**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately report to the physician a significant decline in condition for 1 of 3 residents (R) reviewed for change of condition (R2).The facility did not immediately consult with the resident's physician regarding R2's significant change of condition on 07/13/25 at 3:00 PM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2, and required use of a Hoyer lift for transfers, which ultimately required R2 to be transferred the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis (excessive sweating), and bilateral crackle sounds noted in lungs. R2 was diagnosed with a Cerebrovascular Accident (CVA) (stroke) and pneumonia.The facility's failure to promptly consult with the physician about R2's change of condition, created a finding of immediate jeopardy that began on 7/13/25. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 08/06/25 at 10:01 AM. The immediate jeopardy was removed on 08/06/25; however, the deficient practice continues at a scope/severity level of D (isolated/potential for more than minimal harm) as the facility continues to implement its action plan. Findings include:Surveyor reviewed the facility protocol titled Change in Condition of the Resident, last revised on 09/20/22, which states in part, .References: Change in condition; When to report to the MD. Interact Version 4.5 tool states,Immediate notification with any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed.Vital signs:Report immediately: -if Systolic BP >200mmHg or <90mmHg, Diastolic >115mmHg -Abrupt significant change in cognitive function from usual, with or without altered level of consciousness. -Sudden change in level of consciousness or responsiveness. -Gait disturbances-Abrupt onset of slurred speech, or other new focal neurological findings. -Lung sounds-Abrupt onset of wheezing, rales, or rhonchi (new)-Dyspnea - Abrupt onset of SOB (shortness of breath) with pain, fever, or respiratory distress or with progressive leg edema.-Abrupt change in speech, with or without other focal neurological findings. -Walking difficulty-Acute onset accompanied by other neurological signs. Non-immediate reporting: -Diastolic BP >90mmHg -Persistent change from usual cognitive function with no criteria met for immediate notification. -Gradual change in level of consciousness not associated with other criteria for immediate notification.-Significant recent changes in gait without other symptoms or findings. -Recently progressive or persistent minor SOB without other symptoms. -Recent onset not resolving spontaneously.R2 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinson's disease, muscle weakness, unsteady on feet, pyothorax without a fistula, pneumonitis, schizophrenia, and hypotension.R2's Minimum Data Set (MDS) assessment, dated 07/15/25, identified R2 required assistance from 1-2 people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and transfers. Surveyor reviewed R2's physician orders, which included:.-Monitor VS (vital signs) daily with special attention to blood pressure.-Continue IV antibiotics.-Reassess respiratory status and infection regularly.-Neurology consult.-Full Code. Surveyor reviewed R2's admission assessment, which states in part:-On 07/10/25, R2 did not have any swallowing issues presently. Alert and oriented to time, place, and person. Breath sounds were clear bilaterally. Vital signs are stable. R2's vital signs:On 07/10/25 at 3:47 PM, blood pressure (BP) 126/80, heart rate (HR) 85, and respirations 20. Surveyor reviewed R2's progress notes from 07/10/25-07/18/25:-Nurse daily skilled observation note:On 07/10/25 at 9:00 PM, a daily nurse assessment was conducted, indicating R2's respiratory status was even and regular, unlabored. R2's neuromuscular system had no issues. Progress notes from the Nurse Practitioner (NP): On 07/11/25 at 3:00 PM, NP visit today, the patient [R2] is seen lying in bed, appearing comfortable at rest. She is pleasant during the visit, providing only brief statements and yes or no responses. She tells me that she misses eating food, although she seems to understand the need for tube feeding due to dysphagia. She did experience nausea yesterday, and staff report that this seems to be relieved with as-needed Zofran. She is currently requiring supplemental O2 to maintain SpO2 greater than 90%. Vital signs have been stable, afebrile. There are no indications of increased shortness of breath, chest pain, fever, chills, diarrhea, constipation, dysuria or other urinary concerns. NP's physical examination: general- no acute distress, comfortable at rest. Respiratory- clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Neurological- cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness.On 07/11/25 at 4:39 PM, Occupational Therapy (OT) worked with R2 on sit-to-stand (transfers). R2 completed sit to stand with moderate assist, limited standing tolerance, c/o (complaints of) dizziness and wanting to lie down, pivot transferred to bed. R2 is educated on the use of the call light for all transfers and needs. R2's response to session interventions is that R2 is fatigued and wants to return to bed to rest.On 07/12/25 at 12:21 PM, OT performed Passive Range of Motion (PROM) on R2's upper extremities. 100% physical assistance is required due to compromised strength, technique, and muscle tone to facilitate muscle recruitment to enable increased participation in self-care tasks. Skilled interventions focused on building rapport and attempts at establishing communication techniques were unsuccessful. OT used visual tools to help improve patient communication with the writer, although R2 was not able to consistently demonstrate the ability to respond. R2's eyes were open and able to focus on the writer, but minimal to no verbal attempts were made by R2 to communicate. 0 attempts by R2 to point to yes/or no cards. R2 found with thick phlegm on the right side of her mouth. R2 was attempting to cough throughout the session but was never able to clear what was in her throat. OT discussed concerns with the RN; stated she would perform oral care with R2. Also confirmed that today, she was unable to successfully communicate with R2, and R2 appears more lethargic today than yesterday. On 07/13/25 at 12:42 AM, late entry: On 07/12/25 at 11:30 PM, R2 was not able to pivot transfer assist of 2. Hoyer lift used. R2 had a large amount of foamy secretions.-12:45 AM, R2 had another small amount of foamy secretions, R2 coughing, lung sounds upon both assessments were clear in the left lobes and coarse in the right lobes (wet sounding). R2 opens eyes when spoken to. R2 is resting comfortably. NP notified via email and gave orders to continue to monitor.Surveyor did not find documentation that the nurse notified the physician of R2's mobility and cognition changes that were documented on 7/12 and 7/13/25.Vital signs: On 07/13/25 at 10:01 AM, BP 91/64, and HR 90. Nurse daily skilled observation note: On 07/13/25 at 3:00 PM, R2's respiratory status, with abnormal lung sounds (rales, rhonchi, wheezing). The neuromuscular system decreased movement/mobility, and R2 has paralysis/weakness. Summary: R2 has been resting quietly in bed most of the shift. No s/s (signs/symptoms) of pain or discomfort. Opens eyes and looks at the writer when speaking but does not answer questions. Surveyor did not find documentation that the nurse notified the physician about abnormal lung sounds, paralysis and weakness, and R2's nonverbal status. Daily skilled observation:On 07/13/25 at 5:00 PM, R2's neuromuscular system is paralysis/weakness. Surveyor did not find documentation that the nurse notified the physician about paralysis and weakness, and R2's nonverbal status. On 07/14/25 at an unknown time in the morning, Physical Therapy (PT) was seeing R2 for therapy. R2 not able to respond verbally, not able to gesture, or make eye movement. PT deferred.Surveyor did not find documentation that the nurse notified the physician about paralysis and weakness, and R2's nonverbal status. Vital signs:On 07/14/25: 1:41 PM, BP 100/57, HR 70, and respirations 16. On 07/14/25 at 1:52 PM, R2 has been unresponsive all morning. Mouth care is provided frequently. Drooling at times. R2 diaphoretic. Lung sounds diminished with crackles bilaterally. Sounds as though R2 has fluid in the throat. NP came to assess the resident. Orders to send to Emergency Department (ED) for unresponsiveness, diaphoresis, and crackles bilaterally.Surveyor did not find documentation that the nurse notified the physician all morning about paralysis, weakness, and unresponsiveness. On 07/14/25 at 2:50 PM, the hospital report from the Emergency Department (ED) states, R2 arrived by Emergency Medical Services (EMS) with fever and was non-communicative. R2 had a head Computerized Tomography (CT) scan that revealed diffuse middle cerebral artery Cerebral Vascular Accident (CVA).Telephone call received from radiologist with final report on CT. The patient has a diffuse MCA cerebrovascular accident. Nursing staff contacted the skilled nursing facility, and the last reported normal was this past Friday, 07/11/25, post-discharge from the hospital. The patient is normally speaking and doing some swallowing independently. Currently obtunded, making gurgling noises, respirations. The head of the bed is up at 45 degrees. Chest x-ray pending, maintaining airway at present.On 07/21/25, while R2 was in the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator. R2 changed code status in hospital to Do Not Resuscitate (DNR) and palliative care. On 08/05/25 at 12:52 PM, Surveyor interviewed Registered Nurse (RN) H and asked RN H how R2 presented to RN H the times RN H cared for R2 in the facility. RN H reported that RN H was not familiar with R2 as RN H took care of R2 for the first time on RN H's shift 07/12/25. RN H reported to Surveyor that RN H thought the nonverbal communication and not moving in bed was R2's baseline. RN H did not notify the provider of the nonverbal communication. RN H reported that the day before, the provider was notified and to continue to monitor was the order.On 08/05/25 at 1:08 PM, Surveyor interviewed RN C and asked how R2 was during R2's care when RN C worked with R2. RN C reported that on 07/12/25, R2 could nod yes or no, but couldn't transfer with staff. RN C stated RN C spoke with a Certified Nursing Assistant (CNA) about R2 and CNA stated this was not R2's baseline. RN C acknowledged she did not notify the MD.Surveyor could not find any documentation RN C notified physician of R2's inability to transfer with 2 staff assist.On 08/05/25 at 1:52 PM, Surveyor interviewed hospital RN E and asked RN E how R2 presented to the ED. RN E reported that R2 was very unkempt looking and was non-verbal. RN E reported RN E did not know what R2's baseline was, but through further assessment, found that R2 could not lift or move the right side of the body. RN E immediately activated the stroke protocol, and a CT scan was performed, showing a large stroke affecting the right side of R2's body. RN E reported when RN E called the facility to try and grasp when the last well-known date and time was, a staff member from the facility stated, [R2] has not been well since Friday the 11th and could not use the right side. RN E then reported this to the hospital physician right away. Surveyor asked RN E if RN E remembered the staff member who gave the report, and RN E stated, I do not. RN E reported R2 also presented to the ER with a fever and hypotension. On 08/05/25 at 2:01 PM, Surveyor interviewed RN I and asked RN I how R2 presented on 07/11/25. RN I reported to Surveyor that tube feedings went well and R2 seemed to be quiet but ok. RN I just thought that R2 was at R2's baseline, but RN I did not review what R2's baseline was, so unsure if R2's state was normal for R2. On 08/06/25 at 9:03 AM, Surveyor interviewed Rehab Director (RD) F and asked if R2 was provided PT services or an evaluation of care during R2's stay. RD F reported to Surveyor that R2 was evaluated on Friday, 07/11/25, and RD F worked with R2 personally by assisting R2 with sitting on the edge of the bed and sitting and standing. RD F reported that R2 could answer simple questions with short answers and yes or no answers. RD F reported that come Monday, 07/14/25 in the AM, unsure of time frame, R2 could not move her body or speak at all. R2 would not answer Certified Occupational Therapy Assistant (COTA)'s questions, and the RD F deferred R2 for PT/OT services at this time. Surveyor asked RD F if RD F or COTA reported to any other staff what COTA assessed while working with R2 during the PT session or reported this to anyone. RD F reported to Surveyor that RD F is unsure if COTA reported this to any staff members besides RD F unfortunately. On 08/06/25 at 9:30 AM, Surveyor interviewed MD D, who reported not knowing who R2 was as MD D has been out on medical leave and the NP was following. Surveyor asked MD D if any nurses report to the provider or NP of a decline in cognition, mobility, and communication, what would be the expectation from the provider on call for nursing staff to do. MD D stated that nursing staff should already have a neurological assessment complete and be calling the provider with this information. MD D would immediately order that the resident be sent to the ED with a decline in cognition, mobility, and communication. MD D stated, I would have ordered [R2] to immediately be sent out to the ED. On 08/06/25 at 10:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could explain R2's disposition at the facility on admission and then through the 4-day stay in the facility. DON B reported to Surveyor that DON B was in R2's room on Friday, 07/11/25, in the morning. DON B spoke with R2, and R2 answered questions, yes and no, but was a little slower in answering questions. R2 had trouble with word finding with yes and no, but R2 was comfortably lying in bed. DON B reported that RN C was providing care for R2 on Friday, 07/11/25, Saturday, 07/12/25, and Monday, 07/14/25. DON B reviewed RN C's progress notes and RN C noted lung sound changes in R2, called the provider got an order for chest x-ray. Licensed Practical Nurse (LPN) G had R2 on Sunday, 07/13/25. DON B reported that LPN G was able to give tube feedings to R2 with no issues, and R2 was able to track with eyes. DON B stated that RN C spoke with NP Monday, 07/14/25, as soon as R2 had more secretions, and during tube feeding at around 11 AM, NP assessed R2 while onsite, and determination was made for R2 to be sent out right away to the ED. Surveyor asked DON B if DON B expects that staff should have notified the provider on call on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM,11:30 PM, on 07/13/25 at 3 PM and 5 PM, as well as when a nurse assessment of unresponsiveness was documented on 07/14/25 at 1:52 PM. DON B reported to Surveyor that DON B's expectation is for staff to follow the facility's policy on change of condition and notify the provider of any changes right away.The facility failed to notify R2's physician on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM, 11:30 PM, on 7/13/25 at 3:00 PM and 5:00 PM, and 7/14/25 at 1:52 PM of R2's changes in condition.The facility's failure to promptly notify the physician of a resident's significant change of condition led to a reasonable likelihood for serious harm on 07/13/25 which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 08/06/25; however, the deficient practice continues at a scope/severity level of D (isolated/potential for more than minimal harm) as the facility continues to implement the following action plan:1. In house residents were assessed by Registered Nurse or designee including head to toe assessment using E-interact head to toe and review of skin assessment in last week to ensure residents experiencing a change in condition have complete assessment. Any changes from baseline will be reported to Primary care physician. This assessment will be completed by 8/6/25. 2. The DON initiated re-education with Licensed Nurses on change of condition policy including interact change of condition Sbar documentation to ensure thorough assessment of resident & primary care physician notification as appropriate. Licensed nurses will utilize interact 5.1 tool as guidance to determine change of condition and document in resident's medical record.3. On 8/6/2025, the DON VP of success and Executive Director reviewed facility established policies and guideline including Change in condition Primary Care Provider notification E-interact 4.5 guidelines (MD notification)*Policies and guidelines remain appropriate4. DON/designee to complete audits of nursing documentation and provider notification daily x 2 weeks. This audit will include ensuring accurate and thorough assessment of resident. After the initial audit period, audits will continue 5x week for 6 weeks. Ad Hoc QAPI held on 08/06/25, with Director of Nursing, Executive Director, VP of Success to review recovery plan. 5. Results of audits to be brought to monthly QAPI meeting for further review and recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not ensure 2 out of 3 residents (R) reviewed, (R2, R1), who had changes in condition were provided immediate care and treatment consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for neurological/comprehensive assessments. The facility did not perform neurological assessments from 07/12/25 at 10:46 AM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2 and required use of Hoyer lift for transfers, which ultimately required R2 to be transferred to the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis, and bilateral crackle sounds noted in lungs. R2 was diagnosed with a Cerebrovascular Accident (CVA) (stroke) and pneumonia. While at the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator.The facility's failure to provide immediate care and treatment for a resident who displayed changes in condition from 07/12/25 until 07/14/25, created serious harm for R2, which created a finding of immediate jeopardy that began on 07/12/25. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on 08/06/25 at 10:01 AM. The immediate jeopardy was removed on 08/06/25; however, the deficient practice continues at a scope/severity level of G as the facility continues to implement its removal plan and as evidenced by the following example: The facility did not assess R1 for a decline in cognition and noted reddened penis with purulent drainage from the tip of R1's penis. R1 became unresponsive on 7/14/25 and was transferred to critical care, diagnosed with a urinary tract infection, hypotension (low blood pressure) and decreased oxygen levels. Findings include:Surveyor reviewed the facility protocol titled Change in Condition of the Resident, last revised on 09/20/22, which states in part, When a resident presents with a possible change of condition, such as fall or noted changes in mental or physical functioning:1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident: This assessment could include, but is not limited to the following: A. Vital signs, oxygen saturation, blood glucose level C. Swelling, edema, discoloration. E. Personality, behavioral, and/or cognitive changes F. Alteration in level of consciousness, ability to respond.H. Sensory weakness or change I. Generalized or localized weakness J. Speech disorder K. Gait, posture, or balance changeM. Reflexes, response to stimuli, neurological signs Q. Dyspnea, or irregular breathing 3. Notify the resident's physician of any use-interaction change in condition. a. Immediate notification: for any symptom, sign of apparent discomfort that is: i. Acute or sudden in onset, and ii. A marked change in relation to usual symptoms and signs, or iii. unrelieved by measures already prescribed requires a phone call to the provider.5. Monitor the resident's condition frequently until stable or transported to a higher level of care if needed. 6. Ensure the resident's condition is included on the 24-hour report to be reviewed later by the IDT. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.A nurse conducting a neurological assessment should systematically evaluate the patient's mental status, cranial nerves, motor function, sensory function, coordination, and reflexes. Key actions include assessing the level of consciousness, orientation, pupil reaction, muscle strength, gait, sensation, balance, and performing specific tests for coordination and reflexes.Example 1:R2 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinson's disease, muscle weakness, unsteady on feet, pyothorax without a fistula, pneumonitis, schizophrenia, and hypotension. R2's Minimum Data Set (MDS) assessment, dated 07/15/25, identified R2 required assistance from 1-2 people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and transfers. Surveyor reviewed R2's physician orders, which include:.-Monitor VS (vital signs) daily with special attention to blood pressure. -Continue IV antibiotics.-Reassess respiratory status and infection regularly.-Neurology consult.-Full Code. Surveyor reviewed R2's admission assessment, which states in part: On 07/10/25, R2 did not have any swallowing issues presently. Alert and oriented to time, place, and person. Breath sounds were clear bilaterally. Vital signs are stable. R2's vital signs: On 07/10/25 at 3:47 PM, blood pressure (BP) 126/80, heart rate (HR) 85, and respirations 20. Surveyor reviewed R2's progress notes from 07/10/25-07/18/25: -Nurse daily skilled observation note: On 07/10/25 at 9:00 PM, a daily nurse assessment was conducted, indicating that R2's respiratory status was even and regular, unlabored. R2's neuromuscular system had no issues. Progress notes from the Nurse Practitioner (NP): On 07/11/25 at 3:00 PM, NP visit today, the patient [R2] is seen lying in bed, appearing comfortable at rest. She is pleasant during the visit, providing only brief statements and yes or no responses. She tells me that she misses eating food, although she seems to understand the need for tube feeding due to dysphagia. She did experience nausea yesterday, and staff report that this seems to be relieved with as-needed Zofran. She is currently requiring supplemental O2 to maintain SpO2 greater than 90%. Vital signs have been stable, afebrile. There are no indications of increased shortness of breath, chest pain, fever, chills, diarrhea, constipation, dysuria or other urinary concerns. NP's physical examination: general- no acute distress, comfortable at rest. Respiratory- clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Neurological- cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. On 07/11/25 at 4:39 PM, Occupational Therapy (OT) worked with R2 on sit-to-stand. R2 completed sit to stand with moderate assist, limited standing tolerance, c/o (complaints of) dizziness and wanting to lie down, pivot transferred to bed. R2 is educated on the use of the call light for all transfers and needs. R2's response to session interventions is that R2 is fatigued and wants to return to bed to rest. Nurse daily skilled observation note: On 07/11/25 at 9:00 PM, Shortness of breath on exertion, Neuromuscular system none. R2's vital signs: On 07/12/25 at 10:11 AM, BP 119/55, HR 89, respirations 18. On 07/12/25 at 10:46 AM, the nurse contacted the provider on call and reported R2 on tube feeds/nothing by mouth (NPO). On Intravenous (IV) antibiotics. Currently, R2 is very congested. Sounds like R2 has fluid in her throat. Lungs, sounds diminished bilaterally with rales. BP 119/55; HR 91, and respirations 16. R2 is lethargic and weak. Portable x-ray is here in the building and is willing to get a chest x-ray. Would you be okay with this? Provider ordered yes to Chest x-ray. On 07/12/25 at 12:21 PM, OT performed Passive Range of Motion (PROM) on R2's upper extremities. 100% physical assistance is required due to compromised strength, technique, and muscle tone to facilitate muscle recruitment to enable increased participation in self-care tasks. Skilled interventions focused on building rapport and attempts at establishing communication techniques were unsuccessful. OT used visual tools to help improve patient communication with the writer, although R2 was not able to consistently demonstrate the ability to respond. R2's eyes were open and able to focus on the writer, but minimal to no verbal attempts were made by R2 to communicate. 0 attempts by R2 to point to yes/or no cards. R2 found with thick phlegm on the right side of her mouth. R2 was attempting to cough throughout the session but was never able to clear what was in her throat. OT discussed concerns with the Registered Nurse (RN); stated she would perform oral care with R2. Also confirmed that today, she was unable to successfully communicate with R2, and R2 appears more lethargic today than yesterday. Surveyor did not find a neurological assessment completed for R2. On 07/12/25 at 1:33 PM, the nurse contacted the provider on call and reported R2 has a history of Dysphagia/catatonia/drooling/cognitive disorder/psychosis/empyema of the right pleural space, and atrial fibrillation. Chest X-Ray results Anterior Anterior-posterior view right basilar opacity by 1 view. R2 is being treated for pneumonia on the right side. Vital Signs stable and afebrile, she appears to be at baseline with more fatigue today, yet she has been awake this past afternoon. Would you like to just monitor? Provider ordered to continue to monitor. Surveyor did not find a neurological assessment completed for R2. On 07/12/25 at 1:43 PM, RN C documents R2 had been fatigued today and at times appears she has difficulty swallowing her saliva. Mouth care has been provided frequently due to intermittent drooling and dry lips. Chest x-ray obtained per provider, notified history of fatigue and drooling, which was not reported yesterday on 07/11/25. No new orders, the provider would like staff to continue to monitor. Surveyor did not find a neurological assessment completed for R2. On 07/13/25 at 12:42 AM, late entry: On 07/12/25 at 11:30 PM, R2 was not able to pivot transfer assist of 2. Hoyer lift used. R2 had a large amount of foamy secretions. -12:45 AM, R2 had another small amount of foamy secretions, R2 coughing, lung sounds upon both assessments were clear in the left lobes and coarse in the right lobes (wet sounding). R2 opens eyes when spoken to. R2 is resting comfortably. NP notified via email and gave orders to continue to monitor. Vital signs: On 07/13/25 at 10:01 AM, BP 91/64, and HR 90. Nurse daily skilled observation note: On 07/13/25 at 3:00 PM, R2's respiratory status, with abnormal lung sounds (rales, rhonchi, wheezing). The neuromuscular system decreased movement/mobility, and R2 has paralysis/weakness. Summary: R2 has been resting quietly in bed most of the shift. No s/s (signs/symptoms) of pain or discomfort. Opens eyes and looks at the writer when speaking but does not answer questions.Surveyor did not find a comprehensive neurological assessment completed for R2 when R2 was exhibiting decreased movement/mobility and had paralysis and weakness. Daily skilled observation:On 07/13/25 at 5:00 PM, R2's neuromuscular system is paralysis/weakness.Surveyor did not find a neurological assessment completed for R2 when continuing to exhibit paralysis and weakness. On 07/14/25 at an unknown time in the morning, Physical Therapy (PT) was seeing R2 for therapy. R2 not able to respond verbally, not able to gesture, or make eye movement. PT deferred. Surveyor did not find a neurological assessment completed for R2. Vital signs: On 07/14/25 at 1:41 PM, BP 100/57, HR 70, and respirations 16. On 07/14/25 at 1:52 PM, R2 has been unresponsive all morning. Mouth care is provided frequently. Drooling at times. R2 diaphoretic. Lung sounds diminished with crackles bilaterally. Sounds as though R2 has fluid in the throat. NP came to assess the resident. Orders to send to Emergency Department (ED) for unresponsiveness, diaphoresis, and crackles bilaterally. Surveyor did not find a neurological assessment completed for R2. On 07/14/25 at 2:50 PM, the hospital report from ED states R2 arrived by Emergency Medical Services (EMS) with fever and was non-communicative. R2 had a head Computerized Tomography (CT) scan that revealed diffuse middle cerebral artery Cerebral Vascular Accident (CVA).Telephone call received from Radiologist with final report on CT. The patient has a diffuse MCA cerebrovascular accident. Nursing staff contacted the skilled nursing facility, and the last reported normal was this past Friday, 07/11/25, post-discharge from the hospital. The patient is normally speaking and doing some swallowing independently. Currently obtunded, making gurgling noises, respirations. The head of the bed is up at 45 degrees. Chest x-ray pending, maintaining airway at present. On 07/21/25, while R2 was in the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator. R2 changed code status in hospital to Do Not Resuscitate (DNR) and palliative care. On 08/05/25 at 12:21 PM, Surveyor tried calling NP that was covering R2's care at the time and ordered Continue to monitor when nurses reported R2's symptoms. Surveyor was informed that the NP resigned and went to a different job a couple of weeks ago. On 08/05/25 at 12:32 PM, Surveyor called MD D and had to leave a message for a return call. On 08/05/25 at 12:52 PM, Surveyor interviewed RN H and asked RN H how R2 presented to RN H the times RN H cared for R2 in the facility. RN H reported that RN H was not familiar with R2 as RN H took care of R2 for the first time on RN H's shift 07/12/25. RN H reported to Surveyor that RN H thought the nonverbal communication and not moving in bed was R2's baseline. RN H reported that the day before, the provider was notified and advised to continue to monitor. Surveyor asked RN H what continuing to monitor means. RN H stated to Surveyor, I am not entirely sure, but it just means monitor [R2] further for further decline from [R2's] baseline. Surveyor asked RN H how RN H knew what R2's baseline was. RN H stated, I thought what I was seeing was [R2's] baseline, so I just continued to monitor. On 08/05/25 at 1:08 PM, Surveyor interviewed RN C and asked how R2 was during R2's care when RN C worked with R2. RN C reported that on 07/12/25, R2 could nod yes and no, and RN C thought it was R2's baseline not to talk but R2 could not transfer with staff as well. RN C called a Certified Nurse Assistant (CNA) in who had worked with R2 the previous night before and the CNA reported that it was not R2's baseline and that R2 was transferring with the assistance of 2 with a stand pivot. RN C had to grab the Hoyer lift and assist aides with transferring R2. Surveyor asked RN C how RN C would know what R2's baseline is. RN C reported to Surveyor that RN C usually comes on shift and looks at the admission assessment and then knows what is normal or not for residents. Surveyor asked if RN C reviewed R2's admission assessment to depict if this was R2's baseline. RN C reported to Surveyor that RN C did not review the admission baseline for R2. RN C stated, I just assumed it was her baseline being non-communicative and barely moving. I should have done a thorough exam of [R2] for possible concerns. On 08/05/25 at 1:52 PM, Surveyor interviewed hospital RN E and asked RN E how R2 presented to the ED. RN E reported that R2 was very unkempt looking and was non-verbal. RN E reported that RN E did not know what R2's baseline was, but through further assessment, found that R2 could not lift or move the right side of the body. RN E immediately activated the stroke protocol, and a CT scan was performed, showing a large stroke affecting the right side of R2's body. RN E reported that when RN E called the facility to try and grasp when the last well-known date and time was, a staff member from the facility stated, [R2] has not been well since Friday the 11th and could not use the right side. RN E then reported this to the hospital physician right away. Surveyor asked RN E if RN E remembered the staff member who gave the report, and RN E stated, I do not. RN E reported that R2 also presented to the ED with a fever and hypotension. On 08/05/25 at 2:01 PM, Surveyor interviewed RN I and asked RN I how R2 presented on 07/11/25. RN I reported to Surveyor that tube feedings went well and R2 seemed to be quiet but ok. RN I just thought that R2 was at R2's baseline, but RN I did not review what R2's baseline was, so unsure if R2's state was normal for R2. On 08/06/25 at 9:03 AM, Surveyor interviewed Rehab Director (RD) F and asked if R2 was provided PT services or an evaluation of care during R2's stay. RD F reported to Surveyor that R2 was evaluated on Friday, 07/11/25, and RD F worked with R2 personally by assisting R2 with sitting on the edge of the bed and sitting and standing. RD F reported that R2 could answer simple questions with short answers and yes or no answers. RD F reported that come Monday, 07/14/25 in the AM, unsure of time frame, R2 could not move her body or speak at all. R2 would not answer Certified Occupational Therapy Assistant (COTA)'s questions, and RD F deferred R2 for PT/OT services at this time. Surveyor asked RD F if PT Rehab Director F or COTA reported to any other staff of what COTA assessed while working with R2 during the PT session or reported this to anyone. RD F reported to Surveyor that RD F is unsure if COTA reported this to any staff members besides RD F unfortunately. On 08/06/25 at 9:30 AM, Surveyor interviewed MD D, who reported not knowing who R2 was as MD D has been out on medical leave and the NP was following. Surveyor asked MD D if any nurses report to the provider or NP a decline in cognition, mobility, and communication, what would be the expectation from the provider on call for nursing staff to do. MD D stated that nursing staff should already have a neurological assessment completed and be calling the provider with this information. MD D would immediately order that the resident be sent to the ED with a decline in cognition, mobility, and communication. MD D stated that a neurological assessment is going to show Glasgow Coma Scale (GCS)s, Range of Motion (ROM) for all extremities, vitals, and much more to see what is going on. MD D stated, I would have ordered [R2] to immediately be sent out to the ED. On 08/06/25 at 10:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could explain R2's disposition at the facility on admission and then through the 4-day stay in the facility. DON B reported to Surveyor that DON B was in R2's room on Friday, 07/11/25, in the morning, sometimes to fix R2's television. DON B spoke with R2, and R2 answered questions, yes and no, but was a little slower in answering questions. R2 had trouble with word finding with yes and no, but R2 was comfortably lying in bed when DON B saw R2 at that time. DON B reported that RN C was providing care for R2 on Friday, 07/11/25, Saturday, 07/12/25, and Monday, 07/14/25. DON B reviewed RN C's progress notes and RN C noted lung sound changes in R2, called the provider got an order for chest x-ray. DON B reported that RN C didn't notice a change other than lung sounds in R2. Licensed Practical Nurse (LPN) G had R2 on Sunday, 07/13/25, and DON B spoke with LPN G about R2, and it was LPN G's first time working with R2. DON B reported that LPN G was able to give tube feedings to R2 with no issues, and R2 was able to track with eyes. LPN G reported to DON B that LPN G did not notice anything out of the ordinary for R2 at that time. LPN G reported to DON B that LPN G stated that LPN G thought R2 was at her baseline. DON B stated that RN C spoke with NP Monday, 07/14/25, as soon as R2 had more secretions, and during tube feeding at around 11 AM, RN C assessed residual was greater than 100ml before starting the tube feeding. NP assessed R2 while onsite, and determination was made for R2 to be sent out right away to the ED. Surveyor reported to DON B the findings of lack of nurse neurological assessments on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM, and 11:30 PM. Also, on 07/13/25 at 3 PM and 5 PM. Then on 07/14/25 in the morning, OT was working with R2 and could not due to a decline, as well as a nurse assessment of unresponsiveness on 07/14/25 at 1:52 PM. DON B reported that staff should have assessed R2 more when R2's cognition, mobility, and verbal communication diminished, and staff did not. The failure to conduct neurological/comprehensive assessments and provide immediate care and treatment prevented staff from timely recognizing a significant condition change and from timely contacting the physician, thus delaying treatment. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy which began on 07/12/25. The facility removed the immediate jeopardy on 08/06/25; however, the deficient practice continues at a scope/severity level of G (actual harm/isolated) as the facility continues to implement the following removal plan and as evidenced by example 2 for R1:1. In house residents were assessed by Registered Nurse or designee including head to toe assessment using E-interact head to toe and review of skin assessment in last week to ensure residents experiencing a change in condition have complete assessment. Any changes from baseline will be reported to Primary care physician. This assessment will be completed by 8/6/25. 2. The DON initiated re-education with Licensed Nurses on change of condition policy including interact change of condition Sbar documentation to ensure thorough assessment of resident & primary care physician notification as appropriate. Licensed nurses will utilize interact 5.1 tool as guidance to determine change of condition and document in resident's medical record.3. On 8/6/2025, the DON VP of success and Executive Director reviewed facility established policies and guideline including Change in condition Primary Care Provider notification E-interact 4.5 guidelines (MD notification)*Policies and guidelines remain appropriate4. DON/designee to complete audits of nursing documentation and provider notification daily x 2 weeks. This audit will include ensuring accurate and thorough assessment of resident. After the initial audit period, audits will continue 5x week for 6 weeks. Ad Hoc QAPI held on 08/06/25, with Director of Nursing, Executive Director, VP of Success to review recovery plan. 5. Results of audits to be brought to monthly QAPI meeting for further review and recommendations.The deficient practice continues at a scope/severity of G (harm/isolated), based on the following example:Example 2:R1 was admitted to the facility on [DATE] with diagnoses including, in part, type 2 diabetes mellitus, urinary tract infection, poor hygiene, hypoxia, and hypotension. R1's Minimum Data Set (MDS) assessment, dated 07/13/25, identified R1 required substantial assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, hygiene, and transfers. Surveyor reviewed R1's physician orders, which include: .-On 07/08/25, indicate level of pain using pain scale two times a day.-Catheter care every morning and at bedtime. -Cath care as needed. -Change catheter as needed for infection, obstruction, or leakage.- Urology follow-up appointment recommended - serial ureteral stent monitoring.-Monitor urine output. R1's pain documentation:On 07/08/25, R1 rated pain of 0/10. Surveyor found no other pain rating until 07/15/25 when R1 was back from the hospital. Surveyor reviewed R1's progress notes dated 07/08/25-07/16/25, which state in part:On 07/08/25, R1 was admitted to facility with no skin issues or respiratory issues. On 07/09/25 at 2:51 AM, nurse documented no musculoskeletal issues. On 07/09/25 at 2:30 PM, NP visit today, Patient [R1] seen seated in wheelchair, appears comfortable at rest. He is very hard of hearing and demonstrates poor memory recall, and he tells me more than once, I have no idea what in the hell is going on. Staff report that he has been requiring EZ stand for transfers due to significant weakness and unpredictability during transfers. He continues to experience hematuria, although he denies pain or discomfort in the bladder or urethra. Appetite has been fair, and staff assist him with meals as needed. Patient [R1] denies increased shortness of breath, chest pain, fever, chills, nausea, diarrhea, constipation, flank or suprapubic pain. Physical Examination: General frail appearing, no acute distress, comfortable at rest. Respiratory-clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Skin- warm and dry, no apparent rash or suspicious lesions on exposed skin. Neurological-cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. Psychiatric alert, oriented to person, poor memory, impaired insight and judgement, underlying dementia. On 07/11/25 at 2:30 PM, NP progress note states R1 is seen lying in bed, appears comfortable. He continues to experience hematuria, although he denies pain or discomfort in the bladder or urethra, and urine is now pink-tinged. Appetite has been fair, and staff assist him with meals as needed. Staff report that the patient has been combative with cares, sometimes swinging at nursing staff. Will place referral to psych NP. Physical Examination: General frail appearing, no acute distress, comfortable at rest. Respiratory-clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Skin- warm and dry, no apparent rash or suspicious lesions on exposed skin. Neurological-cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. Psychiatric alert, oriented to person, poor memory, impaired insight and judgement, underlying dementia. R1combative with cares, sometimes swinging at nursing staff. On 07/12/25 at 3:31 AM, the nurse documented skin turgor: normal, neuromuscular: none of the above. musculoskeletal: none of the above. On 07/13/25 at 12:10 PM, the nurse documented R1 had refused to get up for lunch. Staff stated they tried multiple times to see if R1 wanted to have some lunch and the resident refused. Nurse checked on R1and R1 got angry and stated that he did not want to eat lunch either. Will reapproach R1 later and see if he would like a snack later. On 07/13/25 at 4:43 PM, the nurse notified provider of R1's blood sugar of 270 and R1 having behaviors and refusing to eat lunch, stating he was not hungry. No assessment completed.On 07/13/25 at 5:54 PM, the nurse documented R1's penis reddened, discharge noted from tip of penis. |Surveyor could not find treatment for the assessment of R1's tip of penis being reddened and having discharge. Surveyor could not find a pain assessment completed for R1. Nurse did not complete a comprehensive assessment to include vital signs, to assess for signs of infection.On 07/13/25 at 10:14 PM, the nurse documented R1's penis reddened, and discharge noted from tip of penis. On 07/13/25 at 11:00 PM, the nurse notified provider of R1's redness around the base of the glans penis. R1's foreskin is retractable and resident yells it hurts when area is cleansed. Purulent drainage noted from ureteral meatus and urine is dark. No assessment completed. On 07/13/25 at 11:01 PM, R1 is noted to have redness around the base of the glans penis. R1's foreskin is non-retractable, and the resident yells out and states it hurts when the area is cleansed. Purulent drainage is noted from the urethral meatus. Area gently cleansed. Foley patent and draining. Urine is dark in color. No assessment completed. On 07/14/25 at 7:24 AM, provider reported to nurse that NP will see R1 today. There is concern for compartmental syndrome. On 07/14/25 at 8:00 AM, a change in condition form was completed for altered mental status, behavioral symptoms, decrease in food intake, and functional decline. Unresponsiveness. And hypoxia. Surveyor found that no comprehensive assessment was completed by nurses before R1 was transferred to the hospital on 7/14/25. On 07/14/25 at 9:35 AM, R1 left the facility via ambulance to ED for further evaluation. On 07/16/25 at 12:00 PM, NP progress note: History of Present IllnessR1 is an [AGE] year-old male, is being seen today for initial SNF evaluation following a recent hospitalization and emergency department visit on 07/14/2025. R1 was sent to the ED two days ago due to altered level of consciousness, genital swelling with nonretractable foreskin, and poor oral intake. At that time, he was unresponsive to questions and sternal rub, which represented a marked decrease in his level of consciousness from previous visits. Examination had revealed paraphimosis with erythema, crusting, edema, and purulent drainage from the urethra.Following the ED visit, R1 was admitted to the hospital on [DATE] for UTI, transient hypotension, and decreased oxygen level. R1 returned to facility and on 8/6/25 was back to baseline.On 08/06/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor reported a timeline through record review of R1's care before R1 was transferred to the hospital on [DATE]. Surveyor asked DON B what DON B's expectation is when the nurse found redness and drainage on R1's penis on 07/13/25 at 5:54 PM. DON B reported that staff should have followed the facility's change in condition policy and felt the nurse should have reported the finding immediately to the provider on call so that R1 could receive treatment instead of waiting hours later.