementing orders given for residents by MD, and Completion of change in condition evaluation. Interview on [DATE] at 1:45 PM the DON and ADM, stated that change in condition training was completed with all staff available, some came in on their days off; and those who had not received training would be required to have the training before being allowed to work on their next shift. Interviews between [DATE] at 7:10 PM and [DATE] at 2:56 PM with 74% of nursing staff to include LVN's, RN's, CNA's, and NA's employed at the facility revealed trainings were conducted prior to the nurses' shift began on change in condition, notifying the physician and DON of change in condition, and CPR. All nurse staff interviewed voiced that they had no concerns regarding implementing the trainings in their day-to-day assignments. Of the staff interviewed, the included 6 staff who worked 6:30 AM - 2:30 PM, 3 staff who worked 2:30 PM - 10:30 PM, 3 staff who worked 10:30 PM - 6:30 AM, 2 staff who worked 6:00 AM - 6:00 PM, 2 staff who worked 8:00 AM - 8:00 PM, and 5 staff who worked 8:00 AM - 5:00 PM, 2 staff who work 6:30 AM - 10:30 PM, and 5 staff who worked PRN. Record review of staff training reflected 37 of 47 nursing staff across all shifts had been in-serviced. Record review of staff training reflected 37 of 37 staff who worked on [DATE] and [DATE] were in-serviced on change in condition to include what to look for in a change in condition and notifying the charge nurse of a change in condition. Interview on [DATE] at 1:45 PM with the DON and ADM, stated that change in condition training was completed with all staff available, some came in on their days off; and those who have not received training will be required to have the training before being allowed to work on their next shift. During interviews between [DATE] at 7:10 PM and [DATE] at 2:56 PM with 56% of Nurse Aide staff, it was revealed that nurse aide staff had been trained on change in resident condition, notifying charge nurses, and alerts on point-click-care and the trainings were completed prior to beginning their shifts and that they each understood the trainings and had no concerns on implementing the trainings in their day-to-day work. Of the staff interviewed, this included 6 staff who worked 6:30 AM - 2:30 PM, 3 staff who worked 2:30 PM - 10:30 PM, 3 staff who worked 10:30 PM - 6:30 AM, 2 staff who worked 6:00 AM - 6:00 PM, 2 staff who worked 8:00 AM - 8:00 PM, and 5 staff who worked 8:00 AM - 5:00 PM, 2 staff who work 6:30 AM - 10:30 PM, and 5 staff who worked PRN. Record review of staff training reflected 100% of staff who worked on [DATE] and [DATE] were trained prior to working their shift. Record review of New Hire Orientation reflected that trainings relating to change in condition, enteral feeding, physician notification, and communication between staff had been added. Interview on [DATE] at 1:49 PM, the ADM stated that any staff who had not participated in training were PRN staff who would be trained prior to their next shift. The DON/ADON planned to ensure they were available for training the PRN staff prior to their shift. The ADM further stated that all new hire orientation would include training related to the incident to include any training on changes in condition, physician notification, enteral feeding, and communication between staff. Observation on [DATE] at 2:30 PM revealed staff receiving training prior to beginning their shift. Interview on [DATE] at 1:45 PM, the DON stated that education on change of condition and physician notification regulation would be part of new hire orientation. Record review of Quality Assessment & Performance Improvement Plan, dated [DATE], reflected that the DON, ADON, and Charge Nurses would ensure compliance with notifying the physician and DON of any significant changes in condition and documenting notification and any new interventions in the resident's medical record through Resident Chart audits. Tasks listed to ensure that included, but was not limited to: Educating nursing staff on facility protocol for notification of changes, monitoring nursing documentation of 24-hour report during morning meeting for any clinical changes, etc. Interview on [DATE] at 1:53 PM, the DON and ADM stated that the QAPI Performance Improvement Project would be the responsibility of the DON, ADON, and Nursing staff and would be consistently reviewed in the morning meetings as well as QAPI meetings. Record review of Quality Assessment & Performance Improvement Plan, dated [DATE], reflected that the Clinical Team would be responsible for a task titled Monitor nursing documentation of 24hr. Report during morning clinical meeting for any change in condition. Interview on [DATE] at 1:53 PM, the DON stated that they would audit on the 24-hour report during the morning meeting and any changes in condition would be on the 24-hour report. The DON stated that the whole nursing leadership team would be looking at the 24-hour report during morning meetings to ensure any changes in condition were monitored. Record review of Quality Assessment & Performance Improvement Plan, dated [DATE], reflected that the DON/Designee would be responsible for a task titled, Three resident charts will be audited weekly x 4 weeks then two resident charts weekly for two weeks, then two resident charts a month of two months. Interview on [DATE] at 1:54 PM, the DON stated that she or someone from the nursing leadership team would be performing chart audits, using the paper document, to ensure resident charts were reviewed for any change in condition. Record review of Quality Assessment & Performance Improvement Plan, dated [DATE], reflected that the DON/Designee would be responsible for a task titled, Three resident charts will be audited weekly x 4 weeks then two resident charts weekly for two weeks, then two resident charts a month of two months. Interview on [DATE] at 1:57 PM, the ADM stated that the VP RN, would be visiting frequently during the 30-day period to provide insight, the ADM stated the VP RN visited frequently anytime she or the DON needed assistance. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 5:24 PM. While the IJ was [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review LVN A failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 17 residents (Resident #63) reviewed for Full Code status. The facility failed to ensure emergency protocol was followed and failed to ensure Resident #63, who had a Full Code order in place, was provided continuous and uninterrupted CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice on [DATE] when LVN A stopped CPR once and continued after obtaining an AED, and Resident #63 subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on providing basic life support, including CPR, to a resident requiring emergency care. This deficient practice could contribute to a resident's decline in emotional, physical, and psychological health and result in serious injury and or death. Findings include: Record review of the admission Record reflected Resident #63 was a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of encephalopathy [group of disorders referring to brain disease, damage, or malfunction], noninfective gastroenteritis [inflammation in stomach or intestine] and colitis [inflammation in the colon], rhabdomyolysis [condition that causes muscles to disintegrate leading to muscle tissue death], and acute kidney failure. [admission Record did not reflect presence of gastrostomy tube, or advance directive code status.] Record review of the comprehensive MDS assessment dated [DATE], reflected that Resident #63 entered the facility from a short-term general hospital. Resident #63 had unclear speech, but usually was able to make self-understood, and sometimes had the ability to understand others. Further in the document was conflicting data indicating that a BIMS should not be conducted due to the resident was rarely/never understood. Resident #63 was coded as having both short-term, and long-term memory problems, and had some difficulty only in new situations requiring modified independence for daily decision making. Nutritional approaches included feeding tube with 25% or less total calories received thru the feeding tube; 500 CC [milliliters] per day by tube feeding. Record review of the Order Summary Report, printed [DATE] at 4:05 PM, reflected Resident #63 had physician's orders for CPR/Full Code status, dated [DATE]. Resident #63 had physician's orders for enteral feeding orders: two times a day 70 milliliters per hour [did not reflect formula, or volume]. Record review of Resident #63's Progress Note, effective date [DATE] at 8:09 AM and written by LVN A reflected, Resident was restless throughout the night especially after midnight. He was receiving Osmolite 1.5 [complete balanced nutritional formula for tube-fed individuals] @ 70 ml/hr via g tube. Resident complained of stomach discomfort and started having emesis [vomiting] episodes x3. After the first emesis the feeding was turned off and the DON was called. I really wanted to see if we could send this resident out to the emergency room for eval[uation]. Vital 96/57 [blood pressure; according to the American Heart Association, a normal blood pressure for adults is less than 120/80, and low blood pressure is less than 90/60], o2 stat [sic] was 90 [normal oxygen saturation is between 95% and 10] . I immediately got O2 and applied it when notice his sat[uration] had increased with the oxygen. She [the DON] stated that I should call the doctor and see what he wanted to do and that was done. Doctor did not return my call. Bed was changed at 0200 [2:00 AM] with stool and emesis. Changed again at 0315 [3:15 AM], 0400 [4:00 AM]. I decided to go back in the room to check on him with some fresh sheets just in case they were needed, and he was looking straight up to the ceiling, his eyes wide open and that alerted me to assess him pulled him off the bed onto the floor and get the Crash cart Started CPR at 0445 [4:45 AM] called EMS . they came and took charge. Record review of facility schedule and timecards for [DATE] and [DATE], dated [DATE], reflected that CNA M, CNA P, and NA U worked overnight. The facility schedule reflected that CNA M worked from 2:30 PM on [DATE] until 6:30 AM on [DATE], CNA P worked from 10:30 PM on [DATE] until 6:30 AM on [DATE], and NA U worked from 10:30 PM on [DATE] until 6:30 AM on [DATE]. Interview on [DATE] at 6:59 PM, LVN A stated that on [DATE], he arrived for his first shift at 6:00 PM after completing training [new hire orientation] at the facility and was assigned to Station 3. LVN A stated that throughout the course of the night Resident #63 seemed very antsy, the skin of his stomach was red, and he would use his call light to call LVN A every 30 to 45 minutes and LVN A would attempt to comfort the resident. LVN A stated that at one point, Resident #63's oxygen saturation was lower than 90%, and he provided Resident #63 with supplemental oxygen, which raised Resident #63's oxygen saturation back up to 97%. LVN A stated that he changed Resident #63's bed linens multiple times that night due to the linens being soiled from Resident #63's dark brown vomit and bowel movement, and after answering a different resident's call light, he went to check on Resident #63. LVN A stated that he then found Resident #63 staring straight up at the ceiling and called Resident #63's name. After Resident #63 did not answer, LVN A walked to the resident, attempted to rouse him, said his name again, and noticed his eyes were fixed and dilated and Resident #63 had no respirations or pulse. LVN A stated that at that time, he lowered the resident from his bed onto the floor to initiate CPR and noticed emesis in Resident #63's mouth. LVN A stated that he attempted to clear the emesis from the resident's mouth by turning him on his side and continued CPR. LVN A stated that he left Resident #63 during CPR to obtain Station 3's Crash Cart and AED. LVN A stated that during CPR, he called the DON who instructed him to call 911 and the MD. LVN A stated that, according to the EMT's, when EMT's arrived at the facility, they made their way to Station 1 instead of Station 3, and it took a while for them to get to Station 3. LVN A stated once the EMT's arrived to Resident #63's room, they took over CPR on Resident #63. LVN A stated that there was no way for him to have contacted anyone at Nurses' Station 1 or Nurses' Station 2 because he did not know the phone numbers to Station 1 [100-hallway] or 2 [200-hallway] and instead used his personal phone to call the DON and 911. LVN A stated that since there were only 3 residents on Station 3 [300-hallway], there were no CNAs assigned to assist him that night on Station 3. LVN A stated that he did not think to call the MD or DON when Resident #63's oxygen saturation became low due to the resident's oxygen saturation going back up after LVN A had administered oxygen, and the color of the vomit was not concerning to him. LVN A stated the time line of events was as follows: around 11:00 PM Resident #63 complained of pain, had vomiting and fecal incontinence that soiled his linens; Resident #63 had another bout of emesis and fecal incontinence around midnight but also noted his oxygen saturation dropped and LVN A put supplemental oxygen on Resident #63 at 4 liters per minute which raised his oxygen saturation to acceptable levels; Resident #63 had emesis and fecal incontinence three more times at 2:00 AM, 3:15 AM, and 4:00 AM. LVN A stated he returned to check on the resident shortly after the 4:00 AM bout of emesis, around 5:30 AM, when LVN A realized that Resident #63 required CPR. LVN A started CPR immediately, called the DON and 911, and attempted to notify the MD, but did not receive a call back from the MD prior to EMS arriving at approximately 5:45 AM, at which time EMS took over CPR and ultimately pronounced Resident #63 as deceased . LVN A stated that at the time of the incident he did not have any co-workers phone numbers saved in his personal phone and only had the contact information for the DON. Interview on [DATE] at 7:33 PM, RN B stated that she assisted in the admission of Resident #63 and set up his peg tube before leaving the facility after completing her shift. RN B stated that when Resident #63 came in, he seemed depressed and had told her he did not want his PEG tube. RN B stated that her interaction with Resident #63 was brief, and the resident did not appear to be feeling ill before she left for the evening. RN B stated that with 3 residents on Station 3 [300-hallway], there was only one nurse per shift scheduled. RN B stated that a resident suddenly needing and being provided with supplemental oxygen was a change in condition and that the MD and DON should be notified immediately if that occurred. RN B stated that if staff need help, they usually called or texted from their personal cell phones to other staff on duty. RN B stated that other staff have always been very good about responding and assisting when need. RN B stated that, in her experience on day shift, staff would promptly respond or show up to provide hands on assistance as needed. RN B stated she was unsure if the other staff on duty had shared their personal cell phone numbers with LVN A at the time of the incident. Interview on [DATE] at 7:09 AM, CNA M stated that she was the float CNA on her shift on [DATE]-[DATE]. CNA M stated she could not recall any issues that evening, or Resident #63. CNA M stated she was not asked to assist with Station 3, or to float to Station 3, as the census was too low. CNA M stated that when she was assigned the responsibility to be the float CNA for her shift as the float CNA, the expectation was that she would go between the 100-hallway and the 200-hallway. CNA M stated the 300-hallway was not a part of the responsibility for the person assigned as a float CNA. CNA M stated the nurse was expected to perform all care tasks on the 300-hallway, due to extremely low census on that hallway. CNA M stated it reopened around [DATE]. A phone interview was attempted on [DATE] at 8:58 AM with CNA U that was unsuccessful. A phone interview was attempted on [DATE] at 9:24 AM with CNA P that was unsuccessful. Interview on [DATE] at 12:27 PM, the DON stated that on [DATE] around the 4:00 AM hour, LVN A called her and told her that he had put oxygen on Resident #63 and that Resident #63 did not feel good and had a distended stomach, and the DON informed LVN A to call the physician. The DON stated that she did not receive another call until after 6:00 AM when she was informed that Resident #63 had expired. The DON stated she did not receive any calls informing her that LVN A was conducting CPR. The DON stated that she was not on site while the resident was in the building and never met the resident. The DON stated that a resident needing supplemental oxygen was a change in condition and that it was her expectation that staff call her and the MD if a resident was put on supplemental oxygen. The DON stated that while there was no CNA assigned to Station 3 (300 hallway), there was generally a floating CNA who would assist where necessary. The DON stated that the MD had an after-hours phone number, and it was in a notebook at every nurses' stations. The DON stated that the incident was brought to QAPI. The DON stated that if staff know the phone number to the nurses' stations, they can call it from any resident room, but if they do not know the phone number, they would have to use the phone at the nurses' station. The DON stated that her expectation was that if CPR was being performed, the staff would call for assistance to another hall if necessary. The DON stated she was not aware that EMS went to the incorrect hallway, and believed LVN A called another hall for assistance but was not sure who that was. The DON stated she did not receive a call from LVN A while he was performing CPR, and Resident #63 was stable when LVN A called her the first time. The DON stated this was LVN A's first shift after new hire orientation. The DON stated there was not a curriculum or training manual; but that she was in the process of developing one to include a check list of items all nurses needed to know. The DON stated new hires were trained on what to do, when to do it, and what forms were necessary in the EHR for change of conditions or emergency situations, or accidents and incidents. A phone interview was attempted on [DATE] at 1:38 PM with MD that was unsuccessful. In an interview on [DATE] at 1:45 PM the DON stated the MD was on vacation. I In an interview on [DATE] at 9:05 AM, LVN V stated she did not work with Resident #63 and was not aware of any issues on the 300-hallway until later. LVN V stated she was not aware of EMS being called until she saw the ambulance in the parking lot as she was exiting at the end of her shift at approximately 6:30 to 7:00 AM. LVN V stated prior to that she was not told there were any problems on the 300-hallway, was not asked for her assistance and was not directed by anyone to help out on that hallway. LVN V stated she normally worked on the 100-hallway. LVN V stated typically staff call or text each other on their personal cell phones, but one could also call the facilities main phone number and it would ring at each of the nurses' station . LVN V stated she later heard that EMS went to 200-hallway first and that was how staff found out there was something happening on the 300-hallway. LVN V could not recall when or who told her that information. Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation, reviewed [DATE], policy reflected if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct staff member to verify DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 8. Continue with CPR/BLS until emergency medical personnel arrive. The following Plan of Removal (POR) was accepted on [DATE] at 3:59 PM: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]). - Facility Medical Director was notified of the incident. [DATE] - The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy. Inaccuracies were not identified. Completed [DATE] 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]) - Disciplinary action was taken with licensed nurse who did not initiate CPR on the resident. Employee was suspended until 1:1 education with Director of Nursing on the procedure for initiating CPR and the location of code status for each resident. Completed [DATE]. The DON or designee educated all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident. Licensed nurses were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift. Resident care units will be staffed with a minimum of 2 employees. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process . Compliance checks will be conducted 2 times weekly for three months and recorded using a paper audit tool. Findings will be reported at monthly QAA Committee meeting. DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue daily for three months and recorded using a paper audit tool. Findings will be reviewed at the monthly QAA Committee meeting. A Code Blue drill was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held 2 times a month for 3 months and recorded using a paper audit tool. Findings will be reviewed at the monthly QAA Committee meeting. POR Verification: Record review of the email to Medical Director reflected the Medical Director was informed of the incident on [DATE] at 6:17 PM. Interview on [DATE] at 2:00 PM, the DON stated she informed the Medical Director of the incident. Record review of Order Listing Report dated [DATE] at 7:39 PM, reflected a completed review of advanced directives for current census of 64. Interview on [DATE] at 1:35 PM, the DON and ADM stated there were no inaccuracies or inconsistencies found in the chart audit on every resident. Record review of the 1:1 In-Service Record dated [DATE] at 7:30 AM reflected LVN A's training topics included: initiated CPR and location of Code Status for each resident in EHR; Identifying factors that would constitute a Change in Condition; who and how to notify when a Change of Condition has been identified; and Completion of the Change of Condition Evaluation form in the EHR. Training was conducted by the DON. Interview on [DATE] at 1:35 PM, the ADM stated 1:1 training was completed with LVN A on [DATE] at 7:30 AM. Record review of In-Service Record dated [DATE] at 6:00 AM reflected the following topics: where to locate the code status for each resident; when to initiate CPR and what steps are taken during a code status; when and who to call for help during a cardiac arrest. 19 of 22 nurses staff trained; exceptions included: LVN W; LVN X; and LVN Y. Record review of In-Service Record dated [DATE] at 6:00 AM reflected the following topics: where to locate the code status for each resident; when to initiate CPR and what steps are taken during a code status; when and who to call for help during a cardiac arrest. 19 of 22 nurses have been in-serviced. 19 of 19 nursing staff who have worked on [DATE] and [DATE] have received in-servicing. Interview on [DATE] at 1:35 PM, the ADM and DON stated that all staff who had worked had been trained before they began their shift, and all staff who had not worked would be trained before beginning their next scheduled shift. Interviews between [DATE] at 7:10 PM and [DATE] at 2:56 PM with 74% of nursing staff employed at the facility revealed trainings were conducted prior to the nurses' shift began on change in condition, notifying the physician and DON of change in condition, and CPR. All nurse staff interviewed voiced that they had no concerns regarding implementing the trainings in their day-to-day assignments . Of the staff interviewed, this included 6 staff who worked 6:30 AM - 2:30 PM, 3 staff who worked 2:30 PM - 10:30 PM, 3 staff who worked 10:30 PM - 6:30 AM, 2 staff who worked 6:00 AM - 6:00 PM, 2 staff who worked 8:00 AM - 8:00 PM, and 5 staff who worked 8:00 AM - 5:00 PM, 2 staff who work 6:30 AM - 10:30 PM, and 5 staff who worked PRN. Each staff member was asked to describe their knowledge based on the in-service and was able to. Record review of the Employee Schedule for [DATE] and [DATE] reflected that each resident care unit had a minimum of 2 employees staffed . Observation on [DATE] at 8:30 PM reflected appropriate staffing on night shift with no staffing shortage observed. During observation and interviews starting on [DATE] at 10:07 AM around the facility at least 2 nursing staff were present at each station (3 of 3 stations). A sample of 7 residents, including 1 RP, revealed there have been more nursing staff and they were receiving timely care. Observation revealed call lights being answered in a timely manner. Interview on [DATE] at 1:39 PM, the ADM stated they would ensure daily staffing has 2 staff on all halls and the staff schedule would include the hall assignment next to each person's schedule. They would ensure there was a minimum of 2 employees per hall, not including a floating staff member who may be scheduled in addition to the 2 employees per hall. Record review of the Performance Improve Plan, with a started date of [DATE], reflected the following tasks: educate nursing staff on facility protocol for CPR and location of code status for each resident; audit new admissions for advance directives x 3 months; monitor code status via interview nurses about CPR policy and procedures with a return demo of CPR process 2 times weekly for 3 months; code blue mock drill with all nurses over all shifts until all nurses have participated at least once; drills will then be held 2 times a month for 3 months; and weekly audit review in SOC meeting and monthly QAPI meeting. Interview on [DATE] at 1:53 PM, the DON and ADM stated that the QAPI Performance Improvement Project would be the responsibility of the DON, ADON, and nursing staff and would be consistently reviewed in the morning meetings as well as QAPI meetings. Record review of the Order Listing Report dated [DATE] at 7:39 PM, reflected a completed review of advanced directives for current census of 64. Interview on [DATE] at 1:35 PM, the DON and ADM stated there were no inaccuracies or inconsistencies found in the chart audit on every resident. There were no concerns or inconsistencies in the residents advanced directive orders. Record review of POR Binder included a blank template for a Mock code Drill Audit Tool, a blank template for Code Blue Worksheet, and a blank template for In-Service training roster, and an employee list with all nurses' names highlighted. Interview on [DATE] at 1:35 PM, the DON and ADM stated the Code Blue drills were still in the process of being planned and coordinated and had not yet occurred. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 5:24 PM. While the IJ was removed, the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of their 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 who were fed by enteral means, received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for 1 of 7 residents (Resident #63) reviewed for enteral feedings. 1. The facility failed to ensure all the necessary components of an order for enteral feeding were included for Resident #63 when Resident #63 was admitted to the facility on [DATE]; the order did not include formula type, total volume, time of administration, or contraindications. 2. The facility failed to recognize and respond appropriately when Resident #63 had a significant change in condition on 4/28/2024, that included pain, decreased oxygenation, multiple emesis, and fecal incontinence and subsequently died. This deficient practice could place residents with enteral feeding at risk for vomiting, aspiration pneumonia, pain and diarrhea. The findings included: An Immediate Jeopardy (IJ) was identified on 07/26/2024. The IJ template was provided to the facility on [DATE] at 5:28 PM. While the IJ was removed on 07/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of No actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The findings include: Record review of the admission Record reflected Resident #63 was a [AGE] year-old male, admitted on [DATE] with a primary diagnosis of encephalopathy [group of disorders referring to brain disease, damage, or malfunction], noninfective gastroenteritis [inflammation in stomach or intestine] and colitis [inflammation in the colon], rhabdomyolysis [condition that causes muscles to disintegrate leading to muscle tissue death], and acute kidney failure. [admission Record did not reflect presence of gastrostomy tube, or advanced directive code status.] Record review of the comprehensive MDS assessment dated [DATE], reflected that Resident #63 entered the facility from a short-term general hospital. Resident #63 had unclear speech, but usually was able to make self-understood, and sometimes had the ability to understand others. Further in the document contained conflicting data indicating that a BIMS should not be conducted due to the resident was rarely/never understood. Resident #63 was coded as having both short-term, and long-term memory problems, and had some difficulty only in new situations requiring modified independence for daily decision making. Resident #63 was coded as partial/moderate assistance with eating at admission. Resident #63 was coded as not rated for both urinary and bowel continence as resident had a urinary catheter and had an ostomy [surgical procedure that creates an opening in the abdominal wall] or did not have a bowel movement. Resident #63 had health conditions noted of vomiting. Nutritional approaches included feeding tube with 25% or less total calories received thru the feeding tube; 500 CC [milliliters] per day by tube feeding. Record review of the Order Summary Report, printed 07/25/2024 at 4:05 PM, reflected Resident #63 had physician's orders for CPR/Full Code status, dated 04/28/2024. Resident #63 had physician's orders for enteral feeding orders: two times a day 70 milliliters per hour [did not reflect formula type, total volume, time of administration, or contraindications]. Record review of Resident #63's Progress Note, effective date 04/28/2024 at 5:45 PM and written by RN B reflected, Resident arrived via [redacted] Ambulance. EMS stated that nothing significant happened during transfer. [Medical Director] was informed of patients arrival. Stated to continue orders and medications from hospital as well as lab orders of CBC, CMP, Prealbumin, and Ammonia level. Orders to continue Osmolite [complete balanced nutritional formula for tube-fed individuals] at 70mL/hour and to check residuals on PEG tube [percutaneous endoscopic gastrostomy tube, or g-tube] every shift. Patient's emergency contact [Emergency Contact Name] was called at [Emergency Contact Phone Number] to inform her patient arrived. Patient resting comfortably. Record review of Resident #63's Progress Note, effective date 04/29/2024 at 8:09 AM and written by LVN A reflected, Resident was restless throughout the night especially after midnight. He was receiving Osmolite 1.5 @ 70 ml/hr via g tube. Resident complained of stomach discomfort and started having emesis [vomiting] episodes x3. After the first emesis the feeding was turned off and the DON was called. I really wanted to see if we could send this resident out to the emergency room for eval[uation]. Vital 96/57 [blood pressure; according to the American Heart Association, a normal blood pressure for adults is less than 120/80, and low blood pressure is less than 90/60], o2 stat [sic] was 90 [normal oxygen saturation is between 95% and 100%]. I immediately got O2 and applied it when notice his sat[uration] had increased with the oxygen. She [the DON] stated that I should call the doctor and see what he wanted to do and that was done. Doctor did not return my call. Bed was changed at 0200 [2:00 AM] with stool and emesis. Changed again at 0315 [3:15 AM], 0400 [4:00 AM]. I decided to go back in the room to check on him with some fresh sheets just in case they were needed, and he was looking straight up to the ceiling, his eyes wide open and that alerted me to assess him pulled him off the bed onto the floor and get the Crash cart Started CPR at 0445 [4:45 AM] called EMS. they came and took charge. Record review of Resident #63's Progress Note, effective date 04/29/2024 at 9:00 AM and written by LVN A reflected, 1800 [6:00 PM] Initial head to toe assessment was completed, Observed and assessed the g-tube and the feeding, Osmolite 1.5@ 70 ml per hour. @ being set up by the off going nurse. Family came in to visit and to sit with the resident. They introduced themselves and were very pleasant and attentive of [Resident #63's] care. They left after 2 hours at around 2200 [10:00 PM]. Re-evaluated residents g-tube area due to his complaint of pain. The stomach area was slightly red, but it was not an open area or a rash, g-tube site was not red or draining, abdomen was slightly distended and firm to touch. Resident had his first small BM which was soft around 2300 [11:00 PM]. Cleaned resident and changed his bed linen. He ask [sic] me to place something at his bedside because he was feeling nauseated and he thought he had to throw up. He did throw up brownish color secretion, 150 ml. Assisted resident to clean his mouth and placed a pad on the side of the bed so if he had another vomiting episode, he would have some type of covering over his bedding. He had another episode of nausea and vomiting and also he had medium size BM around 0000. Resident became restless and voiced general discomfort. Vital signs were B[lood]/P[ressure] 95/57, Heart Rate 99, O2 sat was 90% on RA [room air]. At this time O2 [oxygen] was applied at 4 lpm via face mask and it brought his O2 sat up to 97% on 4 lpm. Resident continued to be restless and complaining of discomfort to abdomen. Around 0445 [4:45 AM] DON was called and notified of residents change of condition, DON instructed me to call the Doctor. Dr. was called around 0445 [4:445 AM] and message left. Resident continues to be restless and vomits again with another BM around 0500 [5:00 AM]. Changed the bed linen and provided peri care to the resident and placed clean gown on the patient. I checked resident around 0530 [5:30 AM] and noted restlessness, nausea and vomiting, I emptied out his container at his bedside 200 ml brownish colored vomit. As I assessed the resident, noted he had another bowel movement, abdomen remained firm and slightly distended at this time, no change noted. Cleaned up the resident's area with fresh clean linen after peri care applied. I took the soiled linen to the soiled linen area, went to the nurses' station, and then returned to check on resident and noted he was staring straight up to the ceiling with his eyes wide open. I immediately assessed him for his response by calling his name, assessed him breathing and heart rate. They were absent, no heart rate or respiration, immediately I pulled resident off the bed onto the floor started CPR, I had to go and get crash cart came back and called EMS at 0647 [6:47 AM] and started CPR again. Checked for pulse again and initiated CPR. The EMS dispatcher stayed on the line with me until EMS arrived person and was giving instructions and gathering information on the resident while I continue CPR. EMS arrived and assessed the resident and pronounced him @06:56 [6:56 AM]. Record review of Resident #63's Progress Note, effective date 04/29/2024 at 9:15 AM and written by the Treatment Nurse reflected, Contacted Medical Examiner to obtain release of body. Writer was advised additional information is needed. Contacted [family member]. Per [family member] resident was living with [family member] in an apartment prior to hospital admission. The [family member] stated that resident had been losing weight, and stopped eating and began rapidly declining after [family member] received dx [diagnosis] of metastatic breast cancer that had spread to her lungs. Per [family member], resident was admitted for malnutrition. The [family member] advised resident was not previously following with a PCP and was last evaluated by [Physician] 2-3 years ago. Per hospital records resident was found on floor with altered mental status and admitted . Imaging done in hospital and PEG tube placed. Per hospital records no suspicion of abuse. SNF Medical director to sign death certificate. ME notified. Advised by ME per resident age, and no suspicion of abuse/neglect/APS case resident does not meet criteria for autopsy. Resident body ok to release to funeral home. ME #[number], case #[number]. Called [funeral home] and notified them of TOD: 0656AM and that ME released the body. [Funeral Home] advised they would arrive for p/u in 30 min to 2 hours. Record review of Resident #63's Progress Note, effective date 04/29/2024 at 11:00 AM and written by the DON reflected, Time of death was pronounced by EMS at 0656 [6:56 AM]. Record review of Resident #63's Progress Note, effective date 04/29/2024 at 11:25 AM and written by the Treatment Nurse reflected, 2 staff from [Funeral Home] picked up resident body. Family aware . Interview on 7/25/2024 at 6:59 PM, LVN A stated that on 04/28/2024, he arrived for his first shift at 6:00 PM after completing training [new hire orientation] at the facility and was assigned to Station 3. LVN A stated that throughout the course of the night Resident #63 seemed very antsy, the skin of his stomach was red, and he would use his call light to call LVN A every 30 to 45 minutes and LVN A would attempt to comfort the resident. LVN A stated that at one point, Resident #63's oxygen saturation was lower than 90%, and he provided Resident #63 with supplemental oxygen, which raised Resident #63's oxygen saturation back up to 97%. LVN A stated that he changed Resident #63's bed linens multiple times that night due to the linens being soiled from Resident #63's dark brown vomit and bowel movement, and after answering a different resident's call light, he went to check on Resident #63. LVN A stated that he then found Resident #63 staring straight up at the ceiling and called Resident #63's name. After Resident #63 did not answer, LVN A walked to the resident, attempted to rouse him, said his name again, and noticed his eyes were fixed and dilated and Resident #63 had no respirations or pulse. LVN A stated that at that time, he lowered the resident from his bed onto the floor to initiate CPR and noticed emesis in Resident #63's mouth. LVN A stated that he attempted to clear the emesis from the resident's mouth by turning him on his side and continued CPR. LVN A stated that he left Resident #63 during CPR to obtain Station 3's Crash Cart and AED. LVN A stated that during CPR, he called the DON who instructed him to call 911 and the MD. LVN A stated that, according to the EMT's, when EMT's arrived at the facility, they made their way to Station 1 instead of Station 3, and it took a while for them to get to Station 3. LVN A stated once the EMT's arrived to Resident #63's room, they took over CPR on Resident #63. LVN A stated that there was no way for him to have contacted anyone at Nurses' Station 1 or Nurses' Station 2 because he did not know the phone numbers to Station 1 [100-hallway] or 2 [200-hallway] and instead used his personal phone to call the DON and 911. LVN A stated that since there were only 3 residents on Station 3 [300-hallway], there were no CNAs assigned to assist him that night on Station 3. LVN A stated that he did not think to call the MD or DON when Resident #63's oxygen saturation became low due to the resident's oxygen saturation going back up after LVN A had administered oxygen, and the color of the vomit was not concerning to him. LVN A stated the time line of events was as follows: around 11:00 PM Resident #63 complained of pain, had vomiting and fecal incontinence that soiled his linens; Resident #63 had another bout of emesis and fecal incontinence around midnight but also noted his oxygen saturation dropped and LVN A put supplemental oxygen on Resident #63 at 4 liters per minute which raised his oxygen saturation to acceptable levels; Resident #63 had emesis and fecal incontinence three more times at 2:00 AM, 3:15 AM, and 4:00 AM. LVN A stated he returned to check on the resident shortly after the 4:00 AM bout of emesis, around 5:30 AM, when LVN A realized that Resident #63 required CPR. LVN A started CPR immediately, called the DON and 911, and attempted to notify the MD, but did not receive a call back from the MD prior to EMS arriving at approximately 5:45 AM, at which time EMS took over CPR and ultimately pronounced Resident #63 as deceased . LVN A stated that at the time of the incident he did not have any co-workers phone numbers saved in his personal phone and only had the contact information for the DON. Interview on 07/25/2024 at 7:33 PM, RN B stated that she assisted in the admission of Resident #63 and set up his peg tube before leaving the facility after completing her shift. RN B stated that when Resident #63 came in, he seemed depressed and had told her he did not want his PEG tube. RN B stated that her interaction with Resident #63 was brief, and the resident did not appear to be feeling ill before she left for the evening. RN B stated that with 3 residents on Station 3 [300-hallway], there was only one nurse per shift scheduled. RN B stated that a resident suddenly needing and being provided with supplemental oxygen was a change in condition and that the MD and DON should be notified immediately if that occurred. RN B stated that if staff need help, they usually called or texted from their personal cell phones to other staff on duty. RN B stated that other staff have always been very good about responding and assisting when need. RN B stated that, in her experience on day shift, staff would promptly respond or show up to provide hands on assistance as needed. RN B stated she was unsure if the other staff on duty had shared their personal cell phone numbers with LVN A at the time of the incident. Record review of the facility schedule and timecards for 04/28/2024 and 04/29/2024, dated 07/25/2024, reflected that CNA M, CNA P, and NA U worked overnight. The facility schedule reflected that CNA M worked from 2:30 PM on 04/28/2024 until 6:30 AM on 04/29/2024, CNA P worked from 10:30 PM on 04/28/2024 until 6:30 AM on 04/29/2024, and NA U worked from 10:30 PM on 04/28/2024 until 6:30 AM on 4/29/2024. In an interview on 07/26/2024 at 7:09 AM, CNA M stated that she was the float CNA on her shift on 04/28/2024-04/29/2024. CNA M stated she did not recall Resident #63. CNA M stated she did not recall any problems on the 300-hallway. CNA M stated that when she was assigned the responsibility to be the float CNA for her shift, the expectation was that she would go between the 100-hallway and the 200-hallway. CNA M stated the 300-hallway was not a part of the responsibility for the person assigned as a float CNA. CNA M stated she was not asked to assist with the 300-hallway, or to float to the 300-hallway, as the census was too low. CNA M stated the nurse was expected to perform all care tasks on the 300-hallway, due to extremely low census on that hallway. CNA M stated the 300-hallway reopened around April 2024. A phone interview was attempted on 07/26/2024 at 8:58 AM with CNA U that was unsuccessful. A phone interview was attempted on 07/26/2024 at 9:24 AM with CNA P that was unsuccessful. Interview on 07/26/2024 at 12:27 PM, the DON stated that on 04/29/2024 around the 4:00 AM hour, LVN A called her and told her that he had put oxygen on Resident #63 and that Resident #63 did not feel good and had a distended stomach, and the DON informed LVN A to call the physician. The DON stated that she did not receive another call until after 6:00 AM when she was informed that Resident #63 had expired. The DON stated she did not receive any calls informing her that LVN A was conducting CPR. The DON stated that she was not on site while the resident was in the building and never met the resident. When asked if, in this incident, there was a change of condition that should have been reported to the MD, the DON stated that a resident who needed supplemental oxygen was a change in condition and that it was her expectation that staff call her and the MD if a resident was put on supplemental oxygen. The DON stated that while there was no CNA assigned to Station 3, there was generally a floating CNA who would assist where necessary. The DON stated that the MD had an after-hours phone number, and it was in a notebook at every nurses' station. The DON stated that the incident was brought to QAPI. The DON stated that if staff knew the phone number to the nurses' station, they would call from any resident room, but if they do not know the phone number, they would have to use the phone at the nurse's station. The DON stated that her expectation was that if CPR was being performed, the staff would call for assistance to another hall if necessary . The DON stated she was not aware that EMS went to the incorrect hallway, and believed LVN A called another hall for assistance but was not sure who LVN A called. The DON stated she did not receive a call from LVN A while he was performing CPR, and Resident #63 was stable when LVN A called her. The DON stated LVN A an experienced LVN but was new to the facility at the time of the incident. The DON stated this was LVN A's first shift after new hire orientation. The DON stated there was not a curriculum or training manual; but that she was in the process of developing one to include a check list of items all nurses needed to know. The DON stated new hires were trained on what to do, when to do it, and what forms were necessary in the EHR for change of conditions or emergency situations, or accidents and incidents. A phone interview was attempted on 07/26/2024 at 1:38 PM with the MD that was unsuccessful. In an interview on 07/26/2024 at 1:45 PM the DON stated the MD was on vacation. In an interview on 07/26/2024 at 9:05 AM, LVN V stated she did not work with Resident #63 and was not aware of any issues on the 300-hallway until later. LVN V stated she was not aware of EMS being called until she saw the ambulance in the parking lot as she was exiting at the end of her shift at approximate 6:30 AM to 7:00 AM on 04/29/2024. LVN V stated prior to that she was not told there were any problems on the 300-hallway, was not asked for her assistance and was not directed by anyone to help out on that hallway. LVN V stated she normally worked on the 100-hallway. LVN V stated typically staff called or texted each other on their personal cell phones, but one could also call the facility's main phone number and it would ring at each of the nurses' station. LVN V stated she later heard that EMS went to 200-hallway first and that was how staff found out there was something happening on the 300-hallway. LVN V could not recall when or who told her that information. Record review of the facility policy entitled, Enteral Nutrition, reviewed December 2023, reflected, in step 13.) Staff will be trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube; such as: aspiration [inhalation of fluids in to lungs]; leading and skin breakdown around insertion site; perforation of the stomach or small intestine leading to peritonitis. In step 14.) Staff will be trained on how to recognize and report complications relating to the administration of enteral nutrition products such as: nausea, vomiting, diarrhea, and abdominal cramping; aspiration. Record review of the facility's policy entitled, Change in a Resident's Condition or Status, reviewed December 2023, reflected a policy statement, .shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and or status. Under the heading, Policy Interpretation and Implementation: the nurse will notify the attending physician or physician on call when there has been a (an) .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; need to transfer the resident to a hospital/treatment center. Further definitions included a significant change of condition is a major decline . that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). The following Plan of Removal (POR) was accepted on 07/27/2024 at 3:59 PM: 1. Identification of Residents Affected or Likely to be Affected: o The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 7/27/2024) o Facility Medical Director was notified of the incident. 7/26/2024 o Physical assessments were completed by ADON and Charge Nurses on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were not identified. 7/27/2024 o Licensed nurse who was aware of significant change was suspended pending 1:1 education by the Director of Nursing. 7/26/2024 2. Actions to Prevent Occurrence/Recurrence: o The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 7/27/2024) o All licensed nurses were educated by DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure. Including notification of MD and DON after you have identified a change of condition, implementation of new orders received from doctor and completion of the eInteract Assessment in Point Click Care. Completed 07/27/2024 o Nurse aides were educated by DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. The nurse aides have been educated that for emergent changes in a resident condition they are to immediately notify the charge nurse verbally. For non-emergent changes the nurse aides were educated on the Stop and Watch alert in Point Click Care that they can complete. The alerts trigger to the nursing dashboard for the Charge Nurses to evaluate the resident upon alert and proceed as clinically appropriate to address the change. The DON or Designee will review the alert trigger dashboard and run the alert trigger report in morning meeting to ensure all alert triggers have been reviewed and addressed. Completed 07/27/2024 o Resident care units will be staffed with a minimum of 2 employees. o Staff members were not permitted to work a shift until education was completed o New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly. o A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented with a focus on physician notification of significant changes. Completed 7/27/2024 o The PIP resulted in implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition. o The DON/designee will also complete chart audits/health document assessment using a paper chart audit tool: o Three resident charts weekly for four weeks then; o Two resident charts weekly for two weeks then; o Two resident charts a months for two months. o The [NAME] President of Clinical Services, [VP RN] will visit the facility frequently for 30 days to provide general oversight and monitoring of the PIP. POR Verification: Record review of email to Medical Director reflected the Medical Director was informed of the incident on 07/26/2024 at 6:17 PM. Interview on 07/28/2024 at 2:00 PM, the DON stated she informed the Medical Director of the incident. Record review of 100% of residents change in condition assessments were reviewed with no concerns or changes in condition noted. Interview on 07/28/2024 at 1:43 PM, the DON stated that all residents had a change in condition assessment and no changes in condition were noted. Record review of 1:1 In-Service Record dated 07/27/2024 at 7:30 AM reflected LVN A training topics: initiated CPR and location of Code Status for each resident in EHR; Identifying factors that would constitute a Change in Condition; who and how to notify when a Change of Condition has been identified; and Completion of the Change of Condition Evaluation form in the EHR. Training was conducted by the DON. Interview on 07/28/2024 at 1:35 PM, the ADM stated 1:1 training was completed with LVN A on 07/27/2024 at 7:30 AM. The ADM further stated that all new hire orientation would include training related to the incident to include any training included in the approved plan of removal. Record review of staff training reflected 37 of 47 staff have been in-serviced. Record review of staff training reflected 37 of 37 staff who worked on 07/27/2024 and 07/28/2024 were in-serviced on change in condition to include notifying the Medical Director and DON after identifying change in condition, implementing orders given for residents by MD, and Completion of change in condition evaluation. During an interview on 07/28/24 at 11:46 AM, LVN D revealed she worked PRN and was trained on CPR, change in condition, notifying the doctor of change in conditions especially related to new admissions, and residents with higher levels of care such as feeding tubes. Interview on 70/28/2024 at 1:45 PM with DON and ADM, stated that change in condition training was completed with all staff available, some came in on their days off, those who have not received training will before being allowed to work on their next shift. Interviews between 7/27/2024 at 7:10 PM and 7/28/2024 at 2:56 PM with 74% of nursing staff employed at the facility revealed trainings were conducted prior to the nurses' shift began on change in condition, notifying physician and DON of change in condition, and CPR. All nurse staff interviewed voiced that they had no concerns regarding implementing the trainings in their day-to-day assignments. Of the staff interviewed, this included 6 staff who worked 6:30 AM - 2:30 PM, 3 staff who worked 2:30 PM - 10:30 PM, 3 staff who worked 10:30 PM - 6:30 AM, 2 staff who worked 6:00 AM - 6:00 PM, 2 staff who worked 8:00 AM - 8:00 PM, and 5 staff who worked 8:00 AM - 5:00 PM, 2 staff who work 6:30 AM - 10:30 PM, and 5 staff who worked PRN. Record review of staff training reflected 37 of 47 staff have been in-serviced. Record review of staff training reflected 37 of 37 staff who worked on 07/27/2024 and 07/28/2024 were in-serviced on change in condition to include what to look for in change in condition and notifying the charge nurse of a change in condition. Interview on 07/28/2024 at 1:45 PM with DON and ADM, stated that change in condition training was completed with all staff available, some came in on their days off, those who have not received training will before being allowed to work on their next shift. During interviews between 7/27/2024 at 7:10 PM and 7/28/2024 at 2:56 PM with 56% of Nurse Aide staff, it was revealed that nurse aide staff had been trained on change in resident condition, notifying charge nurses, and alerts on point-click-care and the trainings were completed prior to beginning their shifts and that they each understood the trainings and had no concerns on implementing the trainings in their day-to-day work. Of the staff interviewed, this included 6 staff who worked 6:30 AM - 2:30 PM, 3 staff who worked 2:30 PM - 10:30 PM, 3 staff who worked 10:30 PM - 6:30 AM, 2 staff who worked 6:00 AM - 6:00 PM, 2 staff who worked 8:00 AM - 8:00 PM, and 5 staff who worked 8:00 AM - 5:00 PM, 2 staff who work 6:30 AM - 10:30 PM, and 5 staff who worked PRN. During observation and interviews starting on 07/28/24 at 10:07 AM around the facility revealed at least 2 nursing staff were present at each station (3 of 3 stations). Sample of 7 residents, including 1 RP, revealed there have been more nursing staff and they were receiving timely care. Observation revealed call lights being answered in a timely manner. Interview on 07/28/2024 at 1:39 PM, ADM stated they will ensure daily staffing has 2 staff on all halls and the staff schedule will include the hall assignment next to each persons schedule. They will ensure there is a minimum of 2 employees per hall, not including a floating staff member who may be scheduled in addition to the 2 employees per hall. Record review of staff training reflected 37 of 47 staff have been in-serviced. Record review of staff training reflected 37 of 37 staff who worked on 07/27/2024 and 07/28/2024 were trained prior to working their shift. Interview on 07/28/2024 at 1:49 PM, ADM stated that any staff who have not participated in training are PRN staff who will be trained prior to their next shift. The DON/ADON plan to ensure they are available for training these PRN staff prior to their shift. Observation on 07/28/2024 at 2:30 PM of staff receiving training prior to beginning their shift. Record review of Quality Assessment & Performance Improvement Plan, dated 07/27/2024, reflected that the DON, ADON, and Charge Nurses will ensure compliance with notifying the physician and DON of any significant changes in condition and documenting notification and any new interventions in the resident's medical record through Resident Chart audits. Tasks listed to ensure this includes, but is not limited to: Educating nursing staff on facility protocol for notification of changes, monitoring nursing documentation of 24-hour report during morning meeting for any clinical changes, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 12 out of 16 residents (Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #107, #257, and Resident #258) reviewed for diabetic care in that; 1. The facility failed to administer injectable insulin for Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #257, and Resident #258, sporadically from 04/14/2023 to 05/13/2023, due to an update in the electronic medication system. 2. The facility failed to identify and assess for harm, report to the PCP, report to the Residents and/or their Representatives all residents who did not receive their insulin due to the systemic update in the electronic medication administration record. 3. The facility failed to in-service all staff, to include, temporary agency staff, for the update to the electronic medication administration record. 4. The facility failed to implement blood sugar monitoring / checks for levels of blood sugar for Resident # 107 who was diagnosed as diabetic. These failures placed residents at risk for harm, to include death, by declined health status due to abnormal blood sugar levels. An Immediate Jeopardy (IJ) situation was identified on 06/02/2023. While the IJ was removed on 06/03/2023, the facility remained out of compliance at a severity level of potential for actual harm that was not Immediate Jeopardy and a scope of isolated. The findings included: Failures 1 through 2: Resident #2 A record review of Resident #2's admission record, dated 06/02/2023, revealed an admission date of 10/15/2020 with diagnoses which included diabetes mellitus II [a group of diseases that result in too much sugar in the blood (high blood glucose)]. Further review revealed Resident #2 resided on 200-hall. A record review of Resident #2's quarterly MDS, dated [DATE], revealed Resident #2 was a 70-yr-old female who needed medical support for diabetes. A record review of Resident #2's care plan, dated 06/02/2023, revealed, I have diabetes mellitus .intervention: diabetes medication as ordered by doctor. Resident #2 April 2023 A record review of Resident #2's April 2023 PCP order summary revealed the PCP ordered for Resident #2 to receive insulin glargine 100 units/ml, inject 44 units subcutaneous every morning and at bed time for DM; insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM; insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime [insulin aspart = a short-acting, manmade version of human insulin] . A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml, inject 44 units subcutaneous every morning and at bedtime for DM on 04/17/2023 at 08:00 PM; 04/20/2023 at 07:00 AM and 04/21/2023 at 07:00 AM; on 04/22/2023 and on 04/23/2023 at 07:00 AM and 08:00 PM A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml, inject 47 units subcutaneous every morning and at bedtime for DM on 04/30/2023 at 08:00 PM. A record review of Resident #2's April 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime, on 04/17/2023 at 04:00 PM and 08:00 PM; 04/19/2023 at 11:00 AM; on 04/20/2023 at 07:00 AM, 11:00 AM, and 04:00 PM; on 04/21/2023 at 07:00 AM and at 11:00 AM; on 04/22 and 04/23/2023 at 07:00 AM, 11:00 AM, 04:00 PM, and at 08:00 PM; and again on 04/30/2023 at 04:00 PM and 08:00 PM. A record review of the facility's schedule revealed on 04/17/2023, agency nurse LVN BB worked the 06:00 AM 02:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/17/2023, agency nurse LVN Z worked the 02:30 to 10:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/20/2023 LVN H worked the 06:30 AM to 02:30 PM shift and on 04/21/2023 agency LVN O worked the 06:30 AM to 02:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 04/21/2023, on 4/22/2023, and on 04/30/2023 LVN B worked the 06:30 AM to 10:30 PM shift During an interview on 06/03/2023 at 09:40 AM, LVN B stated he was the weekend nurse for the 200-hall. LVN CB stated he recalled during the period of mid-April and mid-May 2023, there was a problem with the electronic medication administration record in that the injectable medications, insulins, were not on the residents MAR. LVN B stated he thought to himself the medications were discontinued and may have not administered some. I did not know the medications were on another tab. LVN B stated he figured it out with reports from other nurses and believes the record will demonstrated he gave the insulins for the residents on 200-hall on weekends [#2, #3, #7, and #34]. LVN B stated he had not received a training for the incident when the injectable medications were missing from the nurses MAR. During an interview on 06/03/2023 at 06:29 PM LVN H stated he was the full-time nurse on the 200-hall days during April - May 2023. LVN H stated he was not informed the injectable medications were removed from the nurse MAR, where he was accustomed to view injectable medications scheduled for residents, to the Alerts tab in the resident's electronic medication record. LVN H stated he may not have administered insulins if he did not know they were scheduled. LVN H stated he might have given some insulins and stated he may have failed to document the administrations. LVN H stated If it is not documented it was not done when asked what the professional standard was for nursing duties. During an interview on 06/03/2023 at 07:38 PM LVN O stated she was an agency nurse and worked temporarily for the facility on 100 and 200-halls. LVN O stated she had worked for the facility during April - May 2023. LVN O stated she administered medications and treatments that were on the nurse MAR and had not received any training to alert her to review the Alerts tab for residents scheduled injectable medications. LVN O stated she may have missed some resident's injectable medications if the medications were not visible on the nurse's MAR. LVN O stated If it is not documented it was not done when asked what the professional standard was for nursing duties. Resident #2 May 2023 A record review of Resident #2's May 2023 PCP order summary revealed the PCP ordered for Resident #2 to receive insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM; insulin glargine 100 unit/ml inject 50 units subcutaneously every morning and at bedtime for DM; and insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 units/ml inject 47 units subcutaneously every morning and bedtime for DM, on: 05/01/2023 at 08:00 PM and 05/05/2023 at 08:00 PM. A record review of the facility's schedule revealed agency nurse LVN Y worked the 02:30 PM to 10:30 PM shift on 05/01/2023 and Facility nurse LVN E worked the 02:30 PM to 10:30 PM shift on 05/05/2023. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 50 units subcutaneously every morning and at bedtime for DM on 05/06/2023, 05/08/2023, 05/09/2023, and 05/13/2023 all at 08:00 PM, both on 200-hall. A record review of the facility's schedule revealed facility nurse LVN B worked the 06:30 AM to 10:30 PM shift on 05/06/2023 and 05/13/2023 and LVN E worked the 02:30 PM to 10:30 PM shift on 05/05/2023, both on 200-hall. A record review of Resident #2's May 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml, inject as per sliding scale: if 200-249 = 2 units; 250-299 = 4 units; 300-349 = 6 units; 350-399 = 8 units; if greater than 400 give 10 units and notify MD. Subcutaneously before meals and at bedtime on 05/01/2023 at 04:00 PM and at 08:00 PM; 05/05/2023 at 04:00 PM and at 08:00 PM; 05/06/2023 at 08:00 PM; 05/08/2023 and 05/09/2023 at 04:00 PM and at 08:00 PM; 05/13/2023 at 08:00 PM; 05/15/2023 at 11:00 AM and 05/16/2023 at 11:00 AM. A record review of the facility's schedule revealed on 05/01/2023 and on 05/05/2023, agency nurse, LVN Y worked the 02:30 PM to 10:30 PM shift and facility nurse LVN A worked the 06:30 AM to 02:30 PM shift on 200-hall. A record review of the facility's schedule revealed on 05/06/2023, and on 05/13/2023 facility LVN B worked the shift from 06:30 AM to 10:30 PM. A record review of the facility's schedule revealed on 05/08/2023, 05/09/2023, 05/15/2023, and 05/16/2023 LVN A worked the 06:30 AM to 02:30 PM shift and LVN E worked the 02:30 PM to 10:30 PM shift. During an interview on 06/03/2023 at 08:47 PM LVN E stated she had worked during the Month of May 2023 as a charge nurse on 200-hall and had not administered some of the residents insulins due to the insulins were moved off of the nurses MAR and onto a tab called the Alert Tab. LVN E stated she had not received training on the Alert Tab and was not aware the residents insulin orders were moved to the Alert Tab. I could not see them .so, I did not know they were scheduled for administration. LVN E stated If it is not documented it was not done when asked what the professional standard was for nursing duties. Resident #3 A record review of Resident #3's admission record, dated 06/02/2023, revealed an admission date of 10/15/2020 with diagnoses which included diabetes mellitus II [a group of diseases that result in too much sugar in the blood (high blood glucose)]. Further review revealed Resident #3 resided on 200-hall. A record review of Resident #3's MDS annual assessment, dated 04/06/2023, revealed Resident #3 was an [AGE] year-old female with diabetes and a BIMS score of 10 out of 15, indicating moderate impairment of mental cognition. A record review of Resident #3's care plan, dated 06/02/2023, revealed, I have diabetes mellitus which requires daily monitoring .interventions: diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. A record review of Resident #3's April 2023 Physician Order Summary revealed, Resident #3 was to receive insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM. A record review of Resident #3's April 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM, on 04/17/2023 at 09:00 PM, on 04/20-21/2022 at 08:00 AM; on 04/22-04/23 at 08:00 AM and at 09:00 PM. A record review of Resident #3's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day at 08:00 AM for DM and insulin glargine 100 unit/ml inject 30 units subcutaneously one time a day 09:00 PM for DM, on 05/06/2023, 05/13/2023, and on 05/14/2023 at 08:00 AM. A record review of Resident #3's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day at 09:00 PM for DM and insulin glargine 100 unit/ml inject 50 units subcutaneously one time a day 09:00 PM for DM, on 05/01/2023 and on 05/05 - 05/10/2023 at 09:00 PM. During an interview on 06/01/2023 at 12:27 PM Resident #3 stated she had not received her insulin several times, I can't remember what days, but it was in May [2023]. Resident #3 stated she reported she had not received her insulin to a female temporary agency nurse. Resident #3 stated the nurse replied, you don't get insulin. Resident #3 stated she experienced the lack of insulin several times but could not recall dates and times other than May 2023. Resident stated she experienced chills, trembling, and anxiety when she did not receive her insulin. During an interview on 06/02/2023 at 12:33 PM LVN A stated she was the facility's nurse for the 200-hall and worked the 06:30 AM to 02:30 PM shift Monday through Friday. LVN A stated she was made aware, by the DON, somewhere around the Middle of May 2023 that there was an additional tab to click on, the Alert tab in the medication administration record, to administer the injectable insulin. LVN A stated the 200-hall utilized temporary agency nurses for the 02:30 PM to 10:30 PM shift. LVN A stated she knew her residents who received insulin, but agency nurses may not if they did not get a good report. LVN A stated she provided good reports to the agency nurses. LVN A stated, If it is not documented it was not done when asked what the professional standard was for documenting nursing duties. Resident #7 A record review of Resident #7's admission record, dated 06/02/2023, revealed an admission date of 12/13/2020 with diagnoses which included diabetes mellitus. A record review of Resident #7's annual MDS, dated [DATE], revealed Resident #7 was a [AGE] year-old female admitted with diabetes and was assessed with an 11 out of 15 BIMS score, which indicated a moderate cognitive impairment. A record review of Resident #7's care plan, dated 06/02/2023 revealed, I have diabetes mellitus .diabetes medication as ordered by physician. A record review of Resident #7's May 2023 physician's order summary revealed Resident #7 was to receive insulin glargine 100 unit/ml inject 10 units subcutaneous at bedtime, 08:00 PM, for DM 2; dulaglutide 1.5 mg/0.5ml inject 1.5mg subcutaneously one time a day every 7 days for type II DM; and insulin aspart 100 units/ml inject per sliding scale if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6units; 301 - 350 = 8 units; 351 - 400 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus. A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of insulin glargine 100 unit/ml inject 10 units subcutaneous at bedtime, 08:00 PM, for DM 2 on 05/17/2023; 05/22 - 05/23/2023; and on 05/29 - 05/30/2023. A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of dulaglutide 1.5 mg/0.5ml inject 1.5mg subcutaneously one time a day every 7 days for type II DM, on 05/17/2023. A record review of Resident #7's May 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml inject per sliding scale if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6units; 301 - 350 = 8 units; 351 - 400 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus, on 05/17/2023 at 11:00 AM, 04:00 PM, and at 08:00 PM, on 05/19-05/21/2023 at 07:00 AM and at 11:00 AM; on 05/22 - 05/23/2023 at 07:00 AM, 11:00 AM, 04:00 PM, and at 08:00 PM, and on 05/29 - 05/30/2023 at 04:00 PM and 08:00 PM. Resident #11 Record review of Resident #11's face sheet, dated 06/02/2023, reflected Resident #11 was an [AGE] year-old male admitted on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), and dementia. Record review of Resident #11's MDS assessment, dated 05/11/2023, reflected a BIMS of 11, indicating moderately impaired cognitive status. Record review of Resident #11's Physician's Orders, dated 06/02/2023, reflected an order for NovoLog Solution 100 unit/ml 3 units subcutaneously two times a day every Monday, Wednesday, and Friday for hypoglycemia dialysis days. Resident #11's Physician's Orders also reflected an order for NovoLog Solution 100 unit/ml 3 units subcutaneously with meals every Tuesday, Thursday, Saturday, and Sunday for hyperglycemia. Record review of Resident #11's April 2023 and May 2023 Medical Administration Record, dated 06/02/2023, revealed blanks in the medical administration record for NovoLog Solution 100 unit/ml. There was no record of NovoLog administration on the following dates and times: 04/14/2023 at 11:30 AM; 04/20/2023 at 11:30 AM; 04/21/2023 at 12:00 PM; 05/1/2023 at 12:00 PM and 06:00 PM; 05/2/2023 at 07:30 AM, 11:30 AM, and 05:00 PM; 05/4/2023 at 07:30 AM, 11:30 AM, and 05:00 PM; 05/11/2023 at 07:30 AM and 11:30 AM; 05/12/2023 at 12:00 PM and 06:00 PM. Observation on 06/02/2023 at 9:00 AM, Resident #11 was observed in their bedroom with the lights off resting. Resident #11 stated they did not want to be disturbed and was not available for interview. Resident #12 Record review of Resident #12's admission record, dated 6/02/2023, revealed an admission date of 06/07/2016 with the diagnoses which included diabetes mellitus II. Record review of Resident #12's annual MDS assessment, dated 4/02/2023, revealed Resident #12 was a [AGE] year-old female who needed medical support for diabetes that included Insulin injections. Record review of Resident #12's care plan, dated 6/02/2023, revealed, I have diabetes mellitus . intervention: diabetes medication as ordered by doctor. Record review of physician progress note dated 5/15/2023 revealed Assessment and Plan for Resident #12 included, Diabetes Mellitus Type 2 with peripheral Neuropathy, continue Levemir [Trulicity], AC Humalog [Insulin Lispro]. Record review of Resident #12's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Humalog Kwik-Pen Solution Pen-Injector 100 Unit/ML (Insulin Lispro) Inject 8 unit subcutaneously before meals with a start date of 2/23/2018; Trulicity solution pen-injector 0.75 mg/ml (dulaglutide) inject 0.75mg subcutaneously at bedtime every Friday for type 2 diabetes with a start date of 7/23/2021. Record review of Resident #12's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Trulicity on 5/12/2023; blank spaces for medication administration of Humalog Kwik-Pen (Lispro) at 11:00 AM on 5/01/2023, 11:00 AM on 5/11/2023, 11:00 AM on 5/12/2023, and 4:00 PM on 5/12/2023. Resident #16 Record review of Resident #16's face sheet, dated 6/1/2023, reflected Resident #16 was a [AGE] year-old female admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Record review of Resident #16's MDS assessment, dated 3/8/2023, reflected a BIMS of 15, indicating intact cognitive status. Record review of Resident #16's Physician's Orders, dated 6/1/2023, reflected an order for NovoLog Flex pen Subcutaneous Solution Pen-Injector 100 unit/ml injected on a sliding scale based on the resident's blood sugar level. The order reflected that this should be injected subcutaneously before meals and at bedtime for the Resident #16's type 2 diabetes mellitus. Record review of Resident #16's April 2023 and May 2023 Medical Administration Record, dated 06/01/2023, revealed blanks in the medical administration record for NovoLog Solution 100 unit/ml. There was no record of blood sugar checks or NovoLog administration on the following dates and times: 04/14/2023 at 09:00 PM; 04/20/2023 at 11:00 AM; 04/21/2023 at 11:00 AM; 04/23/2023 at 11:00 AM; 05/1/2023 at 11:00 AM; 05/11/2023 at 8:00 AM and 11:00 AM; 05/12/2023 at 11:00 AM, 04:00 PM and 09:00 PM. In an interview on 6/2/2023 at 8:40 AM, Resident #16 stated she does not recall staff not providing her medication to her at any time. In an interview on 6/2/2023 at 7:27 PM, LVN G stated she worked on 4/14/2023, 5/11/2023, and 5/12/2023, and that she could not recall any residents not being provided insulin as ordered. In an interview on 6/2/2023 at 4:36 PM, LVN M stated she worked on 4/23/2023 the MAR tells them if they are diabetic or need insulin. LVN M then stated the system changed, but she were not sure why there would be any holes in the MAR even if the system changed. LVN M stated she could not recall any residents not being provided insulin as ordered. In an interview on 6/2/2023 at 9:21 AM, the DON stated Resident #16 occasionally said she did not need insulin as she did not have diabetes. When asked why there was missing documentation on the MAR, the DON stated they had changed the way insulin was documented in their EMR. Resident #21 A record review of Resident #21's quarterly MDS, dated [DATE], revealed Resident #21 was a [AGE] year-old female admitted [DATE] who needed medical support for diabetes that included Insulin injections. A record review of Resident #21's care plan, dated 06/02/2023, revealed, I have diabetes mellitus .intervention: diabetes medication as ordered by doctor. Record review of physician progress note dated 04/26/2023 revealed Assessment and Plan for Resident #21 to included, Diabetic neuropathy, DM2 [Diabetes Mellitus Type 2], continue .SSI [sliding scale Insulin]. Record review of Resident #21's Order Summary Report, active as of 6/02/2023, revealed physician orders for: Humalog Kwik-Pen Subcutaneous solution pen-injector 100 unit/ml (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime, Insulin Glargine subcutaneous solution pen-injector 100 unit/ml, inject 10 unit subcutaneously at bedtime. Record review of Resident #21's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin Glargine on 5/12/2023 at bedtime; blank spaces for medication administration of Humalog Kwik-Pen on 05/01/2023 at 11:00 AM, on 05/11/2023 at 8:00 AM, on 05/11/2023 at 11:00 AM, on 05/12/2023 at 11:00 AM, on 05/12/2023 at 04:00 PM, and on 05/12/2023 at 09:00 PM. Resident #23 Record review of Resident #23's MDS assessment, dated 05/06/2023, reflected a BIMS of 14, reflecting an intact cognitive status. Record review of Resident #23's Physician's Orders, dated 06/02/2023, reflected an order for Humulin Kwik Pen Suspension Pen-injector 100 unit/ml two times daily, and Novo-Fine two times daily for type 2 diabetes mellitus. Record review of Resident #23's May 2023 Medical Administration Record, dated 6/2/2023, revealed blanks in the medical administration record for Humulin Kwik Pen Suspension Pen-injector 100 unit/ml. There was no record of Humulin administration on 05/12/2023 at 07:00 PM. Record review of Resident #23's May 2023 Medical Administration Record, dated 06/02/2023, revealed blanks in the medical administration record for Novo-Fine Miscellaneous 30G X 8 MM (Insulin Pen Needle) on 05/12/2023 at 07:00 PM. In an interview on 6/2/2023 at 8:50 AM, Resident #23 stated he could not recall receiving any of his medications, including insulin. In an interview on 6/2/2023 at 7:27 PM, LVN G stated she worked on 5/12/2023, and she could not recall any residents not being provided insulin as ordered. Resident #34 A record review of Resident #34's admission record, dated 06/02/2023 revealed an admission date of 12/31/2022 with diagnoses which included diabetes mellitus II. A record review of Resident #34's quarterly MDS assessment, dated 04/12/2023 revealed Resident #34 was a [AGE] year-old male who was assessed with diabetes and a BIMS score of 06 of 15 possible, which indicated severe mental cognition impairment. A record review of Resident #34's care plan dated 06/02/2023, revealed, I have diabetes mellitus . interventions; observe document report two doctor as needed signs and symptoms of hypoglycemia. A record review of Resident #34's April 2023 physician's order summary revealed Resident #34 was to receive insulin detemir 100 units/ml inject 12 units subcutaneously in the morning [07:00 AM], for type II diabetes; insulin detemir 100 units/ml inject 5 units subcutaneously in the evening [05:00 PM], for type II diabetes; and insulin aspart 100 units/ml inject per sliding scale if 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 6 units; 350 - 400 = 8 units; 401 - 999 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus. A record review of Resident #34's May 2023 medication administration record revealed blank spaces for medication administration of insulin detemir 100 units/ml inject 12 units subcutaneously in the morning [07:00 AM], for type II diabetes on 05/20 - 05/23/2023. A record review of Resident #34's April 2023 medication administration record revealed blank spaces for medication administration of insulin detemir 100 units/ml inject 5 units subcutaneously in the evening, 05:00 PM on 04/17/2023, 04/20/2023, 04/22 - 04/23/2023, and on 04/29 - 04/30/2023. A record review of Resident #34's April 2023 medication administration record revealed blank spaces for medication administration of insulin aspart 100 units/ml inject per sliding scale if 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 6 units; 350 - 400 = 8 units; 401 - 999 = 10 units if over 400, notify MD., subcutaneously before meals and at bedtime for type II diabetes mellitus on 04/17/2023 at 11:30 AM, 04:30 PM, and 08:30 PM; on 04/19/2023 at 11:30 AM; on 04/20 - 04/21/2023 at 07:00 AM and at 11:30 AM; on 04/22 - 04/23/2023 at 07:00 AM, 11:30 AM, 04:30 PM, and 08:00 PM; 04/24/2023 at 08:00 PM; and on 04/29 - 04/30/2023 at 04:30 PM and 08:00 PM. Resident #257 Record review of Resident #257's admission record, dated 06/02/2023, revealed an admission date of 5/01/2023 with the diagnoses which included diabetes mellitus II. Record review of Resident #257's admission MDS assessment, dated 05/10/2023, revealed Resident #257 was an [AGE] year-old male who needed medical support for diabetes that included Insulin injections. Record review of Resident #257's care plan, dated 6/02/2023, revealed, I have diabetes mellitus . intervention: diabetes medication as ordered by doctor. Record review of Resident #257's physician progress note dated 5/24/2023 revealed Assessment and Plan, Diabetes Mellitus Type 2, continue Lantus, Trulicity [Insulin Lispro]. Record review of Resident #257's Order Summary Report, active as of 06/02/2023, revealed physician orders for: Humalog Kwik-Pen solution (Insulin Lispro) Inject as per sliding scale .subcutaneously before meals and at bedtime with a start date of 05/01/2023; Insulin glargine subcutaneous solution inject 15 units subcutaneously at bedtime with a start date of 05/01/2023. Record review of Resident #257's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin glargine on 05/12/2023 at bedtime; blank spaces for medication administration of Humalog Kwik-Pen (Lispro) at 11:00 AM on 05/11/2023, 11:00 AM on 05/12/2023, 04:00 PM on 05/12/2023 and on 05/12/2023 at 08:00 PM. Resident #258 Record review of Resident #258's admission record, dated 06/02/2023, revealed an admission date of 03/07/2022 with the diagnoses which included diabetes mellitus II. Record review of Resident #258's discharge MDS assessment, dated 05/23/2023, revealed Resident #258 was a [AGE] year-old female who needed medical support for diabetes. Record review of Resident #258's care plan, dated 06/02/2023, no focus areas or interventions related to medical diagnosis of diabetes were included. Record review of physician progress note dated 05/17/2023 revealed Assessment and Plan for Resident #258 included, continue Lantus. Record review of Resident #258's Order Summary Report, active as of 06/02/2023, revealed physician orders for: insulin Regular Human Injection Solution Pen-injector 100 unit/ml inject 40 unit subcutaneously before meals with a start date of 5/09/2023; Lantus solo-star solution pen-injector 100 unit/ml (insulin glargine) inject 65 unit subcutaneously one time a day with a start date of 5/10/2023. Record review of Resident #258's Medication Administration Record for the month of May 2023, revealed blank spaces for medication administration of Insulin solo-star (insulin glargine) on 05/04/2023 at 08:00 PM, 05/05/2023 at 09:00 AM and 08:00 PM, 05/06/2023 at 09:00 AM and 08:00 PM, 05/07/2023 at 09:00 AM and 08:00 PM, 05/08/2023 at 09:00 AM; blank spaces for medication administration of Insulin Regular Human Injection on 05/12/2023 at 11:30 AM. A record review of the facility's grievance for Resident #258, dated 05/15/2023, revealed, Resident #258 made a grievance to the BOM, alleging she had not received her insulin, Resident believes she may have missed a dose of insulin the other day. During an interview on 06/01/2023 at 4:00 PM the DON stated there were holes in the MAR due to the electronic medication administration record received an update where all the injectable medications were moved to a separate tab. The DON stated some staff were unaware of the separate tab and other staff knew residents received injectable insulin and knew to provide the medication. The DON stated the facility investigated system failure and coordinated with the software developer and moved the injectable medications back to the tab where staff were used to access the medication. In an interview on 06/03/2023 at 05:19 PM, the DON stated she did not remember when in April or early May 2023 the high alert injectable medications moved to the alternative tab in the electronic medication system. The DON stated she did not recall why that change occurred. Failure #4 Fail to monitor blood sugar levels. Resident #107 Record review of Resident #107's Face Sheet dated 06/03/2023, revealed Resident #107 was a [AGE] year-old female admitted on [DATE]. Diagnosis information included Type 2 diabetes mellitus without complications with an onset date of 05/24/2023. Record review of Resident #107's comprehensive MDS assessment dated [DATE], revealed Resident #107's primary medical condition category for admission was medically complex conditions related to acute posthemorrhagic anemia [condition that develops when you lose a large amount of blood quickly; tissue and organ damage could be permanent and fatal]. Other active diagnoses included d[TRUNCATED]