**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. On 03/23/24, LVN A and LVN C failed to notify the Medical Doctor 3 out of 7 neuro checks were not being done for 12 hours. Resident #6 was hospitalized on [DATE] and returned 03/27/24 with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . An IJ was identified on 06/07/2024. The IJ template was provided to the facility on [DATE] at 09:00 PM. While the IJ was removed on 06/09/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential harm because all staff not been trained on. The findings were: Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech . Record review of Resident #6's significant change in status MDS, dated [DATE], reflected a BIMS score of 99, indicating resident was unable to complete the interview. Further review of this MDS reflected Resident #6's cognitive skills for daily decision making was severely impaired with short term and long term memory problems. Record Review of nursing progress note, authored by LVN A on 03/22/24 at 01:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress note further revealed NP B ordered neuro checks Q 4 hrs x 3days, notify NP of any deficit. Record review of Orders- Administration Note , authored by LVN C, reflected: 03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep 03/23/24 at 04:55 AM Neuro check was not done due to refusal Record review of Orders- Administration Note , authored by LVN A, reflected: 03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping Record review of Resident #6's Medication Administration Record for March, undated, revealed neuro checks that were done were: 03/22/24 at 04:00 PM and 08:00PM, 03/23/24 at 12:00 PM and 04:00 PM. Record review of nursing notes from 03/23/24 revealed no documentation of NP or MD being notified of neuro checks not being done per order. During an interview on 06/07/24 at 10:20 AM, Resident #6's RP 2 revealed on Friday [03/22/24] Resident #6 had weakness in her hands because she was not able to hold a cup of V8 in order to drink it. They revealed they reported this to LVN A. She further revealed the facility said she was fine so Resident #6's RP 2 let it go. Residents #6's RP 2 continued to reveal the next day on Saturday [03/23/24], Resident #6 speech got worse and Resident #6's balance was off. Resident #6's RP 2 revealed she asked resident to be sent out to the hospital because Resident #6 was not at baseline and got worse. She further revealed the facility called regular transport to send out resident. Record Review of Resident #6's hospital record with admission date 03/23/24 revealed history of CVA and dysphagia s/p cerebral infarction. [Resident #6] present with slurring in speech that started yesterday at 1 PM, as well as clumsiness and weakness in her left upper extremity that was noted when she attempts to hold objects like a cup. Hospital records further reflected a new diagnosis and chief complaint of cerebrovascular accident (CVA). During an interview on 06/07/24 at 12:41 PM, the DON revealed LVN A reported to her that the family declined having Resident #6's vital signs checked overnight and wanted to wait and see if Resident #6 would get better. During an interview on 06/07/24 at 01:17 PM, LVN A revealed Resident #6 had stroke like symptoms on 03/22/24, but family declined having Resident #6 sent out to the hospital. LVN A further revealed the family wanted LVN A to contact Resident #6's NP to see what she recommended. LVN A revealed NP ordered neuro checks every 4 hours for 3 days. LVN A revealed Resident #6's family declined having neuro checks done when Resident #6 was asleep. LVN A further revealed she did not contact NP B that neuro checks were not done. LVN A also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke, so the family knew information about strokes. Left voicemail for LVN C on 06/07/24 at 05:21 PM. During an interview on 06/07/24 at 05:02 PM the DON revealed NP B was not contacted because there were no deficits in neuro checks, which was how the doctor order read. The DON revealed the NP B would not have been contacted if the family refused neuro checks. During an interview on 06/07/2024 at 05:29 PM NP B stated LVN A reported on 03/22/2024 Resident #6 had a change of condition, with weakness in arms and NP B issued an order for Neurological assessments every 4 hours for 3 days. NP B stated she was not aware the orders for Resident #6 Neurological assessments were not performed for 12 hours and would have wanted to be notified when her orders were not followed. NP B stated neurological assessment deficits would indicate a potential for a stroke. NP B stated if the neurological assessment deficit were revealed it would have warranted an immediate hospitalization. During an interview on 06/09/24 at 03:16 PM, the Medical Director stated he was given a report for Resident #6's missed neurological assessments from 03/23/2024 on 06/08/2024. The Medical Director confirmed he did not know about these missed neurological assessments before 06/08/24. He stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. Record Review of facility's policy, revised April 2009, Change in a Resident's Condition or Status, reflected 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: f. refusal of treatment or medications. An Immediate Jeopardy (IJ) was identified on 06/07/2024 at 09:00 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 06/08/2024 01:46 PM. Immediate Jeopardy Plan of Removal Verification 6/8/2024 All residents with orders for neuro checks are at risk of the orders not being followed or prescriber not being notified of the refusals. During an interview on 06/08/24 at 02:30 PM, the Administrator revealed the census was 79 and there were 0 residents currently being assessed for neurological assessments. Action to correct and remove IJ: 1.) Verify that current orders are being followed as prescribed by physician/NP. The DON and/or designee will complete this by noon 6/8/2024. During an interview on 06/09/24 at 12:22 PM, the DON stated she and her staff reviewed all the current residents' physicians' orders for compliance and all evidenced compliant. During an interview on 06/08/24 at 02:30 PM, the Administrator revealed there were no residents on neuro checks and 2 residents had received neurological assessments in the recent past, Resident #44 and Resident #48. During an interview on 06/09/24 at 12:22 PM, the DON stated 2 residents (Resident #44 and Resident #48) had received neurological assessments per post fall protocols. The DON stated there were no residents ordered to receive neurological assessments since 03/23/2024 when Resident #6 was ordered neurological assessments due to her stroke-like symptoms. A record review of the facility's census revealed 2 of 79 residents (Resident #44 and Resident #48) had completed worksheets for neurological assessments: o A record review of Resident #44's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 5 times, assessed every 30 minutes 4 times, assessed every hour three times, and every 4 hours 4 times. o A record review of Resident #48's neurological assessment worksheet dated 05/21/2024, revealed Resident #44 was assessed every 15 minutes 7 times, assessed every hour eight times. 2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP of any refusals that keep us from following orders prescribed. The DON and/or designee will complete in-service with team by 6/9/2024. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who are unavailable will attempt to be reached by phone call, text message, and email by DON/Designee. DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred. During an interview on 06/08/24 at 03:02 PM, the DON provided documents titled in-service education attendance record, dated 06/07/24, and facility policy's Change in a Resident's Condition or Status, revised November 2010, and Refusal of Medications and Treatments, Documentation of, revised April 2009. The DON revealed licensed nurses could not work a shift until they have received in-services for following orders and reporting orders that could not be performed and have been sent an email to go to her office to be educated before working a shift. A record review of the facility's nursing roster revealed 23 / 34 licensed nurses were employed. 19 licensed nurses were full time, and 15 licensed nurses were part time. A record review of the facility's nursing roster and schedule revealed 13 nurses worked the 07:00 AM shift to 07:00 PM shift and 10 worked the 07:00 PM to 07:00 PM shift. A record review of the facility's in-service titled Change of Condition; refusal of treatment . dated 06/07/2024, revealed 23 Nurses received the in-service. Interviews: 07:00 AM to 07:00 PM shift: 7 Of 14 nurses, 50%, who worked the 07:00 AM to 07:00 PM shift were interviewed. A sample of the interviews follow: During an interview on 06/09/24 at 10:53 AM, LVN J revealed he received training on reporting to MD or NP if the resident's doctor's orders were not being fulfilled. During an interview on 06/09/24 at 10:59 AM, ADON D and LVN E revealed they were trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders. During an interview on 06/09/24 at 11:10 AM, RN F, RN G, and LVN H not able to carry out a doctor's order they will notify the doctor or NP. RN gave examples of some doctor's orders that need to be followed. During an interview on 06/09/24 at 02:22 PM, the DON revealed she was in-serviced on change of condition policy and refusal of treatment/medication by the COO. Interviews: 07:00 PM to 07:00 AM shift: 6 of 9 licensed nurses, 67%, who regularly worked the 07:00 PM to 07:00 AM shift were interviewed. A sample of the interviews follow: During an interview on 06/09/24 at 10:59 AM, LVN I revealed she was trained in contacting a resident's MD or NP if they were not able to fulfill doctor's orders. They further revealed they could make person centered changes to help fulfill their orders. During an interview on 06/09/24 at 12:22 PM, DON revealed LVN C (who regularly worked 6 PM- 6 AM) could not be contacted to be in-serviced. LVN C had been taken off the schedule until she was able to be in-serviced. During an interview on 06/09/24 at 01:28 PM, LVN K revealed she was educated recently to follow doctor's orders and report to doctor or NP if a resident was not able to receive a treatment or medication. During an interview on 06/09/24 at 01:43 PM, LVN L revealed she was in-serviced on how to complete a change in condition assessment and notify doctor if any doctor's orders were not fulfilled. During an interview on 06/09/24 at 01:55 PM, LVN M revealed she was educated recently to follow doctor's orders and contact MD or NP if an order was not fulfilled. During an interview on 06/09/24 at 02:01 PM, LVN N revealed she would contact the doctor if a resident refused treatment, refused medication, or had a change in condition. During an interview on 06/09/24 at 02:09 PM, LVN O revealed he was trained to contact the doctor if medications or treatments were not fulfilled. 3.) Physicians/NP partners will be notified to provide team with more concise orders and to consider the nurse's feedback regarding specific resident's characteristics or preferences when deciding a plan of action. The communication with our physician partners will be completed by 6/10/2024. During a joint interview on 06/09/2024 at 11:00 AM the Administrator and the DON stated the facility has partnered with all facility medical providers to have a consensus to develop and implement improved physicians' orders to better reflect residents needs and preferences i.e., may assess while awake, may reattempt x3, and please report to physicians after 2x refusals. the Administrator and the DON stated the facility has sent emails to the medical director and all supporting and attending physicians and nurse practitioners. The Administrator stated the facility held an AD-HOC QAPI meeting to review the Plan of Removal. During an interview on 06/09/2024 at 03:18 PM the Medical Director stated the facility informed him of the immediate jeopardy on 06/08/2024 and the facility held an AD-HOC QAPI meeting to review the immediate jeopardy and develop a plan of removal. The medical Director stated he was given a report for resident #6's missed neurological assessments from 03/23/2024 on 06/08/2023. The Medical Director stated the ideal would be for the prescriber to be given a report when the orders given were not able to be completed. 4.) The DON/Designee will review 24-hour report daily for change of condition UDA including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact DON/Designee if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter. During a joint interview on 06/09/2024 at 11:00 AM the administrator and the DON stated the facility would daily monitor the 24-hour reports for any changes of condition, to include neurological assessments, refusals of any assessments, treatments and or orders: and follow up documentation with reports to physicians. The Administrator and the DON stated the monitoring will be conducted for 14 days, then 4 weeks, and then for 3 months. Record review of Daily Neurological Checks dated 6/8/2024, 6/9/2024 No new neurological checks, created by DON. The Daily Neurological Checks, included Resident name, Date, Notification to family, notification of MD, refusals of vital signs, notification of neurological assessments, Is this care planned and comments sections. Record review of Weekly Neurological Checks blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of Monthly Neurological Checks Monthly blank sheet, includes resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of E-Interact Daily Change of Condition Assessment, dated 6/8/2024 and 6/9/2024. This included resident name, date, notification of family, notification of MD, Refusal of vital signs, Notification of neurological assessments, Is this care planned and comments sections. Record review of Daily 24 hour report, dated 6/8/2024, 6/9/2024 revealed no neurological checks for residents. Record review of Weekly 24 hour report, for weekly monitoring blank, included resident name, date, progress note refusals EMR refusals, order note refusals, Is this care planned and comments section. 5.) All residents have the potential to be affected by this alleged deficit practice. At risk resident will be identified by reviewing 24 hr. report, (for) changes of condition assessment and neurological checks. A record review of the facility's unit 6's Nurses station 24-hr report revealed no residents were followed for a change of condition and no residents had refused any treatments. Reviews: (Monitoring) 1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months. 2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis. Record review of QAPI Performance for Improvement instructor, Administrator dated 6/8/202 from 9 AM -10 AM. Subject: Notify of Changes. The QUAPI in-service included the Administrator, DON, CDM, Admissions, Business Manager, Maintenance, Housekeeping, ADON, Activity Director, Social Worker, Human Resources and Medical Director. System of Concerns: In-service on Notification of Changes. Concerning IJ F580 Notify of Changes. 3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. During an interview on 06/09/2024 at 03:14 PM the Administrator stated the facility's Chief Operating Officer would have oversight and monitoring the facility's Plan of Removal for the following six months. The Administrator and the DON was informed the Immediate Jeopardy was removed on 06/09/24 at 04:07 PM. The facility remained out of compliance at a severity level of potential harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 8 residents (Resident #6) reviewed for notification. The facility failed to ensure Resident # 6 was assessed as ordered for neuro-checks every 4 hours x 3 days. Resident # 6 was sent to hospital and returned to the facility on [DATE] with new diagnoses to include: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. This failure could result in assessments not being completed as ordered could result in residents' not receiving the necessary care resulting in a decline in health and or death. This could affect all resident with assistive devices and could result in no orders for resident care. The findings included: Record review of Resident #6's admission record, accessed 06/07/24, reflected the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid) following cerebral infarction (a type of stroke caused by impaired blood flow to the brain) and dementia (neurodegenerative disease that affects memory, thinking and interferes with daily life). It further reflected Resident #6 returned to the facility on [DATE] with new diagnoses to include: cerebral infarction (a type of stroke caused by impaired blood flow to the brain), hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of one side of the body) following cerebral infarction affecting right dominant side , ataxia (a loss of muscle coordination), and slurred speech. Record Review of nursing progress note, authored by LVN A on 03/22/24 at 1:20 PM, reflected Resident #6's RP reported Resident #6 could not hold her beverage. This progress notes further revealed NP B ordered neuro checks Q 4 hrs x 3days, and to notify NP of any deficit. Record Review revealed Neuro-checks were not started until 4:00 pm. Record review of Orders- Administration Note , authored by LVN C, reflected: 03/23/24 at 02:02 AM Neuro check was not done due to [Resident #6] being asleep. 03/23/24 at 04:55 AM Neuro check was not done due to[family member] refusal. Record review of Orders- Administration Note , authored by LVN A, reflected: 03/23/24 at 09:06 AM Neuro check was not done due to family member refused since [Resident #6] was sleeping. Record review of nursing notes from 03/23/24 revealed no documentation of NP or MD being notified of neuro checks not being done per order. During an interview on 6/25/2024 at 6:35 pm LVN A revealed she did not explain what could happen if Resident #6 had a stroke to the family, because Resident #6 had a history of having a stroke, so the family knew information about strokes. LVN A said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval. During an interview on 6/25/2024 at 6:49 pm, LVN C stated Resident #6's family member did not allow her to do one of the neuro checks (12 midnight) 3/23/2024 the resident was sleeping. The Resident refused neuro checks at 4:00 am. LVN C further revealed she did not contact NP B when neuro checks were not done. LVN C also revealed she did not explain what could happen if Resident #6 had a stroke because Resident #6 had a history of having a stroke.LVN C said when the resident/family refused neuro checks she did not go back and attempt to reassess the resident until the next 4-hour interval. She further revealed she tried once, and the resident hit me. The resident said leave me alone. During a telephone interview on 6/28/2024 at 12:30 pm NP B stated she remembers the nurses calling her in March 2024 regarding stroke like symptoms, she doesn't recall the specifics, but she feels they let her know how the resident was based on their long-time knowledge of the resident. The nurses once they found the resident to have a change sent her to the hospital. She stated based on the statements of the nurses was how she was sent to the hospital. Resident #6 was admitted to hospital on [DATE] and diagnosed with: cerebral infarction and hemiparesis following cerebral infarction affecting right dominant side, and slurred speech. The plan of removal was submitted by the facility and was accepted on 06/29/24 at 10:07 AM. It was documented as follows: Action to correct and remove IJ: 1.) Verify that all assessments were being followed as ordered by physician/NP. The DON and/or designee will complete this by noon 06/29/24. 2.) All licensed nurses will be in-serviced regarding the need to notify physician/NP immediately of any refusals that keep us from following physician ordered assessments. The DON and/or designee will complete an in-service with the team by 06/30/24. Licensed Nurses on vacation, leave, or unavailable will be trained prior to their next scheduled shift. A Licensed Nurse roster is being utilized to track the Licensed Nurses who have responded and have been in-serviced. The identified Licensed Nurses who were unavailable will attempt to be reached by phone call, text message, and email by the DON/Designee. The DON/Designee will work with the scheduler and audit daily to ensure any Licensed Nurse will not be scheduled until the necessary in-service has occurred. 3.) The DON/Designee will review 24-hour report daily for change of condition UDA (Unified Defined Assessment-a change of condition assessment) including neurological checks for any refusals and review for medical provider notification. The Weekend Nurse Manager/Designee will review any refusals and contact the DON/Designee immediately if a resident has a refusal to ensure the medical provider has been notified. Audits will be completed daily x14 days, weekly x4 weeks, monthly x3 months, and periodically thereafter. 4.) All residents have the potential to be affected by this alleged deficient practice. At risk residents will be identified by reviewing 24-hour report, changes of condition assessment and neurological checks. Reviews: 1.) Weekly the DON and/or designee will pull all orders from the EHR for any refusals and review for physician and/or NP notification. The administrator will meet with the DON weekly to audit and verify this review has been completed. This will be ongoing for the next two months. 2.) Reports to the QAPI committee regarding the reviews will be discussed with the team on an ongoing basis. 3.) A corporate designee will audit compliance with orders weekly until stable and monthly for the next six months, quarterly thereafter if stable and report findings to the governing body. The facility's POR verification was as follows: In an interview on 06/29/24 at 12:53 PM the DON stated all but 1 of the 24 nurses had been in-serviced to notify the physician immediately if a resident refused an assessment and the 1 nurse who had not been in-serviced would not be scheduled until they received the in-service. Interviews on 06/29/24 from 12:05 PM to 4:05 PM with 8 nurses (3 RNs and 5 LVNs), five of whom worked the day shift (6 AM to 6 PM) and three of whom worked the night shift (6 PM to 6 AM), revealed they were in-serviced to immediately notify the resident's physician/NP if a resident refused to have an assessment completed, to document the resident refused the assessment in the nurse's progress notes and the physician was notified, and to notify the resident's responsible party. In an interview on 06/29/24 at 4:01 PM, the DON stated she had printed out all the physician orders and verified the assessments had been completed. In a further interview on 06/29/24 at 4:20 PM, the DON stated there was only one resident who had orders for neurological checks that were initiated on 06/28/24 and completed 06/29/24 and the resident did not refuse the neurological assessments. In an interview on 06/29/24 at 4:52 PM the DON stated she would review the 24-hour reports, the orders in the EHR, and the change of condition reports daily for notation of change of condition in a resident. The DON stated the Weekend Supervisor and the ADON would continue the monitoring when she was not in the facility. The DON stated an ad hoc QAPI meeting was held on 06/28/24 with the Medical Director and department heads in reference to the IJ for not completing an ordered assessment. The DON stated the Chief Operating Officer would conduct weekly audits of the facility's monitoring of compliance with ordered assessments. In an interview on 06/29/24 at 5:09 PM the Administrator stated she reviewed the 24-hour reports with the DON for ordered assessments. The DON in-serviced the nurses on ensuring ordered assessments were completed and to notify the physician immediately if an assessment was refused by the resident. The Administrator stated they would obtain daily the 24-hours reports from the EHR to monitor ordered assessments. The Administrator said an ad hoc QAPI meeting was held on 06/28/24 and not notifying the physician when a resident refused an assessment was reviewed and discussed. The Medical Director, the DON, the ADON and other department heads were present at the ad hoc QAPI meeting. The Administrator stated the Chief Operating Officer would conduct the weekly audits of compliance with monitoring physician order assessments. Record review of an undated, untitled list of nurses revealed 24 nurses were employed at the facility. Record review of the In-Service Education Attendance Record dated 06/28/24, for Completing assessments as ordered per physician/NP, revealed 23 nurses had been in-serviced. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the 24-Hour report. The 24-Hour Report monitoring form had columns for the resident's name, date, progress notes refusals, EMH refusals, order note refusals, and if it was care planned. Record review of the facility's POR verification binder revealed on the 24-Hour Report daily monitoring sheets revealed on the first row was handwritten 06/29/24 no refusals (i.e., no refusal of care/medications/assessments). On the second row was handwritten a resident's name, date of 06/30/24, notation the resident refused a medication, it was care planned the resident would refuse the medication, and the physician was informed. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for reviews of the E-Interact Change of Condition Assessment. The E-Interact Change of Condition Assessment monitoring form had columns for the resident's name, date, notification to family, notification to the physician, notification of refusal of treatment, notification of refusal of meds, and if it was care planned. Record review of the Daily E-Interact Change of Condition Assessment form revealed residents who had a change of condition on 06/28/24 and 06/29/24 were listed, all the resident's physicians and RP's were notified and none of the residents refused care or assessments. Record review of the facility's POR verification binder revealed there were daily, weekly, and monthly monitoring sheets for Neurological Checks audits. The Neurological Checks monitoring form had columns for the resident's name, date, notification to family, notification to the physician, refusals of vital signs, notification of neurological assessments, and if it was care planned. Record review of the Order Listing Report, dated 06/29/24, revealed there was only 1 resident with orders for neurological checks to be completed in a 24-hour period. In an interview on 06/29/24 at 4:20 PM, the DON stated there was 1 resident who had orders for neurological checks and there was another resident who had a fall on 06/28/24 that neurological checks were being done on. Both residents were listed on the Daily Neurological Checks monitoring sheet. Record review of the Daily Neurological Checks monitoring sheet revealed 2 residents were listed on 06/28/24 for neurological checks, their physician's and RP's were notified, and the residents did not refuse the assessment. On 06/29/24 there were no residents with orders for neurological checks. Record review of an In-Service Education Attendance Record, dated 06/28/24, revealed an ad hoc QAPI meeting was held at 6 PM to discuss assessment documentation and all assessments were not being completed as ordered could result in residents not receiving the necessary care resulting in a decline in their health or even death. The meeting was conducted by the Administrator and in attendance were the Medical Director, the Activity Director, the ADON, the DON, the BOM, the dietitian, and the housekeeping director. An Immediate Jeopardy was identified on 6/29/2024 . The IJ template was provided to the facility on 6/29/2024 . While the IJ was removed on 6/30/2024, the facility remained out of compliance at a scope of pattern and a severity level lowered to no actual harm that is not Immediate Jeaperdy due to the facility's need to monitor and evaluate the effectiveness of the corrective actions.