-The following was also cited under F689 at a lower severity. The facility also failed to ensure aerosols, medications, perfumes, and creams were not easily accessible to a resident to prevent accidental exposure for the 15 residents on the 100 Hall and 1 (Resident #93) of 8 sampled residents. 2. A review of the facility policy titled, Accident Hazards Prevention, stated, Resident Environment. The environment will be free from accident hazards as is possible; 3. Engages all staff, residents and families in training on safety, and promotes ongoing discussions about safety with input from staff at all levels of the organization. a. On 02/04/2025 at 2:20 PM, during a concurrent observation and interview, Certified Nursing Assistant (CNA #12) was observed by Surveyor picking up a clear plastic bag and putting it back on the counter, wheelchair height, at the 100 Hall nurses station leaving it easily accessible to residents. CNA #12 stated, [Resident #19] could come up here, grab this bag and take off down the hall with it. CNA #12 then took the trash and linen in barrels down the hall leaving the bag unattended. Resident #19 is observed wandering up and down the hallway. Surveyor observed that the clear plastic bag with a lighter and keys on the outside of it hanging off of one of the black handles, inside the bag was a medication bottle, a lighter, creams, alcohol sprays, and perfumes were observed. b. On 02/04/2025 at 2:27 PM, CNA #12 stated that the inside of the bag contained, [Name Brand] antibiotic ointment, alcohol spray, perfume, a lighter, Ibuprofen, and aerosol deodorant spray. CNA #12 stated that the bag was easily accessible to residents who wander up and down the hall, should have been stored out of reach and behind a door to keep residents out of it. CNA #12 continued stating that the items were hazardous to the residents, and they could drink something, or injure themselves with the contents in the bag. LPN #14 stated that hazardous materials should be kept out of reach of the residents. c. On 02/06/2025 at 8:09 AM, during an interview the Director of Nursing (DON) stated that hazardous items such as perfumes, medications, and aerosol sprays should not be left out unattended and easily accessible by residents. The DON stated that a resident could get injured if items are left out unattended. Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #25) of 4 sampled residents reviewed for neglect received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure 2 staff members transferred Resident #25 using the appropriate lift based on Resident #25's needs and care plan which resulted in Resident #25 sustaining a dislocated right shoulder. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 12/18/2024 at approximately 8:45 AM. While CNA #1 was transferring Resident #25, the resident began to complain of pain in their right arm. CNA #1 called for help and CNA #10 came into the room and assisted CNA #1 with transferring Resident #25 into the wheelchair. CNA #1 notified Registered Nurse (RN) #11 that Resident #25 was complaining of pain. RN #11 assessed the resident and noted the resident was still complaining of pain in the right shoulder. RN#11 notified the Nurse Practitioner and received an order for pain medication and an order to get a mobile x-ray due to the continued compliant of pain. The mobile x-ray company arrived at the facility around 10:16 AM and completed the x-ray. The Medical Director was at the facility when the results of the x-ray were received. The Medical Director gave an order to RN#11 for the resident to be sent to the emergency room (ER) for evaluation due to the results of the x-ray and continued complaints of pain. The ambulance arrived at the facility around 10:53AM and transported Resident #25 to the ER. At approximately 11:15 AM RN#11 received notification from the ER that Resident #25's right shoulder was dislocated. The Administrator was notified of the Past Noncompliance Immediate Jeopardy (IJ) on 2/6/2025 at 12:40PM. The facility implemented corrective actions which were completed prior to the State Agency's entry into the facility; thus, it was determined to be a Past Noncompliance citation. The facility had implemented the following corrective actions to correct the deficient practice effective 12/30/2024: 1. 12/19/2024, all residents re-assessed for transfer status by DON (Director of Nursing). Start date:12/19/2024. Completion date:12/30/2024. Comments: facility staff reviewed ADL/Transfer report to ensure all residents have appropriate transfer status documented. a. 02/06/2025- Facility provided evidence of all residents being re-assessed for transfer status prior to survey. 2. 12/19/2024, All care plans reviewed by DON and updated as needed to ensure accuracy. Start date: 12/29/2024 Completion date: 12/27/2024. Comments: Care Plans reviewed by MDS coordinator are ongoing. a. 02/06/2025- Care plans were updated and the facility provided evidence of in services on following the individual care plans. 3. 12/19/2024, an in service for all clinical staff started by the DON on following the individual care plan for transfer status and how to use the kiosk. Start date: 12/19/2024 Completion date: 12/26/2024. Comments: in services in progress. a. 02/06/2025- Facility provided evidence of in services on following the individual care plans. 4. 12/19/2024, the DON/designee began staff transfer/lift competency check off. Start date: 12/19/2024. Completion date: 12/26/2024. a. 02/06/2025- Facility provided evidence of staff transfer/lift competency check offs. 5. 12/19/2024, the DON/designee started monitoring transfers of 5 residents twice a week for 4 weeks to ensure transfers are being completed correctly and safely. Start date: 12/19/2024. Completion date: ongoing. a. 02/06/2025-Facility provided evidence of monitoring transfers of 5 residents twice a week. The findings are: 1. Review of a facility's undated policy titled Accident Hazards Prevention indicated, Residents will receive adequate supervision and assistance devices to prevent accidents. The resident will be assessed upon admission and through the Minimum Data Set (MDS) process to individualize care plan interventions. a. A review of Resident #25's admission Record revealed the resident was admitted to the facility with a diagnosis of a stroke. b. A review of Resident #25's quarterly MDS with an Assessment Reference Date (ARD) of 12/04/2024, revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3, (0-7 indicates severe cognitive impairment). c. Review of Resident #25's Care Plan, updated 10/2/2024, revealed the resident was to be transferred with a mechanical lift with two staff assisting. d. Review of a facility incident report dated 12/19/2024 indicated Certified Nursing Assistant (CNA) #1 was transferring Resident #25 and failed to use the correct lift and proper amount of assistance (number of staff), causing the resident ' s right shoulder to be dislocated. e. A review of the hospital Summary Episode Note, dated 12/29/205, revealed in the section Imaging Narrative Note identified the significant finding was that Resident #25's right shoulder was dislocated f. During an interview on 2/5/2025 at 12:20 PM, CNA #10 stated she remembered the incident. She was asked to describe what happened. She stated when she heard CNA #1 calling for help, so she went to help. CNA #10 stated CNA #1 had the sit-to-stand lift instead of the mechanical lift that was supposed to be used for Resident #25 and that CNA#1 did not have another employee assisting. CNA #10 said the resident was sliding to the floor, so CNA #1 and CNA #10 lowered Resident #25 to the floor to prevent the resident from falling. CNA #10 stated they (CNA #1 and CNA #10) lifted the resident by sliding their arms under the resident's arms and holding on to the back of the resident's pants. CNA #10 stated they (CNA #1 and CNA #11) sat the resident into the wheelchair. CNA #10 was asked how she knew which lift and how many people Resident #25 required for transfers. CNA #10 said the care plan identifies which lift and how many people are required to assist. g. During an interview with RN #11 on 2/5/2025 at 1:00 PM, she said she remembered the incident of Resident #25's shoulder being injured. She was asked to describe what happened. RN #11 said that on 12/19/2025 she heard Resident #25 hollering out due to pain. She stated after she assessed Resident #25, notified the Nurse Practitioner, received an order to get a mobile x-ray, and that the x-ray results revealed that Resident #25's right shoulder was dislocated. She said the Medical Director was at the facility and gave an order for Resident to be sent to the ER for evaluation of right shoulder pain. RN #11 was asked how CNAs would know which lift to use and how many people Resident #25 required the assistance of for transfers. RN #11 stated the care plan for Resident #25 identifies what kind of lift and how many people are required for a safe transfer. h. During an interview with the DON on 2/6/2025 at 10:45 AM, she confirmed the residents' care plans identified which type of lift is required and how many people are required for a safe transfer. The DON also confirmed that CNA #1 did not read the care plan and did not utilize the correct lift and the correct amount of people. The DON stated this failed practice resulted in an injury to Resident #25's right shoulder. i. During an interview with the Administrator on 2/6/2025 at 11:10 AM regarding Resident #25, she confirmed that CNA #1 did not read the care plan and did not utilize the correct lift and the correct amount of people. The Administrator stated this failed practice resulted in an injury to Resident #25's right shoulder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #105: Resident #105 had diagnoses of Chronic inflammatory demyelinating polyneuropathy (a neurological disorder that involves progressive weakness and reduced senses in the arms and legs) and Chronic pain. The 5-Day MDS with an ARD of [DATE] documented Resident #105 scored 15 (13-15 indicates cognitively intact) on a BIMS and that Resident #105 received antidepressants, pain medications, and blood thinner medications during the 7 day lookback period and had no potential clinically significant medication issues identified during the drug regimen review. On [DATE] at 09:48 AM, Resident #105 reported that the resident had been waiting for a transfusion that the resident receives every month but has not received it at this time. Resident #105 had been told since December the facility was trying to figure out who would be responsible for it. Resident #105 stated the medication cost like $1,000.00 so the resident was wondering if that was the reason. On [DATE] at 10:15 AM, Resident #105 reported last year when he/she was here it was an issue then as well, and the resident paid for it themself. There is a transfusion nurse waiting for the medication to arrive so she can transfuse it. The medication was identified as intravenous immunoglobulin (IVIg), which is a biological agent used to manage various immunodeficiency, autoimmune, infectious, and inflammatory states. On [DATE] at 08:45 AM, the DON was asked if she was aware of the medication IVIG for Resident #105. The DON answered, yes and the Advance Nurse Practitioner was checking on it yesterday. On [DATE] at 10:34 AM, during a phone interview the Infusion Nurse confirmed the delay and was waiting on a return call from the regional manager to confirm orders from the pharmacy and confirm the medication is effective in Resident #105's treatment. On [DATE] at 02:05 PM, Resident #105 stated to the Surveyor, This is why I need the medication. The Surveyor asked resident on a scale from 1-10 how would you rate your pain, and Resident #105 stated, A nine out of ten. On [DATE] at 03:48 PM, in a phone conversation the APRN confirmed awareness of the needed medication. The APRN reported they have been trying to figure out the process to get this medication and is working with the facility to coordinate with the pharmacy on the correct protocol. Based on record review and interview, the facility failed to fully assess a resident experiencing respiratory distress in a timely manner, failed to follow physician's order during an acute incident which resulted in a change of condition, and failed to notify the physician of the change in condition in a timely manner for 1 (Resident #368) of 3 sampled residents reviewed for a change in condition. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE] at 07:33 pm, when Resident #368 was in respiratory distress and was not fully assessed which resulted in the resident being sent to a local hospital and expired before arriving at the hospital. The Administrator was notified of the IJ on [DATE] at 01:26 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 11:36 AM. The IJ was removed on [DATE] at 11:00 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F684 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy. The facility also failed to ensure medications received at home were continued after admission to the facility for 1 (Resident #105) sampled resident. The findings are: 1. Resident #368: A review of the Order Summary Report, indicated the facility admitted Resident #368 with diagnoses that included a history of stroke, atrial fibrillation (an irregular heart rhythm), pulmonary hypertension (high blood pressure that affects the lungs and heart), high blood pressure, seizures, cognitive communication deficit, adult failure to thrive, anxiety, and pulmonary edema (when fluid accumulates in lung and can cause shortness of breath, wheezing and coughing up blood). The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #368 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. a. Review of Progress Notes by Licensed Practical Nurse (LPN) #1 dated [DATE] at 07:33 PM revealed Resident #368 was having difficulty breathing and LPN #1 started a breathing treatment per standing order of facility. Resident #368's pulse oximetry (a noninvasive method of measuring the saturation of oxygen in a person's blood) was 33% during the breathing treatment. Resident #368's family member informed LPN #1 that the family member was going to call Emergency Medical Services (EMS). LPN #1 indicated the supervisor and LPN #1 attempted sternal rubs but Resident #368 became increasingly unresponsive. LPN #1 indicated Resident #368's hands and feet had mottled (occurs when blood flow has been disrupted, resulting in a blue-red discoloration of the skin) and the resident's lips were increasingly blue. LPN #1 indicated EMS arrived at the facility at 7:47 PM and EMS and the resident's family member were notified that Resident #368 had a Do Not Resuscitate (DNR) order. LPN #1 indicated that cardiopulmonary resuscitation (CPR) had been initiated but did not indicate by whom, while the resident was in respiratory distress. LPN #1 indicated Resident #368's eyes were unresponsive to light and the resident did not respond to their name being called. LPN #1 indicated EMS transferred Resident #368 to the local hospital at 07:57 PM. b. Review of a narrative received from Emergency Medical Service (EMS) dated [DATE] documented, .responded emergent to [facility] gave conflicting down times, approximately 15 minutes, non-witnessed, EMS initiated CPR . EMS obtained DNR order from [facility] Nursing Staff. EMS initiated ventilation with bag valve mask .EMS discontinued CPR at this time. EMS placed definition pads onto patient, showing Asystole .EMS is transporting the patient to local emergency department . c. Review of Emergency Department [ED] Provider Notes created on [DATE] at 07:45 PM by an emergency room physician indicated the physician received a call from the nursing home facility that a resident was in route to the hospital but had a DNR order. The physician met the resident in the ambulance bay at the hospital and evaluated the resident to be cold and stiff to touch and the resident's pupils were fixed and dilated. The physician also indicated there were no signs of trauma, no spontaneous respirations, no spontaneous cardiac movement, no radial or carotid pulses on either side. An EKG, which measures the hearts electrical activity, had been completed and indicated the resident's heart had stopped and the time of death was 07:38 PM. The final diagnosis within the ED Provider Notes indicated cardiac arrest (heart attack). d. Review of Grievance Form dated [DATE] documented Resident #368's family member reported Resident #368 called the family member and reported the resident was short of breath (SOB). Resident #368 told the family member (the resident) had gone to therapy and was in the resident's room and was experiencing SOB. The family member advised the resident that therapy may have made the resident tired and to lay down and rest. The family member told the resident that they would call back in approximately 10 minutes. When the family member called back, the resident stated they felt worse. The family member drove to the facility to check on the resident. The family member did not see a nurse and asked a CNA (Certified Nursing Assistant) to go get a nurse. The family member asked LPN #1 what the resident's oxygen saturation was, and LPN #1 stated she didn't know. LPN #1 went and got a breathing treatment to give to the resident and the resident became worse as it was being administered. The family member was upset with the resident's condition and stated they were going to call 911. The family member complained to the ADON (Assistant Director of Nurse) that LPN #1 had been rude with the family member and the family was upset with the rudeness and Resident #368's condition. Emergency Medical Service arrived and transported the resident to a local hospital. The form indicated the ADON resolved the grievance by talking to LPN #1. There was no indication of what was discussed between the ADON and LPN #1. A comment at the end of the form indicated that Resident #368 expired, and the family member came back to the facility to remove the resident's belongings. e. A review of Resident #368's electronic health record, including physician's orders did not indicate the resident had a physician's order for oxygen or a breathing treatment as indicated in LPN #1's progress note on [DATE] at 07:33 PM. A review of Standing Orders revised on [DATE], revealed a physician's order to administer oxygen 2-3 L/NC [liters/nasal cannula] as needed SOB [shortness of breath], notify MD [medical doctor] IMMEDIATELY if patient suddenly requires supplemental oxygen. This is a change in condition and abnormal vital sign that requires immediate attention. Further review of the standing orders indicated if a resident was short of breath or had a pulse oximetry of less than 90%, to provide 2 to 4 liters of oxygen per nasal canula as needed. A review of Physical Therapy Treatment Encounter Note(s) with a date of service as [DATE] indicated therapy services were provided to Resident #368. f. During a telephone interview on [DATE] at 08:45 AM, Registered Nurse (RN) #1 stated they were familiar with Resident #368. RN #1 stated they were on duty the evening that Resident #368 went into respiratory distress. RN #1 stated that around 05:00 PM on the night of the incident, a CNA notified her that a family member wanted a resident sent to the hospital due to severe respiratory distress. RN #1 stated, she was told the resident was in severe respiratory distress and the resident was walking down the hall with the family member. RN #1 stated, when she got to the resident's room, the resident was in severe respiratory distress and barely breathing and the family member had already called 911. RN #1 stated, a CNA got a crash cart, and RN #1 got an Ambu bag, (which is used to provide respiratory support to patients), and then the ambulance arrived. RN #1 stated the resident was a DNR and they did not start CPR, however, EMS started CPR but not in facility. RN #1 stated she did not see CPR performed. RN# 1 stated, she was in the room about 5 minutes before the ambulance arrived. RN #1 stated she did not document the event anywhere at all, let the floor nurse (LPN #1) do the documenting, and stated she probably should have. RN #1 stated, as a supervisor she did not review the nurse's notes until a week later. RN #1 stated nurses are trained to do a complete assessment of a resident depending on whether the resident is receiving skilled services. RN #1 stated if a resident had an oxygen saturation of 33%, she would call an ambulance. RN #1 stated Resident #368 was a fairly new resident, and never had any issues before. g. On [DATE] at 10:15 AM, the DON and Administrator were interviewed about completing an investigation for Resident #368. The DON stated she was not aware of an investigation. At this time the DON reviewed LPN #1's documentation on Resident #368, and she did not see anything different that should have been done and she did not have any concerns. The DON stated she did not see any procedures not followed. The DON was asked what nursing staff should do if a resident had an oxygen saturation of 33%, and the DON did not answer. The Administrator responded and stated she would call an ambulance. The Administrator stated since LPN #1 was no longer employed at the facility, she could not give the Surveyor LPN #1's phone number but stated that she would call LPN #1 and ask LPN #1 to contact Surveyor. The Administrator returned and stated she called the numbers listed in LPN #1's personnel chart with no answer and a message was left to call the Surveyor. The Surveyor was not contacted by LPN #1. h. On [DATE] at 11:59 AM, the Surveyor received a text message from Resident #368's family member stating the family member wanted to know why the facility thought giving a heart patient a breathing treatment was a good idea and wanted to know who ordered the breathing treatment to be given to the resident and why facility staff did not check Resident #368's oxygen level when the family member was at the facility when Resident #368 was having difficulty breathing. The family member also asked why no facility staff had a stethoscope with them to listen to the resident's heart or check the resident's blood pressure. The family member stated there was nothing done by facility staff to help Resident #368 other than telling the family member to elevate Resident #368's bed and facility staff providing the breathing treatment which took Resident #368's life. The family member stated the facility had no sense of urgency and the family member felt dismissed. i. On [DATE] at 03:05 PM, CNA #1 stated she was familiar with Resident #368. CNA #1 stated around 05:30 PM on the night of the incident, Resident #368's call light came on. The resident's family member stated the resident was having trouble breathing and asked if she could get a nurse. CNA #1 stated she notified LPN #1 who then went to the resident's room. CNA #1 stated she went back to the dining room and did not know what happened afterwards. j. On [DATE] at 08:54 PM, the family member called the Surveyor to explain more of the scenario of the night in question. The Surveyor asked the family member if CPR was ever started while the family was in the facility. The family member stated no, the CNA came out in the hall and asked the family member about the DNR status because the nurse asked the family member to leave the resident's room. The family member stated they called 911 around 06:30 PM. The family member stated they filed a grievance about what happened with the facility after the resident's death. The family member stated before the resident received the breathing treatment the resident was able to talk but the facility never applied oxygen on the resident or took vital signs. The family member stated the resident was short of breath but was talking and wanted to go for a walk; the resident thought that might help. The family member stated they walked by the nurse's station, and the family member asked LPN #1 who was at the nurse's station what Resident #368's oxygen levels were. The family member stated LPN #1 said the oxygen was at 98% 20 minutes ago. The family member stated the resident was given 2 breathing treatments. The family member stated the first breathing treatment wasn't given correctly because the breathing treatment machine wouldn't work, and LPN #1 left to get another machine. There was no urgency from facility staff. k. On [DATE] at 08:02 AM, the Social Director (SD) stated the grievance process starts when a facility staff member completes a grievance and turns it into the SD, who then was responsible for inputting the grievance into the computer system. The SD stated a grievance date indicates the date the grievance was reported. The SD reviewed the grievance associated with Resident #368 that occurred on [DATE] and stated the weekend RN (RN #1) who was the Supervisor was the staff member who took the grievance. l. On [DATE] at 10:45 AM, The Occupational Therapist (OT) stated therapy sessions are not usually provided on the weekends but if a resident missed a session during the week, it would be made up either in the evening or on weekends. The OT stated therapy is provided Monday through Friday, with skilled residents receiving therapy 5 times a week. The OT stated if a resident started having shortness of breath or fatigue during therapy OT check the resident's vitals and would document it especially if the resident had a diagnosis of something like COPD (Chronic Obstructive Pulmonary Disease). The OT stated she was familiar with Resident #368 and did not recall Resident #368 complaining of experiencing shortness of breath or fatigue during the therapy session on [DATE], but it would have been documented in resident's chart. m. On [DATE] at 11:30 AM, during a phone interview, the Medical Director stated he was not made aware of Resident #368's change in condition on [DATE]. The Medical Director stated the weekend tele-med services are on call with the APRN (Advanced Practiced Registered Nurse) or PA (Physician's Assistant) to do assessments over the phone and provide facilities with orders if needed. The Medical Director stated there are standing orders for something minor like [named brand of acetaminophen] or oxygen as needed for shortness of breath. The Medical Director stated if a resident needed to be assessed quickly, or if oxygen was needed, facility staff should notify the APRN or himself. The Medical Director stated a breathing treatment was not a standing order unless the resident already had an as needed order due to their condition and diagnosis. The Medical Director stated during the week, the APRN was at the facility Monday through Friday, 08:00 AM to 04:30 PM. If a resident had a change in condition, staff would contact the APRN first, then the APRN will contact me if needed. n. During the survey, 11 other facility staff members that had worked around the time of the incident were contacted to interview, however, the staff were either no longer employed, were on a leave of absence, or did not work with the resident. o. Removal Plan: 1. Notified on [DATE] at 01:53 PM by Surveyor that facility was receiving an IJ level deficiency for failure to properly assess a resident in respiratory distress, failure to follow physician's order during an acute incident, and failure to immediately notify a physician of a change in condition on [DATE]. 2. On [DATE] at 07:33 PM, documentation in medical record states Resident #368 experienced a change in condition involving respiratory distress. Documentation does not include proper assessment, following physician orders, or immediate notification to physician. 3. On [DATE] at 02:00 PM, the Minimum Data Set Nurse, Assistant Director of Nursing, Quality Assurance Nurse, and Social Worker Nurse immediately initiated assessments of all current residents for change in condition. Completed [DATE] at 04:50 PM with no negative findings. 4. On [DATE] at 02:00 PM, the Nurse Consultant immediately in-serviced the Director of Nursing on assessment with change of condition, following physician orders, notification of Medical Doctor/Provider for change in condition, and abuse and neglect. The Director of Nursing then immediately initiated in-service to all licensed nurses on duty on assessment with change in condition, following physician orders, notification of Medical Doctor/Provider for change in condition, and abuse and neglect. The Director of Nursing/Designee will in-service all oncoming licensed nurses at the beginning of their shift on assessment with change in condition, following physician orders, notification of Medical Doctor/Provider for change in condition and abuse and neglect. The Director of Nursing/Designee will in-service all oncoming Certified Nurses Aids at the beginning of their shift on change in condition and notifying nurse immediately. 5. On [DATE] at 02:00 PM, the facility immediately initiated a review of medical record documentation to identify changes of condition dating back to [DATE] to ensure residents with change in condition received proper assessment, physician orders were followed, and immediate notification of provider was made. 6. On [DATE] at 02:00 PM, once the facility was notified of the allegation of neglect, the Administrator immediately initiated a reportable to the Office of Long-Term Care for allegations of neglect. 7. On [DATE] at 03:15 PM, the Administrator initiated a report to the Arkansas State Board of Nursing for the nurse against whom the allegation of neglect was made. 8. On [DATE], the Administrator implemented procedures for the Minimum Data Set (MDS) Nurse, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Social Worker Nurse, and Weekend Registered Nurse Supervisor to review medical record documentation daily for change in condition, and if change in condition is noted will ensure proper assessment, immediate notification to provider and physician orders were followed. 9. On [DATE], the facility implemented procedures for Director of Nursing/Designee to complete clinical observation rounds daily on each resident to assess for change in condition and if change in condition is noted will ensure proper assessment, immediate notification to provider, and physician orders were followed . p. Onsite Verification: The IJ was removed on [DATE] at 11:00 AM, after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on [DATE] at 05:00 PM, when a review of assessments initiated on all current residents for 100, 200, 300 and 400 Halls by the MDS nurse, the ADON, the QA nurse and Social LPN were reviewed with no negative findings. A review of medical records dated [DATE] through [DATE] for each resident for change of condition was reviewed by the DON, QA nurse and Social Worker LPN, with no negative findings. A facility procedure was implemented for the DON/Designee to complete clinical observation rounds daily on each resident to assess for change in condition and if change in condition is noted will ensure proper assessment, immediate notification to provider, and physician orders were followed. A total of 14 staff interviews were conducted with staff from the day shift to verify training had been completed. The staff interviewed included 5 CNAs, 2 floor LPNs, 2 floor RNs, the MDS LPN, the Quality Assurance LPN, the Social LPN, the ADON and the DON. The staff interviewed verified in-services were provided on 1) Resident Rights, Dignity, 2) Nail Care, 3) Providing Perineal Care, 4) Hand Hygiene, 5) PPE use, 6) Assessing Residents for change in condition, 7) Reporting to Provider, 8) Following Physician Orders, 9) Routine PRN Standing Orders and 10) Abuse and Neglect. A review of the in-service sheets provided indicated 24 nurses of 25 listed had been provided with training and 50 CNAs of 56 listed had been provided training, (3 staff who were not physically present due to being on leave of absence (LOA).