**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors in that Resident #1 's hospital Discharge summary dated [DATE] stated Stop taking Valacyclovir 1000mg. Resident #1 received 5 doses of Valacyclovir 1000mg after the medication had been discontinued, resulting in readmission to the hospital for altered mental status and metabolic encephalopathy due to Valacyclovir toxicity. The resident had been prescribed Valacyclovir for HSV Opthalmicus (infection of the eye by Herpes Simplex Virus). The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 09/20/2025 and ended on 09/22/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious outcomes such as overdose or death.Findings include: Record review of Resident #1's Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute and Subacute Infective Endocarditis (an infection of the inner lining of the heart (endocardium) and its valves.) Record review of Resident #1's Quarterly MDS, dated [DATE] reflected a BIMS of 15 meaning there is no or very little cognitive impairment. Record review of Resident #1's Care Plan, last updated 08/13/2025 reflected that Resident #1 required Hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so.Record review of the hospital Discharge Instructions dated 09/20/2025 stated stop taking: Valacyclovir 1000mg tablet.Record review of the MAR for September 2025 indicated Resident #1 was administered 3 doses of Valacyclovir on 9/21/25 and 1 dose on 9/22/25. During an interview on 09/26/2025 at 10:47AM, the DON stated Resident #1 was originally admitted to the hospital for Metabolic Encephalopathy (a condition where the brain does not function properly due to an imbalance in the chemicals and nutrients that the brain needs to function normally) then returned to the facility on 9/20/2025. When Resident #1 returned the agency nurse admitted her to the facility and entered the medications per the discharge instructions from the Hospital. There was an order to discontinue the Valacyclovir, but the agency nurse failed to discontinue this medication. Upon learning of Resident 1's rehospitalization, the DON completed an audit of Resident #1's chart and discovered the error. The DON stated she contacted the agency nurse; however, the agency nurse merely stated she was unfamiliar with the version of the electronic medical record and offered no other explanation for the error. The DON stated they have a nurse reference book that describes how to manage orders. It also contained information for contacting members of the nursing management team if there were any questions regarding the management of medication orders. The DON stated they notified the agency of the need to discontinue services of this nurse. The DON stated that upon discovery of the error, a medication error report was completed, and the physician and responsible party were notified. The DON stated they held an Ad Hoc QAPI on 09/22/2025. During an interview with ADON D on 09/26/2025 at 11:25AM, the ADON stated she contacted the agency representative on 09/22/2025 at 2:43PM and reported the error and notified the representative that the agency nurse was not to return to the facility.Record review of the hospital admission records dated 09/22/2025 was due to Metabolic Encephalopathy (a condition in which the brain does not receive enough oxygen or nutrients leading to changes in brain function) due to Valacyclovir toxicity. During an interview on 09/26/2025 at 11:32AM, LVN A stated after breakfast on 09/21/2025, Resident #1's family member stated that Resident #1 was very confused and was not answering questions appropriately. Resident #1 was Spanish speaking only and LVN Awas bilingual. LVN A stated she assessed Resident #1, and she had slurred speech and could not follow commands. LVN A stated she then notified the nurse practitioner who assessed Resident #1 and gave orders for transport to the hospital. Record review of the Facility Investigation Report dated 09/22/2025 indicated actions taken prior to entrance were: Medication error report completed with appropriate physician and responsible party notified. The nurse responsible for medication error suspended pending further investigation. Resident report roster was completed for the 30 days of facility admissions August 23, 2025, to September 22, 2025. These resident's hospital discharge orders were reviewed in comparison to the admitting orders entered into the electronic medical record and the Medication Reconciliation Report. There were no other errors found during the audit. Re-education of Administrative Nurses by Clinical Services Director on process of medication reconciliation with admission orders and confirmation of admission orders with physician. DON/Designee will re-educate staff nurses, before nurse completes new admission or re-admission. Ad Hoc QAPI was held on 09/22/2025. Record Review of the Inservice Sign in sheets dated 09/22/2025 revealed staff were educated on the medication reconciliation process.During interviews on 09/26/2025 with staff, the following was stated:*At 2:43PM ADON D stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025.*At 5:13PM The DON stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. She stated weekend staffing was amended to include a member of the nursing leadership team to ensure a second nurse reviews medication reconciliation during non-business hours. She stated she, the 2 ADONs, and the MDS nurse will now work one weekend per month to provide this coverage. *At 5:14PM RN F stated she received training of second nurse review of medication reconciliation.*At 5:50PM LVN I stated she received training of second nurse review of medication reconciliation. LVN I stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. Record Review of the Ad Hoc QAPI agenda and sign in sheet revealed the meeting was held. Record Review was conducted of the audit of resident hospital discharge orders as compared to admitting orders and outcomes were confirmed on 09/26/2025 by conducting a Record Review of the medical records of 5 Residents selected for the random sample. Record Review of the undated policy Medication Reconciliation was conducted on 09/26/2025. Policy statement #2 read: Residents who are being readmitted to our facility after an acute care stay will have review of the most current SNF discharge medication profile with the readmission medication orders to validate that the resident has a comprehensive and accurate medication profile.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 09/20/2025 and ended on 09/22/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents, hazards, and supervision, in that: The facility failed to provide adequate supervision to prevent injury for an incident that occurred on on 08/09/2025 at 4:30PM in the Dining Room, Resident #4 was attempting to get a cup of coffee. The cup overflowed and spilled coffee in Resident #4's lap and resulted in urns with 3 blisters to the left upper thigh. The facility failed to take the temperature of the coffee and keep temperature logs of the coffee. The facility failed to assess other residents for hot liquids An (IJ) Immediate Jeopardy was identified on 08/26/2025. The IJ template was provided to the ADM on 08/26/2025 at 7:28PM. While the IJ was removed on 8/28/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #4's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, unspecified (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen and nutrients) and Hemiplegia (the total or severe loss of motor function on one side of the body, resulting in paralysis) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction affecting right dominant side, diabetes, Hypertension, Burn of unspecified degree of left thigh Record review of Resident #4's quarterly MDS, dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) Section G of the MDS reflected for eating and drinking resident# 4 required the need for supervision, oversight, encouragement and cueing. Record review of Resident #4's Care Plan, last updated 08/18/2025 reflected that Resident #4 required some minimal assistance with ADLs. History of CVA with right hemiparesis, Current. Care Planned interventions include the following: Approach: Eating: Assist of 1 staff member.During an interview with DA C conducted on 08/20/2025 at 2:38PM, she stated she saw Resident #4 trying to get coffee and she tried to help. DA C stated there was a lid on the cup, but it spilled anyway, and DA C reported the event immediately to the nurse. During the verbal assessment performed by the nurse, Resident #4 denied any injury. DA C stated she was in-serviced on removing the coffee servers from the Dining Room and placing them in the locked Nutrition Room after each meal service and the dietary staff are not to bring the coffee into the Dining Room unless nursing staff are present. On 08/20/2025 at 2:42PM, conducted a phone interview with the Dietary Manager. The Dietary Manager confirmed the coffee available for self-service to the residents prior to Resident #4 receiving the burn injury was not temperature tested. On 08/20/2025 at 3:13PM conducted an interview with LVN E. She stated Resident #4 informed her about the burns to his legs on the day following the event. LVN E stated she assessed the leg on 08/10/2025 at 7:27AM and obtained orders for care of the wounds and notified the DON. She stated she did find 3 open areas that appeared to be blisters that had burst. Record review of Resident #4's progress note dated 08/09/25 at 6:30 PM Recorded as Late Entry on 08/12/2025 at 08:53 AM- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record Review on 8/20/2025 of the progress note dated 08/09/2025 at 6:30PM written by LVN D regarding the coffee spill. LVN D documented that she asked the resident if he was injured, and Resident #4 denied being injured. Record review of Resident #4's incident report dated 08/10/25 reflected incident date 08/09/2025 resident was observed in the dining room with pants wet with coffee. Resident reported trying to get coffee with kitchen staff assistance. Resident assessed immediately for pain and burn. Resident reported not feeling pain or burn stating I'm fine I don't feel any pain. Resident proceeded with getting another cup of coffee and returning to his room.Record review of Resident #4's progress note dated 08/10/25 at 6:00 PM [Recorded as Late Entry on 08/12/2025 at 08:51 AM] reflected Resident reported dressing came off. Assessed skin and affected area. Skin appears pink and moist. Changed dressing. Resident reported feeling pain during procedure. Resident was given PRN acetaminophen. Cleaned skin with normal saline and gauze. Xeroform Petrolatum dressing placed on affected area. Covered dressing with Non adhesive super absorbent wound dressing and secured with skin tape. Assessed resident for discomfort. Resident tolerated procedure with no further discomfort after receiving PRN pain medication. Record review of Resident #4's prescription orders dated 08/10/25 reflected order description: for Silvadene (silver sulfadiazine) cream; 1%; amt: small amount cover wounds; topical, frequency: twice a day 1: 06:00 AM- 06:00 PM 2: 06:00 AM- 06:00 PM. Special instructions: apply cream to 3 open wounds on left thigh.Record review of Resident #4's progress note dated 08/10/25 at 11:30 AM -- INVALID -- On 8/9/25, at 6:30PM, reflected resident was found in dining room with pants wet with coffee spilled on himself. Resident assessed for pain and burn. Resident reported not feeling pain or burn. resident returned to room with coffee. Record review of Resident #4's progress note dated 08/10/25 at 11:25 AM -- INVALID-- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record review of Resident #4's progress note dated 08/10/25 at 9:45 AM reflected Call made to resident's family member to inform about coffee spilling on resident's left thigh. Discussed treatment plan ordered by provider. Advised that will continue to monitor resident for any signs of infection. Answered all questions and listened to concerns had. Family member stated that she will be at facility later today to see resident. Record review of Resident #4's progress note dated 08/10/25 at 9:32 AM reflected Call to on-call provider to notify that resident had coffee spilled onto left thigh. Rec'd order for Silvadene cream to be applied to areas 2x per day. Wound care order to cleanse area with normal saline, apply thick layer of Silvadene cream and to cover with non-stick dressing and monitor for sign/symptoms of infection. Record review of Resident #4's progress note dated 08/10/25 at 8:23 AM reflected Spoke with resident about coffee spill incident that occurred on Saturday evening. Resident stated that after dinner the dietary aide helped him get coffee while in the dining room. Resident was using the cup with the lid, but it must have been overfilled. Stated that the coffee spilled onto his leg. He stated the dietary aide put towels on the area and took him to his room. Resident reports that it was not painful. Assessed left thigh and observed approximately dollar size open area, quarter sized open area, and dime size area open area. No signs/symptoms of infection noted. Will continue to monitor for changes. Record review of Resident #4's progress note dated 08/10/25 at 7:27 AM reflected Resident came up to this nurse and stated he was in the dining room getting coffee with another resident yesterday and they spilled coffee on his lap. Resident L thigh has 3 open areas where it appears to have bubbled then burst. Area cleaned and dressing placed. Weekend supervisor and DON notified. Record review of a therapy screening form dated 08/11/25 for Resident #4 reflected nursing referral for difficulty performing ADLs: feeding. Resident with coffee burn, assessment of AE referral, occupational therapy is recommended. Record review of Resident #4's progress note dated 08/11/25 at 1:22 PM reflected Resident seen by provider due to recent burns to left thigh. New orders received to start Doxycycline 100mg BID x10 days to prevent infection. Orders updated on MAR; family member aware. No other concerns at this time. Care ongoing.Record review of Resident #4's progress note dated 08/13/25 at 1:21 PM reflected Resident seen for initial visit by Dr. for Burn Wound of Left, Anterior Thigh w/Partial Thickness and Burn Wound of Left Medial Thigh w/Partial Thickness. Burn wound #1 is located on left anterior thigh caused by hot beverage; wound measures 6.1 x 4.5 x 0.1 cm/surface area 27.45 cm2. Light serous drainage (clear, watery fluid) noted. 100% dermis observed. Edges attached to wound base. Redness noted to peri-wound. Temperature is warm to touch. Burn wound #2 is located on the left medial thigh; measuring 2.3 x 13 x 0.21 cm/surface area 29.90 cm2. Light serous drainage noted. Erythema (superficial reddening of the skin)and fluid filled blisters noted to peri wound. Edges attached to base. 100% Dermis observed. New orders apply Silver Sulfadiazine to wounds, cover with Xeroform Gauze dressing, and wrap wounds with Gauze Roll Kerlix 4'5, and secure Kerlix with Ace Bandage or Coban 3(three) times daily. Emergency contact updated on wound visit with WCD. No concerns verbalized at this time.On 8/20/2025 at 11:15am attempted observation and interview with resident# 4, not available not in room. Attempted to locate resident # 4 throughout the day. On 08/20/2025 at 4:45PM conducted an in-person interview with the DON. The DON stated she was not notified that the resident sustained burns to his upper leg on the evening it occurred. She was notified on 8/10/2025 by the Nursing Supervisor, LVN E, after Resident #4 had complained to her that morning about having the burns on his leg. The DON stated she notified her corporate supervisor as soon as she was notified of the event. The DON then described the follow up actions of both nurses to include they received instructions for wound care. The DON also verbally confirmed the documented in-service training received by herself, the Administrator, and the Dietary Director. The DON further stated she initiated in-service training with the staff immediately. The DON stated she was not notified of the event in a timely manner; therefore, she implemented corrective action with the responsible nurse. In an interview on 8/26/2025 with the DON at 4:00pm revealed they completed an observation assessment on 8/10/2025 and 8/18/2025. The DON stated each resident who had access and drank coffee was observed this included 19 other residents. The DON stated they did not have a formal assessment for the observation that was completed. The DON was not able to state what the observation included in order to determine if a referral to PT (physical therapy) was needed. The DON stated the results of the observations completed was not documented. Record Review of the policy Guidelines to Reduce Risk of Burns from Hot Beverages. Dated 08/01/2020. The policy statement stated, Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). he policy described the recommended coffee brewing temperatures as between 195- and 205-degrees Fahrenheit. The actual serving temperatures should range from 155 degrees to 175 degrees based on individual preference. An (IJ) Immediate Jeopardy was identified on 08/26/2025 at 7:15PM due to the above failures. The Census was 64. The ADM was notified on 08/26/2025 at 7:28PM. The ADM was provided with the (IJ) Immediate Jeopardy template on 08/26/2025 at 7:28PM, and a Plan of Removal (POR) was requested. A Plan of Removal was first submitted by the ADM on 08/26/2025 at 9:20PM. The Plan of Removal was accepted on 08/28/2025 at 3:43PM. The facility failed to ensure that the resident environment remained free from accidents and was appropriately supervised. Performed Record Review of facility investigation and follow up of the incident on 08/20/2025. Charge Nurse verbally questioned resident on 8/9/25 regarding burn and pain, resident denied both. Identified resident had skin assessment completed on 8/10/25 by charge nurse and on call nurse practitioner notified. Treatment orders were received and implemented on 8/10/25. Nurses note entered on 8/10/25 by charge nurse of notification and orders received. The Electric urn used for self-service coffee was disconnected on 8/10/25 by the Dietary Manager. The Dietary manger was reeducated by the Clinical Consultant on 8/10/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents.Kitchen staff were reeducated by the Dietary manger by 8/27/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents. An audit was completed by Nursing Leadership, Dietary Department and Administrator to identify residents in house who drink coffee. 20 were identified. Head to toe skin audits on the 20 identified residents were completed by the Licensed Nurses on 8/10/25 on paper and uploaded to the resident's medical record. No additional concerns were identified. An Evaluation will be completed on Residents who consume coffee to identify their ability to manage hot beverages independently by the Director of Nursing/Designee by 8/27/25. Those identified as needing assistance will have care plans updated by the Director of Nursing/Designee with needed safeguards individualized by resident needs to reduce the risk of burns from hot beverages. Clinical Consultant reeducated Administrator, Director of Nursing and Dietary Manager on appropriate notification and assessment if a coffee burn is identified on 8/10/25. Nursing staff and dietary staff were reeducated by the Director of Nursing/Designee on guidelines to reduce the risk of burns from hot beverages on 8/26/25 including: Pot or urns containing hot liquids will not be left unattended Facility staff will pour hot beverages Use of resident specific additional safeguards if indicated If a resident sustains an injury, an assessment from the licensed nurse will be completed immediately. Director of Nursing and physician will be notified for further direction This re-education will be completed by 8/26/25. Nursing staff or dietary staff not receiving this re-education by this date will receive prior to next scheduled shift. This will be provided for agency staff and new hire orientation through verbal education by the Director of Nursing/Designee. The Dietary Manager/Designee will assess newly admitted residents thorough the diet history observation in the electronic medical record Monday - Friday to identify those residents that request and/or consume coffee and communicate to the Director of Nursing/Designee to validate any needing assistance with hot beverages have care plans in place with needed safeguards. The Director of Nursing/Designee will review new admissions in clinical morning meeting Monday - Friday to validate residents identified as needing assistance with hot beverages have care plans updated with needed safeguards, recording on the clinical morning meeting form. The medical director was notified of the immediate jeopardy on 8/26/2025 by the administrator.An Ad Hoc Quality Assurance Performance Improvement meeting was held on 8/26/2025 regarding the contents of this plan. Monitoring on 08/27/2025 and 08/28/2025 included the following:Record review of Resident #4's care plan dated 07/16/25 reflected: Problem Start Date: 08/27/2025 Resident should have a lid on all hot liquids and should be sitting at a table while drinking or eating them. Goal Target Date: 12/27/2025 Resident will not get a burn Approach Start Date: 08/27/2025Resident to use cup with lid, temp will not exceed 175 degrees, resident should be sitting at table while eating or drinking hot fluids, staff to assist. 08/27/25 Regarding hot liquid safety, resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and has been seeing therapy. Record review of Resident #4's progress note dated 08/27/25 @ 10:00pm written by LVN S, regarding hot liquid safety, reflected resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and has been seeing therapy. On 08/27/25 at 4:00 PM Observation of the dining room revealed the electric urn was removed. On 8/27/25 at 5:13 PM observation of the coffee urn in the locked nutrition room by the nurse's station revealed the item name, date, temperature reading, and employee initial. Dietary Staff R. On 8/27/25 at 5:15 PM Interview with the Dietary Manager who stated she worked at the facility for 10 months. She stated she was re-educated on abuse, neglect, rights, and coffee service for residents. She stated re-education on coffee services for residents included temperatures for hot beverages and had to be documented on a daily log. She stated the temperature had to be between 155 degrees- 175 degrees; not to exceed 175 degrees. She stated dietary staff use a stainless-steel thermometer. She stated the coffee urn is not to be left unattended. She stated facility staff would pour and serve hot beverages. She stated the facility ordered new coffee cups with lids. She stated they are using Styrofoam cups with tear back lids until the new cups arrive. She stated some of the residents use a specialized cup with lid. She stated coffee would be placed in the locked nutrition room for nursing staff to serve if residents request. She stated she was re-educated on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. She stated she would report to the DON immediately. She stated she was re-educated on assessing newly admitted residents. She stated she would assess newly admitted residents the day after admission. She stated she goes over the resident's preferences and identifies residents that request coffee. She stated she documents in the resident profile under meal tracker, care plan, meal ticket and communicates with the DON alerting her of hot beverages the residents are getting and how often. She stated she would update preferences upon request by residents. She stated she re-educated all dietary staff on the hot beverage procedure, and daily coffee temperature log. She stated she put a sticker on the in-service sheet which showed the item, date, time, temperature, and staff initial. Coffee temperatures are checked before the urn is put on the food cart or brought to the nurse station which also include sticker. The urn for the dining room stays in the kitchen until nursing or CNA staff are in the dining room feeding and serving residents. Dietary staff are monitoring drinks during all meals in the dining room. She stated after meal services hot beverages will be put in the nutrition room for as needed services. On 08/27/25 at 5:45 PM Observed several staff in the dining room assisting residents with meal and drinks. Observed a Sign posted on the wall that said, Coffee available upon request located in the nutrition room between meals. Observed a coffee urn in the dining room on the counter which included a sticker with item, date, temperature reading 159 degrees, and staff initial. Observed staff pouring and serving coffee in a Styrofoam cup with lid and specialized cups to residents. On 08/27/25 at 5:56 PM Interview with Med Aide N who stated she had worked at the facility for 5 months. She stated she had been trained on abuse, neglect, rights, notification of resident change, and hot beverages. She stated staff are in-serviced every other week. She stated they went over the proper way of handling and serving the coffee. She stated coffee is served from an urn. She stated staff had to pour and serve all hot beverages. She stated staff serve coffee in Styrofoam cups with lids. She stated dietary staff check the temperature and put a sticker on the urn with the temperature before bringing it to the dining room. She stated the coffee cannot be brought out until the charge nurse is in the dining room. The coffee urn will never be left unattended.She stated if a resident asked for coffee, she would tell the resident she would have to get with the charge nurse or offer a different type of beverage. She stated the temperatures should be around 155 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse. On 08/27/25 at 6:10 PM Interview with CNA J. She stated she had worked at the facility 3 years. She stated she had been in-serviced on abuse, neglect, rights, notification of resident change and hot beverages. She stated staff are in-serviced every week. She stated staff had to pour and serve coffee for the residents. She stated coffee is served in styrofoam cup with a lid or specialized cup with lid. She stated the coffee is not to be left unattended, and when finished serving staff would take the coffee urn to the kitchen. She stated a coffee urn is kept locked in the nutrition room by the nurses' station. She stated the electric coffee urn was taken out of the dining room. She stated if a resident wanted coffee she would tell the resident to go to the dining room and she would bring coffee to them in a Styrofoam cup with a lid. She stated dietary staff check the coffee temperature and put a sticker on the coffee urn. She stated the coffee temperature ranges between 155degrees -175 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse in charge. On 08/27/25 at 6:20 PM Interview with [NAME] F who stated she had worked at the facility for one year. She stated she had been in-serviced on abuse, neglect, rights, and checking the temperature for hot beverages and hot beverage policy. She stated staff are in-serviced monthly. She stated the big coffee pot had been taken out of the dining room. She stated nursing staff had to request coffee from the kitchen. She stated staff had to pour coffee for the residents and the coffee is now being served out of an insulated coffee pitcher. She stated temperatures are checked before coffee is brought to the dining room with a stainless-steel thermometer. She stated temperature checks for hot beverages include the start and serve temperatures. She stated temperatures should be between 155 degrees and 175 degrees and logged on a temperature log. She stated a label is put on the coffee pitcher which includes the item, date, time, temperature, and employee initial. She stated the coffee pitcher will not be left unattended. She stated coffee is kept locked in the nutrition room by the nurse station and staff had to serve the resident coffee. Record Review of in-service dated 08/10/25 reflected 3 administrative staff had been in-serviced on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. Record Review of facility nutrition policies and procedures revision date 08/01/2020 reflected Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). 1. Hot beverages should be consumed at temperatures between 155 F and 175 F. Palatability is affected by temperature and varies from person to person, based on individual preference. 2. Commercial coffee brewing equipment is designed to heat water and hold coffee at desirable temperatures.A. Coffee should be brewed at temperatures between 195 F and 205 F to extract the full flavor. Storing coffee at temperatures between 175 F and 190 F will maintain the fresh brewed flavor for a limited period.B. Hot water dispensed from commercial coffee urns will be in the 185 F to 200 F range. 3. Pots or urns containing hot liquids should not be left unattended. 4. Facility staff should pour all hot beverages. 5. Locations where hot beverages may be prepared and/or re-heated such as employee break rooms or nourishment rooms should be safeguarded. 6. Patients or residents should not carry hot beverages without a lid while walking or moving in a wheelchair. 7. Beverages should not be re-heated by patients or residents or visitors. 8. The Facility may consider using china or ceramic cups, in lieu of plastic mugs, or foam cups, which do not provide for rapid cooling. 9. When serving hot beverages to patients or residents:A. Transfer the beverage from its brewing urn to a serving container. Beverages served directly from the brewing urn will be hotter.B. Do not overfill cups.C. Explain to patient/resident that a hot beverage is being served.D. Place cup away from the edge of the table and within patient's/resident's field of vision and reach of dominant hand.E. Remove lids to allow beverage to cool faster.10. When hot beverages are available for self-service: (e.g. dining room, lobby, beverage cart on unit)A. Coordinate beverage set-up in supervised areas only.B. Transfer the beverage from its brewing urn to a serving container.C. Do not overfill serving containers.D. Use only containers with safety or screw top lids rather than loose lids.E. Pre-pour beverages whenever possible into cups with lids. Record Review of in-service dated 08/10/2025 reflected that 5 staff had been in-serviced on hot beverage procedures regarding start and serving temperature and check of the beverage until it has reached a temperature range of 155 degrees-175 degrees per company policy. Once the proper temperature is reached staff will write out a ticket of type of beverage, date, time, and temperature. No hot beverage will be put out for serving until nursing staff is there to start. After all meal services hot beverages will be put in the nutrition room for as needed service. Record Review of skin monitoring: comprehensive CNA shower review dated 08/11/2025 reflected head to toe audits for 19 residents who drink coffee. No concerns were noted. Record Review of hot beverage temperature log sheet for August 2025 reflected start and serve temperatures. No concerns were noted. On 08/28/25 at 12:42 PM Interview with LVN E who stated she had worked at the facility for 2 years.She stated she had been in-serviced on abuse, neglect, rights, notification of resident change, and hot beverages and hot cereal. She stated staff are in-serviced every two weeks. She stated the coffee is served in an urn with a handle. She stated they went over serving temperature which is 155 degrees. She stated dietary staff check coffee temperature in the kitchen and put a label on the urn which includes the item, date, temperature, and staff initial. She stated the coffee is brought to the dining room when nursing staff is in the dining room and urns containing hot liquids will not be left unattended.She stated staff had to pour and serve hot beverages to the residents. She stated staff use Styrofoam cups with lids. She stated some of the residents have a specialized cup with lid. She stated the Administrator had ordered new cups with lids; they are using Styrofoam cups with lids until the new cups arrive. She stated coffee is kept in the nutrition room for nursing staff to dispense if residents request. She stated most of the residents that drink coffee are independent.She stated if a resident sustained an injury she would immediately assess the resident, notify the family, DON, and PCP. On 08/28/25 at 12:57 PM Interview with [NAME] O who stated she had worked at the facility for 1 year. She stated she had been in-serviced on abuse, neglect, rights, and hot beverages and cereal. She stated staff are in-serviced once a month. She stated dietary aides are supposed to check the temperature when coffee is freshly brewed and served. She stated the serving temperature should be between 155 degrees -175 degrees. She stated dietary staff had to wait until nursing staff asked for the coffee to be brought to dining room. She stated the coffee is served in an urn with a label which included item, temperature, date and staff initials. She stated the nursing staff had to pour the coffee and serve to residents. She stated coffee is poured in Styrofoam cups with a lid until the new cups and lids arrive. She stated coffee will not be left unattended. She stated a coffee urn is placed in the nutrition room for staff to dispense if residents request. She stated dietary staff also have to check the temperature and label the hot cereal. She stated a temperature log is kept daily for hot beverages. Temperatures are checked with a stainless-steel thermometer. She stated if a resident asked for coffee she would tell the resident to go ask the nurse. She stated if a resident sustained an injury, she would immediately notify nursing staff. On 08/28/25 at 1:15 PM conducted Interview with CNA P who stated he had worked at the facility for about 4 months. He stated he had been in-serviced on abuse, neglect, rights, hot beverages, and notification of resident change. He stated staff are in-serviced monthly. He stated coffee is served from an urn and only when nursing staff is in the dining room. He stated coffee is not to be left unattended in the dining room. He stated after meals the coffee is brought to the nutrition room which is kept locked. He stated the temperature should be between 155 degrees -175 degrees. He stated the coffee is served in an urn which had a sticker that shows the item, temperature, and staff initial. He stated staff pour and served the coffee for residents. He stated if a resident asked for coffee, he would go get the coffee and bring it to the resident. He stated most of the coffee drinkers are independent. He stated coffee is served in a Styrofoam cup with lid. He stated some of the residents had a specialized cup with lid. He stated if a resident sustained an injury he would immediately report to the nurse in charge. Record Review of in-service dated 08/10/2025 reflected 13 staff from different shifts had been in-serviced on abuse, neglect, and resident rights. Record Review of in-service dated 08/10/2025 reflected 18 staff had been in-serviced on the hot beverage policy. Record Review of evaluations completed for all residents. Their criteria were all the same for the evaluations. Residents were screened for cognition, mobility, dexterity, and behaviors to see if they were safe with hot beverages. Record Review of facility daily monitor log for appropriate hot beverage cup/lids reflected 08/11/25 through 08/15/25 no concerns. On 08/28/25 at 3:00 PM conducted Interview the DON stated she had worked at the facility for four months.She stated she had been trained on abuse, neglect, resident rights, and hot beverages. She stated the electric urn was discontinued immediately. She stated coffee is being served from an urn. She stated the dietary manager, DON, and Administrator were reeducated on coffee service for the r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of ten residents reviewed for changes in condition. The facility failed to notify the CHF clinic or the MD of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. Contact MD if noted. Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room. She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been notified. In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in resident's condition and notification to provider as ordered. None were identified. The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes. revealed staff were educated on: - Prompt notifications documented in residents medical record to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. - Shortness of breath - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. - Shortness of breath. - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Shortness of breath - Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: - Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: - Respiratory care all nurses validate resident is receiving oxygen per MD orders. - Change of condition recognition and notification to providers. - Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. - Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. - Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed to notify the CHF clinic of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. Contact MD if noted. Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room. She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been notified. In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in resident's condition and notification to provider as ordered. None were identified. The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes. revealed staff were educated on: - Prompt notifications documented in residents medical record to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. - Shortness of breath - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. - Shortness of breath. - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Shortness of breath - Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: - Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: - Respiratory care all nurses validate resident is receiving oxygen per MD orders. - Change of condition recognition and notification to providers. - Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. - Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. - Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 6 residents (Resident#1) reviewed for respiratory care. The facility failed to supply oxygen to Resident #1 while she was out on pass to a medical clinic appointment on 02/13/2025 and 02/21/25 resulting in increased shortness of breath, anxiety, and an inability to breath. An Immediate Jeopardy (IJ) was identified on 2/25/25 at 6:07 p.m. The IJ template was provided on 02/25/2027 at 6:07PM. While the IJ was removed on 2/27/25, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents on continuous oxygen at risk of experiencing desaturation, unconsciousness, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of acute on chronic systolic heart failure (a condition in which the heart is too weak to pump the blood around the body to meet its needs), chronic obstructive pulmonary disease (a group of lung conditions making it difficult to breath), personal history of COVID-19, and wheezing. Record review of Resident #1's care plan dated 01/08/2025 reflected there were no care plans to reflect Resident#1's need for oxygen, disease process of COPD (Chronic Obstructive Pulmonary Disease), disease process of CHF (Congestive Heart Failure), or her ADL (Activities of Daily Living) needs. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Resident #1 required substantial/maximal assistance indicating the helper did more than half the effort or the helper lifted or held trunk or limbs and provided more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 received oxygen therapy while a resident continuously. Record review of Resident #1s' Physician orders for February 2025 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 02/17/2025. Record review of Resident #1s' Physician orders history report for dated of 01/01/2025 through 02/25/25 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 12/20/2024. The order history report also reflected an order to check Resident #1 every hour to ensure the oxygen delivery is functioning properly. Report any complications to the DON or Administrator. This order was started on 01/10/2025 and then discontinued on 01/26/2025. Record review of the facility's grievance log for January and February 2025 reflected Resident #1's RP had filed a grievance on 01/10/2025 stating when Resident #1 was at an appointment the oxygen tank was not turned on after being transported from the facility. The RP turned the oxygen on. Then later within the same day the RP was dropping off laundry and noticed the residents' eyes looking glassy so she checked her oxygen tank and found the tank was full but not turned on and she had to turn it on again. The internal investigation revealed there were new oxygen regulators at the facility and had not been attached to the oxygen tank appropriately. Staff were in serviced on 1/17/25 on oxygen regulators and the grievance was closed as resolved. Record review of Oxygen saturation Vital sign report reflected on 02/13/25 Resident #1 had her oxygen level checked at 1:18pm and it was 97% with oxygen in place at 2 pm. Record review reflected on 02/21/25 at 2:39am the facility staff checked Resident #1's oxygen level, and it was 98% with oxygen in place at 2 lpm. Record review of a Medical Clinic visit reflected that on 2/13/25 at 9:35 Resident #1 arrived at the medical clinic and she had an oxygen saturation level on room air (without oxygen flowing) of 84% but recovered up to 100% after being placed on oxygen at 2 liters per minute in the clinic. In an interview on 02/25/25 at 10:15 The Private Caregiver for Resident #1 stated there have been many times that Resident #1 was sent out to a medical appointment with an empty oxygen tank causing her shortness of breath, changes in mental status, and severe anxiety. She stated she meets the resident at the medical clinic to relay to the family if there were any changes in residents' condition or care. She stated that the resident's RP had filed a complaint with the facility back in January 2025 and had an emergency care-plan meeting with the facility staff related to the residents need for working oxygen tanks. She stated they thought the issues were resolved but this month the resident had been sent to the specialty medical clinic twice with empty portable oxygen tanks. On 2/13/25 and on 2/21/25 the resident was sent with a portable oxygen tank to the medical clinic that was reading red indicating the oxygen tank was empty. This caused the resident to have low oxygen level while at the medical clinic causing Resident #1 confusion, shortness of breath, and anxiety. The Private Caregiver stated that the medical clinic staff were able to intervene and place Resident #1 on their in-house oxygen unit and brought her oxygen levels back up. She stated the facility staff did not check the tanks prior to the resident leaving and never monitored if the tanks were full or empty. In an interview on 02/25/25 at 10:25 Resident #1 stated she had a constant problem with the facility not ensuring there was oxygen in the portable oxygen tanks. She stated she had a diagnosis of CHF and COPD (both disease process will cause shortness of breath) and has difficulty breathing. She stated she always used oxygen continuously. Resident #1 stated she must see a medical specialist weekly for management of her CHF and COPD disease processes. She stated she was sent to the medical clinic the last 2 visits on 2/13/25 and on 2/21/25 with empty oxygen tanks. The specialty clinic staff changed her from her empty potable tanks (sent by the facility) to the wall oxygen unit in the medical clinic. Resident #1 stated she became confused, belligerent, and has severe crippling anxiety due to feeling as if she must struggle to breathe without adequate oxygen supply. Resident #1 stated she was transported to the medical clinic by ride safe a transport company. She stated the nurses do not check the oxygen tank to see if it's empty or full prior to leaving to her medical appointments. Resident #1 stated she was told to use the oxygen concentrator in her room. She stated that limits her mobility to freely move around the building and she did not like being grounded to her room, it was like a punishment. Resident #1 stated she could not take her oxygen concentrator with her to the appointments as it required electricity to function. She stated the oxygen tank problem had been reported to the administrator previously in a grievance form in January 2025. She stated she attended an emergency care-plan meeting with her RP regarding the issue, and the facility staff began to check the oxygen more frequently. Then the staff stopped checking the oxygen. So, it did not last long them checking the tanks. In an interview on 02/25/25 at 10:25 the RP of Resident #1 stated she has found Resident #1 with either her oxygen off, attached wrong, with an empty oxygen tank, or the liter flow set to the wrong amount multiple times. She stated she did meet with the facility ADM in January and drafted an emergency plan for the facility to increase the frequency of checking Resident #1's oxygen and then they stopped. The RP stated Resident #1 has shown up for two appointments in the last 2 weeks with empty oxygen tanks at the specialty medical clinic. At one of those appointments her oxygen saturation was 84%, normal range is above 90%. She said Resident #1 was belligerent, confused, short of breath, and having anxiety. The RP said the nurses at the clinic were able to transfer Resident #1 to their in-house oxygen unit on the wall and brought her level up to 100% but she still suffered from anxiety and not being able to breathe. She stated Resident #1 wears her oxygen continuously. She was never without it unless the facility failed to ensure she has oxygen on. In an interview on 02/25/25 at 11:15 am the RN Specialty Clinic Director stated it was their expectation that all residents coming from a facility should have a working portable oxygen tank with them If they were oxygen dependent. She stated Resident #1 had been to the clinic 2 times with an empty portable oxygen tank on 02/13/25 and 02/21/25. She stated when a Resident #1 arrived at the clinic the staff checked her vital signs and, on the 02/13/25, when Resident #1 came into the facility, she had a saturation level of 84% indicating a critically low oxygen level and Resident #1 was not receiving enough oxygen in her blood to function. The RN Specialty Clinic Director stated a normal oxygen level is above 90%. She stated the staff immediately hooked Resident #1 to their in-house oxygen unit on the wall and within 3 minutes Resident #1s oxygen saturation went up to 100%. She stated it was a very similar situation on 2/21/25 when the resident arrived again with an empty tank. She stated clinical staff did call the facility and addressed it with the charge nurse of Resident #1. She stated the lack of oxygen caused Resident #1 to feel like she was unable to breath, causing shortness of breath, anxiety, and confusion from hypoxia (low oxygen level). She stated Resident #1 did have anxiety, confusion, and shortness of breath at both clinical visits on 02/13/25 and 02/21/25. In an interview on 02/25/25 at 1:15 pm the Interim DON stated she has been at the facility for 2 weeks. She stated the nurses were instructed to check oxygen tanks and should check portable oxygen tanks prior to the residents leaving the facility. She stated staff should always make sure the portable oxygen tank was on and full for mobile residents. She stated the staff were educated on monitoring the tanks verbally and with written in-services. She stated the DON was responsible for providing education to the staff. She stated she was aware of a recent in-service given in January on oxygen concentrator/regulator monitoring. The Interim DON stated she was not aware of an emergency plan for Resident #1 to have increased monitoring. She stated the negative outcomes for having empty oxygen tanks in use for a resident that required oxygen while out to medical appointments could be confusion and respiratory distress due to inadequate oxygen delivery. In an interview on 02/25/25 at 1:35 pm the Interim ADM stated he was not aware of the Emergency Plan for Resident #1. He stated that Resident #1 was hardly in her room and sometimes would leave on ride safe without checking with the nurses prior to leaving. He stated he was aware of a recent complaint related to the oxygen regulators. He stated the facility had bought new regulators and the nursing staff had to be educated on them. The Interim ADM stated all residents should be sent out on pass to medical appointments or anywhere with adequate amount of oxygen if they require continuous oxygen to prevent shortness of breath. On 02/25/25 at 2:15 pm a call was placed to The Medical Director and a message was left for a return call. In a record review of facility policy titled Oxygen Therapy dated 02/12/2024 reflected: Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. PRECAUTIONS: The administration of oxygen to patients/residents with Chronic Obstructive Pulmonary Disease (COPD), especially a carbon dioxide retainer, must be carefully monitored as too much oxygen can cause a decrease in respirations due to Carbon dioxide narcosis. Special Considerations: Maintain the patient's/resident's target oxygen saturation level within the provider's recommended range. If the patient/resident has COPD or another risk factor for hypercapnic respiratory failure, a saturation of 88%-92% may be necessary. DOSAGE: Oxygen therapy will be used to administer a FI02 (Fraction of Inspired Oxygen) (the amount of air a person is breathing in) greater than 21 % by means of various administration devices. Oxygen therapy will be used to raise the patient's/resident's Pa02 (Partial Pressure of Oxygen in the arterial blood flow) to an acceptable baseline using the lowest FI02. Preparation of Equipment: The licensed nurse is to check the oxygen outlet port to verify flow in accordance with provider's order. An Immediate Jeopardy was identified on 2/25/25 at 6:07 p.m. and an IJ template was provided to the Interim ADM and Interim DON. The following Plan of Removal submitted by the facility was accepted on 02/27/2025 at 7:48 a.m. Plan of Removal for F695 Head to toe comprehensive assessment, including assessing the respiratory system for abnormalities, signs of distress or change in condition completed on Resident #1 by Director of Nursing/Designee on 2/25/25 with no negative effects and physician notified. Resident #1's responsible party notified on 2/25/25. An observation of the 6 residents currently in the facility with orders for continuous Oxygen was completed on 2/25/25 by the Director of Nursing/Designee to validate oxygen is being delivered per physician orders. No issues identified. Administrative Nurses were reeducated on Oxygen Administration on 2/25/25 by the Clinical Consultant including: Validate residents are receiving oxygen per physician's orders. Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Licensed nurses were reeducated on Oxygen Administration on 2/25/25 by the Director of Nursing/Designee including: Validate residents are receiving oxygen per physician's orders. Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Licensed Nurses working on 2/25/25 received this education. All nurses that have not worked will receive education by the Director of Nursing/Designee prior to their next scheduled shift. This education will also be completed in New Hire and agency orientation by the Director of Nursing/Designee. Member of Nursing Management will interview 2 staff members per week for 4 weeks to validate comprehension of provided reeducation. Members of Nursing Management will round daily and document on the validation tool for 5 days to validate that oxygen is being delivered per physician's orders, then 3x per week for 2 weeks. Director of Nursing/designee will validate and document on the validation tool that the leave of absence form is completed for residents who leave the facility and have orders for continuous oxygen, including documentation that the resident was sent with a full portable cylinder. This will be validated daily for 5 days, then 3x per week for 2 weeks. QAPI was held on 2/25/25. The Medical Director was notified of the Immediate Jeopardy on 2/25/25. Monitoring of the plan of removal included the following: 2/27/25 10:28am- Record Review reflected a head-to-toe comprehensive assessment including respiratory system was completed on Resident #1 on 2/25/25 by the DON with no negative finding. Record review reflected that 6/6 residents who wore oxygen continuously were evaluated to ensure physicians orders were being followed and residents were receiving oxygen. Record review reflected on 2/25/25 the DON and the ADON were reeducated by the Clinical Services Director on verifying oxygen was on and tank had enough for residents when going out on pass and during activities in the building. Record review reflected that licensed nurses (10/12) have been reeducated on oxygen administration on 2/25/25 by the DON including validating residents were receiving oxygen per physicians' orders, validating residents with orders for continuous oxygen had a full tank prior to going out of the facility, and documenting on the residents leave of absence form adequate supply of oxygen. Record review reflected that 1 random staff member had been audited by the DON for comprehension on education provided related to oxygen dated 2/26/25 and passed. Record Review reflected that the DON rounded daily, and documented oxygen was being delivered as ordered for those residents requiring oxygen dated 2/25/25, 2/26/25, and 2/27/25. Record review reflected that Resident #1 was provided a leave of absence form on 2/26/25 and the oxygen tank was verified by the DON to be full prior to the resident's exit from the facility for a medical appointment. Record review reflected that on 2/25/25 at 7:00PM a QAPI was held attended by the Medical Director, Interim Administrator, Interim DON, and the Clinical Services Director. During the meeting the IJ was discussed along with the writing of the POC. Observation on 2/27/25 at 11:38 am rounds were completed and reflected 6/6 residents requiring continuous oxygen had oxygen in place as ordered by their physician. Their portable tanks were secured and full or almost full. Interviewed 10 nursing staff (2-night shift LVN A and LVN B, 1 agency staff nurse LVN C, 1 PRN LVN D, a Weekend Supervisor RN E, and 5-day shift nurses LVN F, LVN G, LVN H, LVN I, LVN J ) they stated they had been educated on receiving oxygen orders, oxygen administration, oxygen order verification, and validating residents who required oxygen had it in place as ordered by the physician. They stated they were aware of the leave of absence form and to verify in writing on the form, that residents who were going out on pass and required oxygen, that their tanks were full. The Nurses stated the pass forms were printed from their matrix (an electronic medical record) system and in writing the nurse validated the amount of oxygen in the tank onto the form to ensure the resident was safe for transportation. In an interview on 2/27/25 at 2:35 pm the Interim DON stated she was educated by the clinical services director on oxygen administration, checking oxygen, and ensuring residents were adequately equipped with oxygen prior to leaving the facility. She stated she educated the nursing staff on the above in person and by phone. There were 2 nurses that work night shift that have not worked since the IJ was called and they would be educated prior to their next shift. She stated she did do a head-to-toe full comprehensive assessment on Resident #1 with no negative findings. The DON stated an audit was completed on residents with oxygen and all residents receiving oxygen had adequate supply within their portable tanks. She stated she has questioned 1 nurse this week so far to ensure comprehension of new oxygen plan and plans to continue audits x 4 weeks. The DON stated since Resident #1 frequently leaves for appointments and was out of her room the facility was planning on obtaining her a portable concentrator for her to take with her that will be battery operated with a backup battery in case it was needed. The portable concentrator had already been ordered at that time. The plan was for all residents to have adequate oxygen supply if needed and no negative outcomes. In an interview on 2/27/25 at 2:50PM the Interim ADM stated the POR had been implemented as written, the nursing mangers were educated and in turn the nurses were educated by the managers. He stated that an audit was completed on residents receiving oxygen and all residents were receiving it per physicians' orders. He stated Resident #1 had a full body assessment and there were no negative findings. He stated a QAPI meeting was help with The Medical Director for the development of the POR and all residents would receive an out on leave form printed from their EMR. The nurses were to sign the form ensuring residents leave the facility with a full bottle of oxygen. He stated that today the facility had ordered a portable concentrator for Resident #1 to ensure she always had adequate supply of oxygen because she was out of her room often and the portable concentrator would not restrict her freedom to roam the building as she desired. The Interim ADM and Interim DON were informed the Immediate Jeopardy was removed on 02/27/2025 at 3:45 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated 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 ensure each resident receives adequate supervision with assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure Resident #1 received assistance, in an appropriately sized space, while being lifted out of her wheelchair using a mechanical lift, as specified in the care plan. CNA B did not ensure Resident #1 was positioned in the center of the lift sling and CNA D failed to stay by Resident #1's side with hand on assistance. The noncompliance was identified as PNC. The IJ began on 11/4/24 and ended on 11/23/24 The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injuries, falls, and a decline in quality of life. Findings included: Record review of Resident #1's face sheet dated undated reflected; Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included fracture of the left femur (broken thigh bone), poly osteoarthritis (painful inflammation in five or more joints), cerebral infarction (blocked blood flow to the brain causing brain tissue to die), muscle weakness, hemiplegia (paralysis on one side of the body), hemiparesis (one sided muscle weakness) following unspecified cerebrovascular disease (conditions that affect blood flow to the brain) affecting left dominant side. Record review of Resident #1's annual MDS assessment, dated 1/18/24, section C (Cognitive Patterns) reflected no BIMS score as resident was rarely or never understood. Section GG (Functional Abilities) reflected she was dependent for bed mobility and bed to chair transfers. Record review of Resident #1's comprehensive care plan, revised 11/15/24, reflected in part, Resident has side rails on bed for repositioning. She is at risk for falls. She also has a full torso harness attached to her wheelchair as she has zero trunk control. She will thrust herself forward at times. She is a mechanical (lift brand name) for transfers. Intervention added 11/07/24, Rearrange furniture and bed in (Resident #1's) room to ensure smooth transition for the (lift brand name). Record review of a progress note dated 11/4/24 reflected, Witnessed Fall RP present. Res being transferred to bed via (mechanical lift brand name) 2 CNAs and grandmother present CNA (CNA B and D's names) stated while positioning (Lift) alongside bed res raised up leaned forward slide out of the sling onto the floor. Standing outside the door I immediately went into the room observed res laying on the floor. Head to toe assessment completed VS: 104/70 90 20 97.0 97% RA res is nonverbal assisted onto bed off the floor. Dr notified transported to (Local) Hospital for further evaluation. Record review of Resident #1's Local Hospital Emergency Department Discharge Instructions dated 11/5/24 revealed no new orders. X-ray results were noted to be negative. Record review of Resident #1's progress note dated 11/5/24 reflected, Resident #1 returned from the hospital with no injuries having been found. The nurse documented This nurse was made aware of a hematoma (a collection of blood that pools outside the blood vessels) on the left hip. Residents [family member] requested the area be re-x rayed as it may be a delayed injury related to a fall the week prior. Record review of Resident #1's radiology reports from a mobile x-ray provider (performed at the facility), dated 11/14/24 reflected in part, HIP UNI W OR W/O PELVIS 2-3 V, LEFT Results: The left hip joint is in alignment, but there is narrowing of the joint space due to mild degenerative changes. There is mild degenerative spurring involving acetabular border and femoral head and neck junction. No fracture or dislocation is seen. Pubic rami are intact. Conclusion: Mild osteoarthritis of the left hip. Record review of Resident #1's progress note dated 11/20/24 included additional x-rays were ordered. The nurse documented the x-ray results in her progress note as follows: Acute fracture distal femur with some displacement and impaction noted. Orders received from provider to send resident to ED for further evaluation. Record review of Resident #1's radiology reports from a mobile x-ray provider (performed at the facility), dated 11/20/24 reflected in part, Femur 1 View, Left. Results: Acute fracture distal femur with some displacement and impaction. No acute findings elsewhere. Conclusion: Distal femoral fracture. Record review of Resident #1's Local Hospital Emergency Department Discharge Instructions dated 11/20/24 revealed a diagnosis of a closed femur fracture. A referral to a local surgeon for scheduling of surgery, and an immobilizer for left knee. During an observation, and an interview on 11/24/24 at 3:04pm in Resident #1's room revealed Resident #1 was in bed and a FM was sitting in a chair next to the bed. When asked if she was aware of Resident #1's fall, FM replied that she had been visiting when the drop, not a fall from the lift occurred. FM stated she feels responsible because she was not paying attention to the lift, she was trying to move Resident #1's wheelchair out of the way since it was a tight fit to use the lift in the small space available. FM stated she had since watched the video of the lift and pointed out a camera in the room pointing toward Resident #1's side of the room. FM opened the video on her phone. The video dated 11/4/24 showed CNA B in the room entranceway, which had an opening between the adjoining room wall and the wall/door to the bathroom. Resident #1 was sitting in her wheelchair with a lift sling under her. CNA D came into the area, walking sideways between the wall and the wheelchair, Resident #1 was lifted into the air by the mechanical lift. Resident #1 was observed tilting to the left with her head and upper body on the edge of the sling as she became visible to the camera prior to the fall. CNA B was standing at the foot of Resident #1, controlling the lift and CNA D, was standing on Resident #1's left side, she begins to turn Resident #1 suspended in the air, towards the bed. Resident #1 position while suspended is at the foot of the bed to the right side of the bed and between the bathrooms outer wall. Resident #1 is not over the bed. There was a pause and CNA D moved herself towards Resident #1's feet away from Resident #1's left upper body side, there did not appear to be room beside the resident and the edge of the bed. Resident #1 slid to the left and off the sling, upper body first, landing on the floor and the metal mechanical lift leg extensions. At time stamp 14:34:17 on the video Resident #1 can be seen on the floor laying towards her left side with her thigh area on top of the mechanical leg extension. During an interview on 11/24/24 at 12:20pm LVN A stated had been working on 11/20/24 when Resident #1's FM pointed out to her that Resident #1 had a new area of swelling on her left leg. LVN A stated Resident #1 had been indicating via grimacing that she was in pain and was being provided pain medications since the fall from the lift. She stated multiple x-rays had been taken, that they and the hospital had not seen an injury. On 11/20/24 she called the doctor and was given orders for Resident #1's entire left leg; those x-rays showed the fracture. During an interview on 11/24/24 at 2:36pm CNA B stated when she first arrived on 11/4/24 Resident #1's FM asked for Resident #1 to be put into bed. She stated CNA D assisted her since Resident #1 required the use of a mechanical lift. CNA D stated she started having trouble moving the left because of the positioning of the bed, CNA D came toward her to help with the lift positioning. Resident #1 unexpectedly leaned forward at the same time CNA D moved and Resident #1 fell out of the sling. CNA B stated there was not enough room to maneuver the lift. The room had been arranged the same way for a while and she knew the room had limited space. CNA B stated Resident #1's room had since been rearranged so we do not have that problem any longer. CNA B stated LVN C had been in the hallway outside Resident #1's room, she had immediately entered the room to check on Resident #1. CNA B stated she did not understand how Resident #1's fracture could be from that fall as the resident hit her head not her leg. CNA B stated Resident #1 was positioned correctly on the sling it happened because Resident #1 unexpectedly leaned forward. During an interview on 11/24/24 at 3:58pm LVN C stated she had been in the hallway outside Resident #1's room preparing medications. She heard screaming and ran into Resident #1's room. She stated Resident #1 was on the floor, CNA B and CNA D were standing back on the other side of the lift and Resident #1's FM was behind all of them. LVN C stated the CNA's told her the resident had hit her head in the fall she did an assessment of Resident #1 and did not see any injuries, including on the resident's legs. She called emergency services right away because the resident had hit her head. LVN C stated she did not see the actual lift for Resident #1, but the FM had shown her a video and Resident #1 was leaning to the left and not positioned correctly in the center of the sling. During an interview on 11/24/24 at 4:47pm CNA D stated she had started working at the facility a week before the incident. CNA D stated by the time she got to the room to assist, Resident #1's sling was already hooked up. CNA D stated the fall happened because Resident #1 had leaned forward and to the left. When asked about the positioning of Resident #1 in the sling prior to the fall, CNA D stated everybody keeps talking about this video like it shows something and discontinued the call/interview. During an interview on 11/24/24 at 4:29pm the DON stated all staff receive training on using a mechanical lift upon hire and while shadowing a staff the first three days on the floor. She stated after the fall occurred all staff had been provided an in-service on appropriate use of the lift, including positioning. DON stated prior to Resident #1's fall they had to use the lift between the wall and the bed, making it difficult to maneuver. She stated they rearrange the room so it would not be as difficult to put mechanical lift legs under the bed. DON stated she had seen sections of the video that Resident #1's FM had but not the entire video. She was not aware of Resident #1 leaning to the left but stated they had included in the in-service the correct positioning and sling to be used. DON stated CNA B and CNA D should have positioned Resident #1 better in the sling and kept someone at Resident #1's side. DON stated the outcome of not using lift correctly could be harm to the resident. During an interview on 11/24/24 at 5:31pm the Adm stated she was made aware of Resident #1's having fallen out of the lift at the time it happened. She stated although Resident #1 returned from the hospital without injuries, they did in-services with all staff and rearranged the furniture in Resident #1's room. She stated they had done an additional set of x-rays at the facility after continued expressions of pain. On 11/20 swelling was noted and x-rays were again performed and that set of x-rays showed a fracture. The Administrator stated she wondered if the injury was because of the fall. She stated she had not seen the video of the fall, but the DON had seen parts of the video and planned to look at the entire video. Adm stated they have been and will continue to do monitoring of mechanical lifts. Record review of CNA B's Infection Prevention and Control Boot Camp Class evaluation, dated 2/4/24, includes mechanical lift training and transfer techniques. Record review of CNA D Check off sheet evaluation, dated 10/25/24 includes mechanical lift training and transfer techniques. Record review of the facility Record of Inservice, dated 11/7/24, given to CNAs Band D reflected the following was included, one staff always have a hand on the resident and position patient/resident for maximum comfort. Record review of the facility Record of Inservice, dated 11/23/24, given to all staff reflected the following was included, one staff always have a hand on the resident and position patient/resident for maximum comfort. The inservice includes review of policy which includes need for full back support, head support and the residents medically appropriate position. Review of the facility policy dated 3/27/2017 Mechanical Lifts: General Guidelines reflected in part, H. 3) Clear path for the lift device. a) Ensure adequate space for lift to pivot and move freely to receiving area. b) Ensure lift can fit under or around receiving surface and through doorways, as needed.