**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after a resident expressed suicidal ideations (she wanted to die). The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or harm. Findings include: Record review of an undated, face sheet indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (loss of cognitive functioning), diabetes (chronic condition that affects the way the body processes blood sugar), stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off ), difficulty speaking and swallowing due to a stroke, major depression, (medical illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of physician orders, dated 7/10/2023, indicated Resident #1 received psych services for evaluation and monitoring. The orders indicated she received Depakote 125 mg one time a day for mood disorder and Paroxetine 40 mg one time a day for depression and anxiety. Record review of an annual MDS, dated [DATE], indicated Resident #1 was usually understood and usually understood others. A BIMS score of 12, which indicated Resident #1 was moderately impaired cognitively. Resident #1 required limited to extensive assistance with most ADLs. Resident #1 had signs and symptoms of delirium to include disorganized thinking behaviors present. Record review of Resident #1's care plan, dated 12/01/2021, indicated Resident #1 was at risk for behavioral symptoms/suicidal ideation related to vocalized wanting to die when she was mad. The care plan interventions included to allow her time to answer questions and to verbalize feelings perceptions, and fears; consult with pastoral care, social services, or psych services; and when conflict arises, remove to a calm safe environment, and allow to vent/share feelings. Record review of a progress note dated 9/4/2023, from NP D from psychiatric services, indicated the resident was negative for suicidal ideations. Resident #1 was being seen 2-3 times a month by psych services for major depression disorder, insomnia, and medication monitoring. Record review of a progress note for Resident #1, dated 9/10/2023 at 10:10 p.m., LVN A indicated Resident #1 was sitting up in her wheelchair in her room. Resident #1 refused medications at 8:30 p.m. and was yelling at staff to leave her alone, she just wanted to die. LVN A tried to redirect the resident, but the resident continued to yell get out, just leave me alone. LVN A left Resident #1 alone in her room and when she came back to the room, the resident was not yelling. LVN A found Resident #1 with shoestrings tied around her neck. LVN A cut the shoestring off and asked the resident if she did that to kill herself and Resident #1 screamed out I sure did! Resident #1 was placed on 24-hour 1-on-1 monitoring, and the MD, RP, and DON were notified. A call was placed for EMS to transport the resident to the local hospital for evaluation and treatment. When EMS arrived, Resident #1 continued yelling, was aggressive and refused to cooperate with staff and EMS. EMS administered Haldol (antipsychotic medication) intramuscularly, but the medication was ineffective. While EMS transferred Resident #1 from her wheelchair to the stretcher, the resident was alert and yelling and hitting EMS as they exited the facility. The RP was notified. During a telephone interview on 9/13/2023 at 5:05 p.m., LVN A said she was the nurse on duty for Resident #1 the evening of 9/10/2023, the date the incident occurred. She said around 8:45 p.m. - 9:00 p.m. she checked Resident #1's fingerstick blood sugar level, but the resident became aggressive when she returned to give her the scheduled 9 p.m. medications. She said the resident started hollering, screaming, and cussing at her telling her to get the hell out, don't want to live/want to die. She said CNA B was in the room behind the privacy curtain providing care for Resident #1's roommate. LVN A said she left the room to get CNA C who could calm Resident #1 down and get her to take medications and/or allow staff to provide care. LVN A said as she was leaving the room, she told CNA B to keep an eye on Resident #1. LVN A said she returned to Resident #1's room with CNA C around 9:15 p.m. and found the resident had 2 shoestrings tied together around her neck tightly. She said the resident was combative (slapping the nurse's hands back), but she was able to release tension of the shoestrings from around the resident's neck. LVN A said she directed for CNA C to get scissors to cut the string. She said when CNA C returned to the room with the scissors from the nurses' station, she cut the shoestrings and removed them from the resident's neck. She said after cutting the string, there were red marks to the left side of Resident #1's neck. LVN A said she asked the resident if she did that to kill herself and the resident screamed out I sure did! She said Resident #1's MD, the DON, administrator, and RP were notified. She said Resident #1 was placed on 24-hour 1-on-1 monitoring at 9:30 p.m. until the ambulance arrived at 9:45 p.m. to transport her to the hospital for evaluation. She said when EMS arrived, the resident was combative and hollering out. LVN A said EMS administered Haldol to Resident #1, but it was ineffective as she continued yelling and hitting the EMS staff as they exited the facility. LVN A said she did not recall this resident ever being this aggressive and combative. LVN A said the resident had a history of episodes of hollering and fighting staff at times with episodes of crying saying she wanted to die. LVN A said when she was upset or had those behaviors, she usually would be calmed down by certain staff. During a telephone interview on 9/13/2023 at 5:27 p.m., CNA B said around 9 p.m. (on 09/10/23), she was in Resident #1's room providing care to the resident's roommate. She said she heard when Resident #1 was refusing her medications, yelling at the nurse to get the hell out, and saying she wanted to die. CNA B said LVN A told her to keep an eye on Resident #1 as she (the nurse) left the room for assistance. CNA B said she did not stay in the room with Resident #1 once she finished providing care to the roommate, she left the room. She said LVN A did not direct her to provide 1:1 care to Resident #1, and she was not assigned to provide care for Resident #1. CNA B said you could hear Resident #1 hollering and screaming from the hallway. During a telephone interview on 9/13/2023 at 5:35 p.m., CNA C said on 09/10/2023, she was assigned to care for Resident #1 and when she provided care for the resident around 7:30 p.m., the resident was not as talkative as usual but did not make any statements about wanting to die. CNA C said LVN A went to her and asked her to go to Resident #1's room to help calm her down so she would take her nighttime medications and get ready for bed. CNA C said her and LVN A walked into the resident's room around 9:15 p.m. She said LVN A asked the resident, What is that around your neck? She said when LVN A reached for the shoestrings around the resident's neck, she slapped at LVN A's hands. CNA C said LVN A told her to go get scissors from the nurses' station. She said when she returned to the resident's room with the scissors, LVN A was trying to release tension on the shoestrings. She said LVN A cut the shoestrings from around the resident's neck and asked the resident, Did you do that to kill yourself? CNA C said Resident #1 screamed out, I sure did! She said Resident #1 was placed on 1-on-1 supervision at that time. CNA C said it was a very scary incident and said she would never thought Resident #1 would have done anything like that. CNA C did not recall seeing any other staff in the room prior to them entering. Record review of Resident #1's hospital records, dated 9/11/2023, indicated she was transferred from the facility to the acute care hospital and later seen by the associated behavioral unit. During a telephone interview on 9/14/2023 at 12:19 p.m., NP D said he was a psych service NP and visited with Resident #1 two to three times a month for a year or more. He said he was seeing the resident for delusions, depression/sadness, sleep disturbances, and for management of psychotropic medications and side effects, and to monitor the effects of medications and for dose adjustments. He said he was surprised to hear the resident made suicidal ideations or expressed any desire or plan to commit suicide because she denied risk of self-harm during visits. NP D said Resident #1 could be moody at times and depending on her mood, she might not speak with anyone or allow anyone to assess her. NP D said the facility notified him of Resident #1's suicide attempt and her being sent out for evaluation. He said he would visit with her when she returned to the facility. NP D denied knowledge of the resident having occasional episodes of crying and hollering out and saying she wanted to die. Record review of progress note on 9/14/2023 at 12:30 p.m. indicated Resident #1 returned to facility on 9/13/2023 at 11:00 pm. During an observation and interview on 9/14/2023 at 1:30 p.m., Resident #1 was sitting up in her wheelchair in her room. She had slurred speech but was able to answer questions and made her needs known. Resident #1 answered questions, but when asked about the 09/10/2023 suicide attempt incident, she would not respond. Resident #1's room was clean, and no hazardous materials were noted (shoes with no shoestrings or elastic shoes with strings sewn in, no sharp objects). During an interview on 9/14/2023 at 3:00 p.m., the DON said Resident #1 had been a resident at the facility for several years and had a history of making statements about wanting to die when she was mad. The DON said she was aware of Resident #1 making the statements of wanting to die at times. She said the resident would do this at times when her family would leave after visiting or it seemed to happen when she was mad or seeking attention. The DON said the facility care planned those behaviors with interventions to include staff talking with her and see why she was upset or mad. She said usually the staff could resolve the issue and Resident #1's behavior. She said prior to Resident #1's suicide attempt, if a resident made a suicide threat or expressed they wanted to die, the expectations of staff's response to the resident depended on who the resident was and if this was a previously identified behavior. The DON said (on 09/11/2023) after Resident #1's suicide attempt, the facility implemented a new suicidal prevention policy to include if any resident expressed or voiced thoughts of suicide/wanting to die, the resident would not be left alone and 1-on-1 care would be provided until arrangements could be made for the resident to receive emergency psychiatric care or until the resident's physician determined when the resident was no longer a suicide risk. She said all staff prior to working their next shift were in-serviced on the new suicidal precautions and expectations. She said Resident #1's care plan was updated to include interventions of: provide counseling with psych services, keep family involved, provide one to one care if a resident expressed wanting to die and consult psych services, psych would continue to follow the resident and treat her for depression. She said when Resident #1 returned the facility on 09/13/23, the facility implemented every 15-minute observations for 72 hours following recent behavioral hospital stay for suicide attempt, provide calming atmosphere, engage resident in activities, provide care, and alert MD of any negative changes. The DON said her expectations were all residents with suicidal ideations were not to be left alone, and staff to monitor 1:1 until the resident was sent out for evaluation or when the resident received a psych emergency evaluation. The DON said no other residents in the facility have been identified as a suicide risk. Record review of an undated care plan dated indicated Resident #1 was placed on every 15 minute frequent monitoring by staff observations related to a recent behavioral hospital stay for a suicide atempt for the next 72 hours with a target date of 09/17/23. Record review of an undated care plan indicated Resident #1 had a psychosocial well-being problems, often making statements of wanting to die. The resident was sent out to the emergency room on [DATE] for an attempted suicide and returned to the facility on [DATE]. The interventions included: counseling would be provided with psych services, provide 1:1 care when resident was having episodes of stating she wanted to die and consult psych services, and psych would continue to follow residents and treat for depression. The target date was 11/05/23. Record review of the facility policy, implemented date of 9/11/2023, titled Suicide Prevention Policy: it is the policy of the facility to act quickly and appropriately if a resident expresses thoughts of suicide. Definitions: 'Suicide' is defined as a death from injury, poisoning or suffocation where there is evidence that the death was self-inflicted. 'Suicidal Ideation' is defined as self-reported thoughts about engaging in suicide-related behaviors .1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker .2. Immediately notify the resident's physician if the resident presents with suicidal ideation even if he or she isn't specific about a plan or intent .3. If applicable, notify the resident's responsible party of the resident's suicidal ideations and any orders received from the residence physician .4. The resident will not be left alone. One-on-one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the residence physician determines that the risk of suicide is no longer present .5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record .6. If the resident requires inpatient psychiatric service state specific guidelines and requirements will be followed. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 LVNs (2 from each shift- LVN A, LVN L, LVN I, LVN K, LVN G, LVN N), were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 CNAs (2 from each shift- CNA B, CNA C, CNA M, CNA H, CNA E, CNA O, CNA P) were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 2 MAs (one from each shift- MA F and MA J) were able to identify suicidal expressions, both were knowledgeable of the new suicide policy implemented 09/11/2023, both were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. Record review of a QAPI Committee Report, dated 9/11/2023 & 9/15/2023, indicated there was a meeting held on 9/11/2023and 9/15/2023 at 8:00 a.m. consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, the wound care nurse, the MDS nurse, the social worker, the wound care nurse, the psych services NP, and the MD. The following interventions were put in place: New Policy: Suicide prevention In-service: Suicide Prevention Care planning for suicidal ideations and attempts The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was an accident which resulted in injury and required physician intervention for 1 of 10 residents (Resident #1) reviewed for change of condition. Resident #1 was on an anticoagulant therapy and the facility did not: *consult with the physician when Resident #1 fell and hit her head sustaining a laceration to her head on [DATE] at 2:00 p.m. *consult with the physician when Resident #1 began vomiting at approximately 5:00 p.m. On [DATE] at 3:30 a.m., Resident #1 was found to be unresponsive with nonreactive pupils and was transferred to an acute care hospital with a diagnosis of intracranial hemorrhage and died on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), irregular heartbeat, neuropathy (damage to the nerves located outside of the brain and spinal cord), difficulty walking, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination (uncoordinated movement), and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record of physician order dated [DATE] indicated Resident #1 was prescribed Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) 2.5 mg BID related to chronic atrial fibrillation (longstanding chaotic and irregular atrial arrhythmia). Record review of an MDS dated [DATE] indicated Resident #1 was able to make herself understood, sometimes understands others, had severe impaired cognitive skills, was not able to focus and had disorganized thinking. She had behaviors daily that included physical and verbal behaviors directed at others. She required extensive physical assist for most ADLS. Resident #1 required limited physical assist for walking. She was not stable during walking but was able to stabilize without staff assist. She utilized a walker for mobility. She was incontinent off bladder and bowel. Record review of a care plan dated [DATE] indicated Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. Interventions included anticipate needs, provide prompt assistance, IDT to review fall risk every 90 days and after each fall, notify MD/family of falls, and frequent rounds. Record review of a care plan dated [DATE] indicated Resident #1 was on anticoagulant therapy Eliquis (blood thinner) related to her disease process. Interventions included daily skin inspection and report abnormalities to the nurse, take precautions to avoid falls, and monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: .nausea, vomiting, . Record review of a fall assessment dated [DATE] indicated Resident #1 was a moderate risk for falls due to recent fall and multiple falls within last three months. She was unable to come to a standing position independently, had loss of balance while standing, required hands on assist to move from place to place, and used an assistive device. Conditions that could increase risk for falls included cardiovascular diagnosis, unsteady gait pattern, joint pain/arthritis, impaired hearing, impaired vision, anxiety/agitation, and chronic condition which makes resident unstable. Record review of incident and accident report dated [DATE] 2:00 p.m., completed by LVN A, indicated she was called to Resident #1's room by CNA B. Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. A small laceration was present on the left side of her forehead, above the eyebrow. Pressure was applied, the area was cleansed and steri strips (thin adhesive bandages) were applied. There were no other injuries present. Resident #1 had full range of motion in all extremities. She was assisted to the bed and neuro checks were initiated. BP was 165/92, pulse was 112, RR was 22 even and labored, and hand grasp was equal bilaterally. Pain level was assessed at a 7. Resident #1 was alert and normally ambulatory without assist. The report also indicated DON was notified at 2:27 p.m., the physician was notified at 2:28 p.m., and the RP was notified at 2:29 p.m. Record review of undated neuro check for Resident #1 indicated: from 2:00 PM to 3:30 PM the neuro checks indicated the resident had equal grip strength. 2:00 p.m. alert, pupil equal and reactive, equal hand grasps, moves all extremities, no pain response-completed by LVN A. 3:30 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A. 5:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response, vomit X1 completed by LVN A 6:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A. 10:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C. 2:00 a.m. drowsy, eye (see note), unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C Note: 3:00 a.m. right eye dilated Record review of a nurse note dated [DATE] at 3:30 p.m., completed by LVN A, indicated continued neuro check related to fall. Resident #1 was resting with both eyes closed, unable to follow commands related to hearing impairment but opened her eyes when LVN A tapped her hand. Laceration above left eye remained covered in steri strips and appeared slightly swollen and light purple in color. The RP and MD notified. Record review of a nurse note dated [DATE] at 5:00 p.m., completed by LVN A, indicated Resident #1 vomited after dinner. Record review of a nurse note dated [DATE] at 5:01 p.m., completed by LVN A indicated the RP was notified of Resident #1's vomiting and the RP told the nurse she would come and check on the resident in the morning. The MD was notified. Record review of a nurse note dated [DATE] at 3:30 a.m., completed by LVN C, indicated she checked on Resident #1 and Resident #1 had vomited and was not very responsive. Her left pupil was not responsive. Resident #1 was sent to the hospital for further evaluation. LVN C contacted the RP. Resident #1 was transferred out of the facility at 4:01 a.m. by EMS. LVN C notified the MD and the ADON. Record review of hospital records dated [DATE] at 4:36 a.m. indicated Resident #1's CT indicated a 6.8 cm acute intraparenchymal (a bleed that occurs within the brain parenchyma, the functional tissue in the brain) hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) in the left frontal cerebrum (front-most part of your brain), with moderate surrounding vasogenic brain edema (cerebral edema in which the blood brain barrier (BBB) is disrupted). There was a small intraventricular (bleeding inside or around the ventricles) hemorrhage in the left lateral ventricle, third ventricle, and fourth ventricle. There was a small acute subdural (bleeding in the area between the brain and the skull) hematoma in the right frontal temporal (behind the temple area on each side of the head, and the lobe extends backward along the side of the brain to a point just behind the ears) region. There was a small acute subdural hematoma in the left temporal region/middle cranial fossa (a butterfly-shaped depression of the skull base, which is narrow in the middle and wider laterally). There was a small acute subarachnoid hemorrhage in the left temporal sulci (bleeding in the space that surrounds the brain). There was a resultant mass effect with regional sulcal effacement, effacement of the left lateral ventricle, and 1.3 cm midline shift, left to right. Impression: 1. Multifocal acute intracranial hemorrhage including intraparenchymal, subdural, subarachnoid, and intraventricular hemorrhage. 2. Mass effect with midline shift, left to right (when the midline of the brain shifts, it indicates a significant increase in pressure in the brain. A midline brain shift is considered a medical emergency). Record review of a nurse note dated [DATE] at 3:45 p.m., completed by ADON E, indicated Resident #1 was re-admitted to the facility. Resident #1 had no facial grimacing, purple bruising noted to left orbital with small laceration. Resident #1's pupils were unreactive and sluggish. She was unable to respond to verbal stimuli. Resident #1 was admitted to hospice care and remained a DNR. During an observation on [DATE] at 2:00 p.m., Resident #1 was lying in bed. She was not responsive to verbal stimuli. She had a bruised area around her left eye with steri-strips on the laceration above her left eyebrow. Record review of a nurse note dated [DATE] at 6:45 a.m., completed by ADON E, indicated Resident #1 had no VS or pulse. Hospice and family notified of change of condition. Record review of a nurse note dated [DATE] at 7:00 a.m., completed by ADON E, indicated RN was present at Resident #1's bedside and she was pronounced deceased . During an interview on [DATE] at 2:45 p.m., the DON said Resident #1 was found with her head resting on the leg of the bedside table. She said the roommate called for help. She said the roommate heard the fall but did not see the fall. She said Resident #1 sustained a brain bleed. She said Resident #1 was ambulatory but at times was unsteady and would use a wheelchair. She said Resident #1 did have a history of falls. She said Resident #1 was alert but not oriented. She said there was no change of condition until the middle of the night on [DATE]. She said neuro checks were in progress at the time. During an interview on [DATE] at 9:14 a.m., CNA B said on [DATE] she assisted Resident #1 to the middle of the bed. She said it was approximately 1:45 p.m. She said she talked to NA G and continued with other resident care. She said she looked over approximately 15 minutes later and saw staff in Resident #1's room. She said she was asked to bring the medication cart to the room. She said Resident #1's roommate indicated Resident #1 hit her head on the corner of the bedside table. She said she fed Resident #1 supper that evening. She only ate ½ of her salad and fruit cup. She said Resident #1 refused her milk. She said she was changing another resident when she was told Resident #1 had vomited. CNA B said Resident #1 seemed off. She said Resident #1 was usually aggressive when she changed her and she was not aggressive when she cleaned up the vomit and changed her clothes. She said Resident #1 did not scream like usual and kept her arms close to her. She said the nurse even said she was acting different. She said LVN H checked Resident #1's eyes and said they were equal and reactive. She said Resident #1 went to sleep after she was cleaned up. She said Resident #1 usually slept a lot throughout the day. She said Resident #1's eye area turned purple and was swelling. She said the nurses said her vital signs were normal. During an interview on [DATE] at 12:09 p.m., LVN A said she was called to Resident #1's room by CNA B. She said Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. She said there was small laceration on the left side of her forehead, above the eyebrow. She said the bleeding was stopped and RN F applied steri strips. She said Resident #1 had full ROM of all extremities and neuro checks were initiated. She said Resident #1 was usually alert and could ambulate without staff assist. She did not did not speak and consult with the the physician after the fall or the vomiting During an interview on [DATE] at 1:07 p.m., LVN C said Resident #1 was resistive and would not move her extremities on command after the fall. She said she thought her left eye was not reactive after the vomiting incident. She said Resident #1 was not resistive at 3:00 a.m. and she had vomited a second time. She said she called for a second nurse (LVN H) who was more familiar with her. She was re-assessed and was not alert. She was limp. She said an ambulance was called. She said Resident #1 had a twitch or a shake on her left shoulder. LVN C said she left the doctor a message before Resident #1 was transferred to the hospital on [DATE]. She said Resident #1 was transferred to the hospital for evaluation. During an interview on [DATE] a 1:57 p.m. RN F said LVN A was supposed to notify the physician of Resident #1's fall and head injury. She said a message qualified as notification and should be documented in the nurse note. She said the doctor would call back after he received a message. She said Resident #1 had a laceration above her left eye. She said the bleeding was stopped and she cleaned the wound and applied the steri-strip. She said Resident #1 appeared to be her normal. She said Resident #1's family had just left and barely made it down the road. She said Resident #1 was placed back in bed and the bleeding completely stopped. She said any change of condition should be reported to the doctor. During an interview on [DATE] at 2:10 p.m., the DON said the protocols for resident fall included neuro checks, assessment for pain and injury, and notifications of MD and RP. She said MD notification was a fax or call. She said leaving a message for the MD depended on level of urgency for a change of condition. She said she was called after Resident #1 vomited and was told the vital signs were normal. She said the only change noted was Resident #1 was not combative. She said Resident #1 had a history of resting but would respond to tactile stimulation. She said Resident #1 would open her eyes and look and then close her eyes and go back to sleep. Physician notification during office hours would be calling the physician's office number. Physician notification after hours included calling his mobile number directly and via fax. The DON said she could not say Resident #1 should have been sent out to the hospital because she had dementia and was not able to follow commands which was probably her baseline. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 2:17 p.m., NA G said she had just arrived at work and Resident #1's roommate said Resident #1 needed help on [DATE]. She said she found Resident #1 on the floor and she was bleeding from her head. She said the nurses came in the room, got her up from the floor, stopped the bleeding and patched up her head. She said Resident #1 was checked on every 15 minutes. During an interview on [DATE] at 2:46 p.m., LVN H said LVN A asked her to check Resident #1's pupils. She said Resident #1 was in a recliner and she was being changed. She said she Resident #1's pupils were normal. She said MD I was contacted via his cell phone by LVN A. She did not know if LVN A spoke with MD I. She said he was usually contacted via text. She said sometimes he responded and sometimes did not. She said if Resident #1 was acting out of her normal she would have sent her to the hospital if she did not reach the physician. She said delay of sending a resident to hospital for evaluation and treatment could result in worse condition and death. During an interview on [DATE] at 5:09 p.m., LVN A said Resident #1 vomited right after dinner [DATE]. She said the family indicated they had given her candy prior to leaving which probably made her stomach upset. She said Resident #1's vital signs were fine. She said her pupils were reactive and her baseline was confused. She said Resident #1 continued to fight during wound care so that was how she knew Resident #1 had a strong grip. She said it was typical for Resident #1 to fight during care. She said Resident #1 was hard of hearing but would open her eyes to touch. She said Resident #1 was cleaned up. She said she did notify MD I (who is also the medical director) on [DATE]. She said she did not speak to the doctor directly but left him a message. She said on the weekend the doctor did not usually respond back to messages. During an interview on [DATE] at 10:48 a.m., the DON said LVN A did not specify Resident #1 was on Eliquis. She said if she had been informed of the Eliquis, she would have notified the doctor and then called the doctor if he did not respond to a text or voicemail. She said Resident #1 was a DNR so the facility went by the RP's wishes to not send Resident #1 to the hospital. She said if a resident was full code they would be sent to the hospital regardless of directives. She said the RP was informed and updated of Resident #1's status until she was sent out on [DATE]. She said she was aware vomiting was a sign of a head injury and Eliquis increased the chances of a severe head injury/brain bleed and injury. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:53 p.m., LVN A said she was not ware Resident #1 was on the anticoagulant Eliquis. She said she probably would have sent Resident #1 to the hospital at the time of the fall had she been aware. She said she was not aware because the medication aides gave medications and she did not review the medications or check for blood thinners. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:56 p.m., RN F said she was not aware Resident #1 was on Eliquis. She said she would have sent Resident #1 out to the hospital at the time of the fall for evaluation if she had known. She said she did not check Resident #1's medications. She said Resident #1's head laceration stopped bleeding. She said she would have checked the medications if the bleeding had not stopped. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 12:06 p.m., Resident #1's family member said she was aware Resident #1 was on a blood thinner, Eliquis. She said the facility did not specifically tell her Resident #1 was at increased risk of brain injury or brain bleeding. She said she was made aware of the fall and head laceration. She said she told the facility she would check in on Resident #1 in the morning, following the fall. She said she was notified of the change of condition and that the facility was transferring Resident #1 to the hospital for evaluation. She said she told the facility to do what they thought was best for Resident #1. During an interview on [DATE] at 12:40 p.m., MD I said the facility had his direct number to call and text. He said they were to call him for all falls and injuries. He said when in doubt the facility should send the resident to the hospital for evaluation. He said if the staff were not able to get in touch with him, they should send out the resident to the hospital. When asked if he was notified by the facility of Resident #1's fall and injury on [DATE], MD I would only say the facility followed the family wishes and he was aware of the family wishes for Resident #1. Record review of Eliquis (https://www.eliquis.bmscustomerconnect.com/) accessed [DATE] indicated possible serious side effects included bleeding. Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away accessed on [DATE] indicated blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage after a head injury. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. Record review of the facility's Head Injury policy dated 2020 indicated: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Gridlines: 1. Assess resident following a known, suspect, or verbalized head injury. The assessment shall include, at a minimum: a. vital signs. B. General condition and appearance. Neurological evaluation for changes in i. Physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech o slow to answer questions d. Evaluation of he, eyes, ears, and nose for significant changes of vision, hearing, smell, or bleeding. E. Any injuries to head, neck, eyes, or face including lacerations, abrasions, or bruising. F. Pain assessment. 2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. 3. Notify the physician and follow orders for care. a. Provide information from physical assessment. b. Describe how the injury occurred and how the situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. 4. Perform neuro checks as indicated or as specified by the physician. 5. Limit activity and/or implement seizure precautions following the injury as specified by the physician. 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify t family and document all assessments, actions, and notifications. Record review of the facility's Notification of Changes Policy dated 2022 indicated: The purpose of this policy is to ensure the facility informs residents, consults with the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is change requiring notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated [DATE] indicated: 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] @11:00 PM) The DON or designee notified the facility Medical Director of the incident. Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. The DON and/or designee provided in-service and education to LVN A related to notification of physician, and complete documentation to include physician response. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE] @ 4:30 PM). All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, complete documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Licensed nursing staff will continue to monitor anticoagulant use and adverse effects through Nursing MAR and has been added to SBAR to include anticoagulant use. When a change in condition is suspected, Staff will utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. For any non-emergent situations, utilize SBAR and send to MD I [NAME] fax number at (fax number). Alternate fax number: (alternate fax number). The nurse is to note a 24-hour report awaiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) MD is to be notified by cell phone at (cell phone). If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. After the plan of care has been completed, fill out SBAR and fax to MD. Attach confirmation sheet to SBAR and place in DON/ADON box. Nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Nurse 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 in orientation by human resources/designee. The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on PHYSICIAN NOTIFICATION OF SIGNIFICANT CHANGES. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review physical assessments of all residents were completed. Changes of condition were noted and the physician was notified and reply pending for 2 of 4 residents, 1 resident was sent out to hospital for assessment and returned with no new orders, and 1 resident had new orders implemented. Record review of LVN A's in-service and education related to physician notification and completion of documentation was completed on [DATE] and [DATE]. Record review of licensed nurse training and check off list indicated all nurses received training on change of condition and physician notification regulations, completing documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Training included to notify the physician via phone call and document in the electronic records. If there was no response the nursing staff would notify the DON. If there was no immediate response from the physician nursing staff would send the resident to the hospital. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., the DON, ADON, 1 RN, 10 LVNs who worked all shifts indicated they would continue to monitor anticoagulant use and adverse effects through the MAR, for a suspected change in condition they would utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. They said any non-emergent situations, they would utilize SBAR and send to MD. They were able to give examples of non-emergent situations. They would note in the 24-hour report if they were waiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) they would notify the MD is to be notified by cell phone. If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. They indicated after the plan of care has been completed, they would fill out SBAR and fax to MD and then attach confirmation sheet to SBAR and place in DON/ADON box. Record review of staff training dated [DATE] indicated all nursing staff from all shifts received a group text advising them of the updated training. Nursing staff signed the training record as they came on shift. Nursing staff would continue to sign the training record as they were scheduled and before working any shifts. Record review of new hire packets indicated education included change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. There were no new hires in training as of [DATE]. Record review of in-service dated [DATE] indicated nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., interviews with 5 CNAs who worked all shifts indicated they would immediately advise the charge nurse of resident change of condition. During an interview on [DATE] at 11:37 a.m., the DON said she sent a mass text to all nursing staff and they initialed acknowledgment of changes and corrections to facility policy and protocol. She said all staff would sign the in-service as they came into works shifts and prior to taking the floor. She was able to indicate what emergent conditions were. She said standing physician orders related to physician notification and emergent conditions incorporated into the facility policy, were posted at the nurse station, and incorporated into the new hire training. During an interview on [DATE] at 12:53 p.m., the Administrator said during emergent situations all residents would be sent out to the ER via EMS for evaluation. She said the 24-hour reports were reviewed daily in morning meeting by the DON or designee (Administrator or ADON). She said the RN on duty would review the weekend 24-hour reports and report significant events to the DON and the administrator immediately. She said all nursing staff would receive training on the policy changes prior to working their next scheduled shifts. She said the new policy changes would continue until all staff were trained. She said the new policy addendums were added to the new hire packets. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 10 residents (Resident #1) reviewed for treatment and services. The facility did not consult with the physician or provide interventions when Resident #1 fell and hit her head and began vomiting approximately 3 hours after the fall on [DATE]. The resident was on anticoagulant therapy and was admitted to the hospital with a diagnosis of intracranial bleed on [DATE]. Resident #1 was admitted to Hospice services and died on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care as required and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), neuropathy (damage to the nerves located outside of the brain and spinal cord), difficulty walking, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination (uncoordinated movement), and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record of physician order dated [DATE] indicated Resident #1 was prescribed Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) 2.5 mg BID related to chronic atrial fibrillation (longstanding chaotic and irregular atrial arrhythmia). Record review of an MDS dated [DATE] indicated Resident #1 was able to make herself understood, sometimes understands others, had severe impaired cognitive skills, was not able to focus and had disorganized thinking. She had behaviors daily that included physical and verbal directed at others. She required extensive physical assist for most ADLS. Resident #1 required limited physical assist for walking. She was not stable during walking but was able to stabilize without staff assist. She utilized a walker for mobility. She was incontinent off bladder and bowel. Record review of a care plan dated [DATE] indicated Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. Interventions included anticipate needs, provide prompt assistance, IDT to review fall risk every 90 days and after each fall, notify MD/family of falls, and frequent rounds. Record review of care plan dated [DATE] indicated Resident #1 was on anticoagulant therapy Eliquis (blood thinner) related to her disease process. Interventions included daily skin inspection and report abnormalities to the nurse, take precautions to avoid falls, and monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: .nausea, vomiting, . Record review of a fall assessment dated [DATE] indicated Resident #1 was a moderate risk for falls due to recent fall and multiple falls within last three months. She was unable to come to a standing position independently, had loss of balance while standing, required hands on assist to move from place to place, and used an assistive device. Conditions that could increase risk for falls included cardiovascular diagnosis, unsteady gait pattern, joint pain/arthritis, impaired hearing, impaired vision, anxiety/agitation, and chronic condition which makes resident unstable. Record review of incident and accident report dated [DATE] 2:00 p.m., completed by LVN A, indicated she was called to Resident #1's room by CNA B. Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. A small laceration was present on the left side of her forehead, above the eyebrow. Pressure was applied, the area was cleansed and steri strips were applied. There were no other injuries present. Resident #1 had full range of motion in all extremities. She was assisted to the bed and neuro checks were initiated. BP was 165/92, pulse was 112, RR was 22 even and labored, and hand grasp was equal bilaterally. Pain level was assessed at a 7. Resident #1 was alert and normally ambulatory without assist. The report also indicated DON was notified at 2:27 p.m., the physician was notified at 2:28 p.m., and the RP was notified at 2:29 p.m. Record review of undated neuro check for Resident #1 indicated: from 2:00 PM to 3:30 PM the neuro checks indicated the resident had equal grip strength. 2:00 p.m. alert, pupil equal and reactive, equal hand grasps, moves all extremities, no pain response-completed by LVN A. 3:30 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A 5:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response, vomit X1 completed by LVN A 6:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A 10:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C 2:00 a.m. drowsy, eye (see note), unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C Note: 3:00 a.m. right eye dilated Record review of a nurse note dated [DATE] at 3:30 p.m., completed by LVN A, indicated continued neuro check related to fall. Resident #1 was resting with both eyes closed, unable to follow commands related to hearing impairment but opened her eyes when LVN A tapped her hand. Laceration above left eye remains covered in steri strips and appeared slightly swollen and light purple in color. The RP and MD notified. Record review of a nurse note dated [DATE] at 5:00 p.m., completed by LVN A, indicated Resident #1 vomited after dinner. Record review of a nurse note dated [DATE] at 5:01 p.m., completed by LVN A indicated the RP was notified of Resident #1's vomiting and the RP told the nurse she would come and check on the resident in the morning. The MD was notified. Record review of a nurse note dated [DATE] at 3:30 a.m., completed by LVN C, indicated she checked on Resident #1 and Resident #1 had vomited and was not very responsive. Her left pupil was not responsive. Resident #1 was sent to the hospital for further evaluation. LVN C contacted the RP. Resident #1 was transferred out of the facility at 4:01 by EMS. LVN C notified the MD and the ADON. Record review of hospital records dated [DATE] at 4:36 a.m. indicated Resident #1's CT indicated a 6.8 cm acute intraparenchymal (a bleed that occurs within the brain parenchyma, the functional tissue in the brain) hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) in the left frontal cerebrum (front-most part of your brain), with moderate surrounding vasogenic brain edema (cerebral edema in which the blood brain barrier (BBB) is disrupted). There was a small intraventricular (bleeding inside or around the ventricles) hemorrhage in the left lateral ventricle, third ventricle, and fourth ventricle. There was a small acute subdural (bleeding in the area between the brain and the skull) hematoma in the right frontal temporal (behind the temple area on each side of the head, and the lobe extends backward along the side of the brain to a point just behind the ears) region. There was a small acute subdural hematoma in the left temporal region/middle cranial fossa (a butterfly-shaped depression of the skull base, which is narrow in the middle and wider laterally). There was a small acute subarachnoid hemorrhage in the left temporal sulci (bleeding in the space that surrounds the brain). There was a resultant mass effect with regional sulcal effacement, effacement of the left lateral ventricle, and 1.3 cm midline shift, left to right. Impression: 1. Multifocal acute intracranial hemorrhage including intraparenchymal, subdural, subarachnoid, and intraventricular hemorrhage. 2. Mass effect with midline shift, left to right (when the midline of the brain shifts, it indicates a significant increase in pressure in the brain. A midline brain shift is considered a medical emergency). Record review of a nurse note dated [DATE] at 3:45 p.m., completed by ADON E, indicated Resident #1 was re-admitted to the facility. Resident #1 had no facial grimacing, purple bruising noted to left orbital with small laceration. Resident #1's pupils were unreactive and sluggish. She was unable to respond to verbal stimuli. Resident #1 was admitted to hospice care and remained a DNR. Record review of Resident #1's clinical chart, including physician orders, nurse progress notes, and care plans, indicated there was no written documentation Resident #1 was not to be sent out to hospital for acute illnesses/injuries. During an observation on [DATE] at 2:00 p.m., Resident #1 was lying in bed. She was not responsive to verbal stimuli. She had a bruised area around her left eye with steri-strips on the laceration above her left eyebrow. Record review of a nurse note dated [DATE] at 6:45 a.m., completed by ADON E, indicated Resident #1 had no VS or pulse. Hospice and family notified of change of condition. Record review of a nurse note dated [DATE] at 7:00 a.m., completed by ADON E, indicated RN was present at Resident #1's bedside and she was pronounced deceased . During an interview on [DATE] at 2:45 p.m., the DON said Resident #1 was found with her head resting on the leg of the bedside table. She said the roommate called for help. She said the roommate heard the fall but did not see the fall. She said Resident #1 sustained a brain bleed. She said Resident #1 was ambulatory but at times was unsteady and would use a wheelchair. She said Resident #1 did have a history of falls. She said interventions included a low bed and call light in reach. She said Resident #1 was alert but not oriented. She said she was not aware of a change of condition until the middle of the night on [DATE]. She said neuro checks were in progress at the time. During an interview on [DATE] at 9:14 a.m., CNA B said on [DATE] she assisted Resident #1 to the middle of the bed She said it was approximately 1:45 p.m. She said she talked to NA G and continued with other resident care. She said she looked over approximately 15 minutes later and saw staff in Resident #1's room. She said she was asked to bring the medication cart to the room. She said Resident #1's roommate indicated Resident #1 hit her head on the corner of the bedside table. She said she fed Resident #1 supper that evening. She only ate ½ of her salad and fruit cup. She said Resident #1 refused her milk. She said she was changing another resident when she was told Resident #1 had vomited. CNA B said Resident #1 seemed off. She said Resident #1 was usually aggressive when she was changed her and she was not aggressive when she cleaned up the vomit and changed her clothes. She said Resident #1 did not scream like usual and kept her arms close to her. She said the nurse even said she was acting different. She said LVN H checked Resident #1's eyes and said they were equal and reactive. She said Resident #1 went to sleep after she was cleaned up. She said Resident #1 usually slept a lot throughout the day. She said Resident #1's eye area turned purple and was swelling. She said the nurses said her vital signs were normal. During an interview on [DATE] at 12:09 p.m., LVN A said she was called to Resident #1's room by CNA B. She said Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. She said there was small laceration on the left side of her forehead, above the eyebrow. She said the bleeding was stopped and RN F applied steri strips. She said Resident #1 had full ROM of all extremities and neuro checks were initiated. She said Resident #1 was usually alert and could ambulatory without staff assist. During an interview on [DATE] at 1:07 p.m., LVN C said Resident #1 was resistive and would not move her extremities on command. She said she thought her left eye was not reactive after the vomiting incident on [DATE] at 5:00 p.m. She said a second nurse (LVN H) assessed her and said both pupils were reactive. She said Resident #1 was not resistive at 3:00 a.m. and she had vomited a second time. She said she called for a second nurse (LVN H) who was more familiar with her. She was re-assessed and was not alert. She was limp. She said an ambulance was called. She said Resident #1 had a twitch or a shake on her left shoulder. LVN C said she left the doctor a message. She said Resident #1 was transferred to the hospital for evaluation. During an interview on [DATE] a 1:57 p.m. RN F said LVN A was supposed to notify the physician of Resident #1's fall and head injury. She said a message qualified as notification and should be documented in the nurse note. She said the doctor would call back after he received a message. She said Resident #1 had a laceration above her left eye. She said the bleeding was stopped and she cleaned the wound and applied the steri-strip. She said Resident #1 appeared to be her normal. She said Resident #1's family had just left and barley made it down the road. She said Resident #1 was placed back in bed and the bleeding completely stopped. She said any change of condition should be reported to the doctor. She said she knew LVN A had called and left a message for MD I but did not know if the physician had responded. During an interview on [DATE] at 2:10 p.m., the DON said the protocols for resident fall included neuro checks, assessment for pain and injury, and notifications of MD and RP. She said MD notification was a fax or call. She said leaving a message for the MD depended on level of urgency for a change of condition. She did not say the nurses had to speak with the physician. She said she was called after Resident #1 vomited and was told the vital signs were normal. She said the only change noted was Resident #1 was not combative. She said Resident #1 had a history of resting but would respond to tactile stimulation. She said Resident #1 would open her eyes and look and then close her eyes and go back to sleep. Physician notification during office hours would be calling the physician's office number. Physician notification after hours included calling his mobile number directly and via fax. The DON said she could not say Resident #1 should have been sent out to the hospital because she had dementia and was not able to follow commands which was probably her baseline. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 2:17 p.m., NA G said she had just arrived at work and Resident #1's roommate said Resident #1 needed help. She said she found Resident #1 on the floor and she was bleeding from her head. She said the nurses came in the room, got her up from the floor, stopped the bleeding and patched up her head. She said Resident #1 was checked on every 15 minutes. During an interview on [DATE] at 2:46 p.m., LVN H said LVN A asked her to check Resident #1's pupils. She said Resident #1 was in a recliner and she was being changed. She said she Resident #1's pupils were normal. She said the physician was contacted via his cell phone. She said he was usually contacted via text. She said sometimes he responded and sometimes did not. She said if Resident #1 was acting out of her normal she would have sent her to the hospital if she did not reach the physician. She said delay of sending a resident to hospital for evaluation and treatment could result in worse condition and death. During an interview on [DATE] at 5:09 p.m., LVN A said Resident #1 vomited right after dinner on [DATE]. She said the family indicated they had given her candy prior to leaving which probably made stomach upset. She said Resident #1's vital signs were fine. She said her pupils were reactive and her baseline was confused. She said Resident #1 continued to fight during wound care so that was how she knew Resident #1 had a strong grip. She said it was typical for Resident #1 to fight during care. She said Resident #1 was hard of hearing but would open her eyes to touch. She said Resident #1 was cleaned up. She said she did notify the doctor. She said she did not speak to the doctor directly but left him (MD I) a message. She said on the weekend the doctor did not usually respond back to messages. During an interview on [DATE] at 1:56 p.m., RN F said she was not aware Resident #1 was on Eliquis. She said she would have sent Resident #1 out to the hospital at the time of the fall for evaluation if she had known. She said she did not check Resident #1's medications. She said Resident #1's head laceration stopped bleeding. She said she would have checked the medications if the bleeding had not stopped. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:53 p.m., LVN A said she was not aware Resident #1 was on the anticoagulant Eliquis. She said she probably would have sent Resident #1 to the hospital if she was aware. She said she was not aware because the medication aides give the medications and she did not review the medications or check for blood thinners. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 10:48 a.m., the DON said LVN A did not specify Resident #1 was on Eliquis. She said she did not look at Resident #1's chart. She said residents on blood thinners were monitored on MARS. She said if she had been informed of the Eliquis, she would have notified the doctor and then called the doctor if he did not respond to a text or voicemail. She said Resident #1 was a DNR so the facility went by the RP's wishes to not send Resident #1 to the hospital. She said if a resident was full code they would be sent to the hospital regardless of directives. She said the RP was informed and updated of Resident #1's status until she was sent out on [DATE]. She said she was aware vomiting was a sign of a head injury and Eliquis increased the chances of a severe head injury/brain bleed and injury. She said as of [DATE] all residents with head injuries would be sent out if the physician did not respond immediately. She said it was part to the POR and would be included in the new staff training. During an interview on [DATE] at 12:06 p.m., Resident #1's family member said she was aware Resident #1 was on a blood thinner, Eliquis. She said the facility did not specifically tell her Resident #1 was at increased risk of brain injury or brain bleeding. She said she was made aware of the fall and head laceration. She said she told the facility she would check in on Resident #1 in the morning, following the fall. She said she was notified of the change of condition and that the facility was transferring Resident #1 to the hospital for evaluation. She said she told the facility to do what they thought was best for Resident #1. During an interview on [DATE] at 12:40 p.m., MD I said the facility nursing staff had his direct number to call and text. He said they were to call him for all falls and injuries. He said when in doubt the facility should send the resident to the hospital for evaluation. He said if the staff were not able to get in touch with him they should send out the resident to the hospital. When asked if he was notified by the facility of Resident #1's fall and injury on [DATE] and if he was aware she was on Eliquis, MD I would only say the facility followed the family wishes and he was aware of the family wishes for Resident #1. Record review of Eliquis (https://www.eliquis.bmscustomerconnect.com/) accessed [DATE] indicated possible serious side effects included bleeding. Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away accessed on [DATE] indicated blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage after a head injury. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. Record review of the facility's Head Injury policy dated 2020 indicated: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Gridlines: 1. Assess resident following a known, suspect, or verbalized head injury. The assessment shall include, at a minimum: a. vital signs. B. General condition and appearance. Neurological evaluation for changes in i. Physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech o slow to answer questions d. Evaluation of he, eyes, ears, and nose for significant changes of vision, hearing, smell, or bleeding. E. Any injuries to head, neck, eyes, or face including lacerations, abrasions, or bruising. F. Pain assessment. 2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. 3. Notify the physician and follow orders for care. a. Provide information from physical assessment. b. Describe how the injury occurred and how the situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. 4. Perform neuro checks as indicated or as specified by the physician. 5. Limit activity and/or implement seizure precautions following the injury as specified by the physician. 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify t family and document all assessments, actions, and notifications. Record review of the facility's Notification of Changes Policy dated 2022 indicated: The purpose of this policy is to ensure the facility informs residents, consults with the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is change requiring notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated [DATE] indicated: 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] @ 11:00 PM) The DON or designee notified the facility Medical Director of the incident. Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. The DON and/or designee provided in-service and education to LVN A related to notification of physician, and complete documentation to include physician response. No need for any emergency treatment identified with completion of resident physical assessments. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE] @ 4:30 PM). 1. All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, complete documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. 2. When a change in condition is suspected, Staff will utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. Licensed nursing staff will continue to monitor anticoagulant use and adverse effects through Nursing MAR and has been added to SBAR to include anticoagulant use. For any non-emergent situations, utilize SBAR and send to MD I fax number at (fax number). Alternate fax number: (fax number). The nurse is to note on 24-hour report awaiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) MD is to be notified by cell phone at (cell phone) If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. After the plan of care has been completed, fill out SBAR and fax to MD. Attach confirmation sheet to SBAR and place in DON/ADON box. Nurse aides were educated by DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Nurse 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, including but not limited to life threatening conditions, clinical complications, need to alter treatment, accidents resulting in injury, adverse consequences as well as facility policy and procedure, accordingly in orientation by human resources/designee. The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on: QUALITY OF CARE to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered plan, and the residents' choices. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review physical assessments of all residents were completed. Changes of condition were noted and the physician was notified and reply pending for 2 of 4 residents, 1 resident was sent out to hospital for assessment and returned with no new orders, and 1 resident had new orders implemented. Record review of LVN A's in-service and education related to physician notification and completion of documentation was completed on [DATE] and [DATE]. Record review of licensed nurse training and check off list indicated all nurses received training on change of condition and physician notification regulations, completing documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Training included to notify the physician via phone call and document in the electronic records. If there was no response the nursing staff would notify the DON. If there was no immediate response from the physician nursing staff would send the resident to the hospital. Record review of 3 residents' MARs indicted anticoagulants were monitored as required. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., the DON, ADON, 1 RN, 10 LVNs who worked all shifts indicated they would continue to monitor anticoagulant use and adverse effects through the MAR, for a suspected change in condition they would utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. They said any non-emergent situations, they would utilize SBAR and send to MD. They were able to give examples of non-emergent situations. They would note in the 24-hour report if they were waiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) they would notify the MD is to be notified by cell phone. If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. They indicated after the plan of care has been completed, they would fill out SBAR and fax to MD and then attach confirmation sheet to SBAR and place in DON/ADON box. Record review of staff training dated [DATE] indicated all nursing staff from all shifts received a group text advising them of the updated training. Nursing staff signed the training record as they came on shift. Nursing staff would continue to sign the training record as they were scheduled and before working any shifts. Record review of new hire packets indicated education included change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. There were no new hires in training as of [DATE]. Record review of in-service dated [DATE] indicated nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., interviews with 5 CNAs who worked all shifts indicated they would immediately advise the charge nurse of resident change of condition. During an interview on [DATE] at 11:37 a.m., the DON said she sent a mass text to all nursing staff and they initialed acknowledgment of changes and corrections to facility policy and protocol. She said all staff would sign the in-service as they came into works shifts and prior to taking the floor. She was able to indicate what emergent conditions were. She said standing physician orders related to physician notification and emergent conditions incorporated into the facility policy, were posted at the nurse station, and incorporated into the new hire training. During an interview on [DATE] at 12:53 p.m., the Administrator said during emergent situations all residents would be sent out to the ER via EMS for evaluation. She said the 24-hour reports were reviewed daily in morning meeting by the DON or designee (Administrator or ADON). She said the RN on duty would review the weekend 24-hour reports and report significant events to the DON and the administrator immediately. She said all nursing staff would receive training on the[TRUNCATED]