**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's right to be free from neglect by failing to provide the necessary care and services to 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 was found on the floor by S3 LPN and complained of neck pain. Resident #1 was placed back into bed and S3 LPN failed to notify the Physician of Resident #1's fall and failed to medicate Resident #1 for complaints of pain. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and then complained of neck, back, and head pain at that time. Resident #1 was transported to the hospital on [DATE] at 7:40 a.m. and was diagnosed with a fracture of his C-4, C-5 and C-6. Pain medications that were ordered and available for Resident #1 were not administered.S1 Administrator was notified of the Immediate Jeopardy situation on 08/27/2025 at 2:45 p.m.This deficient practice continued at a potential for more than minimal harm for all residents in the facility that had the potential to fall or required the need for pain medications. The census was 89.Findings: On 08/25/2025, a review of the facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025, revealed in part., Definitions: (G). Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. On 08/25/2025, a review of the facility's policy titled Falls, with no revision date, revealed in part.Procedure: 3. Ascertain extent and type of injury.4. Make resident as comfortable as condition permits.5. Notify physician for further orders. Follow nursing interventions if required.6. Notify family or guardian.7. Document details in nurses' notes. (All shifts will complete a follow-up note for at least 72 hours.)8. Fill out incident/accident formReview of Resident #1's medical record revealed an admit date of 07/21/2025 with diagnoses that included in part.Heart Disease Unspecified, Dementia in other Diseases, Mood Disturbance, Anxiety and Type II Diabetes Mellitus. Review of Resident #1's Discharge MDS with an ARD of 07/26/2025 revealed a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #1's MDS revealed he required supervision or touching assistance with oral hygiene, personal hygiene; partial/moderate assistance with toileting hygiene, bathing and set-up or clean up assistance with eating. Resident #1 used a manual wheelchair for mobility had no impairments to upper/lower extremities. Review of Resident #1's care plan with a target date of 10/19/2025 revealed in part.1. Physical mobility impaired with interventions that included to assist with bed mobility, transfers, locomotion as necessary or requested, monitor for decline in mobility and notify physician of changes.2. Self-care deficit with interventions that included for resident to receive person-centered care; needs with assist with bathing, hygiene, dressing, and grooming.3. High Risk for falls related to Cerebrovascular Accident and Heart Disease with interventions that included turn bars on bed times two to assist with mobility, assist with transfers as needed, keep assistive devices in reach, keep bed in lowest position with wheels locked, and keep call light in reach. Review of an incident report dated 07/24/2025 at 4:30 a.m. by S4 LPN revealed in part .Nursing Description: This nurse was notified by CNA that resident was lying on the floor. As this nurse entered the room this nurse observed resident lying on the floor on his back between the bed and the air conditioner. Resident stated he didn't know what happened or how he got on the floor. No injuries noted anywhere to residents body upon full body assessment. Range of Motion within normal limits. Resident stated he was having some back, head and neck pain. Daughter notified of incident and transfer of resident to ER to be evaluated and treated. Immediate Action Taken: Full body assessment, Vital signs taken, pain assessment, assisted back into bed x 3 person assist to wait on ambulance to transfer to hospital. Level of Pain-10. Review of Resident #1's Medication Administration Record and Narcotic Log revealed no documentation of pain medicine administered on 07/24/2025. Review of Resident #1's nursing progress notes dated 07/24/2025 at 7:40 a.m. by S2 DON revealed in part.ambulance here to transport resident to the hospital per stretcher due to pain from fall. Nursing progress note dated 07/24/2025 at 1:20 p.m. revealed in part. report received from the hospital regarding resident. Nurse reports CT of the head clear but neck shows C-4 and C-5 fracture and resident will be coming back to the nursing home in a C-collar and to follow up with neurosurgery in 2 weeks. Family aware and has been at the hospital with resident. Review of Resident #1's x-ray dated 07/24/2025 revealed in part.CT of Cervical Spine without contrast. History: Neck pain, fall. Impression: Osteoporosis, mild anterior subluxation C4-C5 and prior anterior and posterior bony fusion C5-C7. Transverse fracture through the body of C5 with additional transverse fractures extending through the fused posterior elements of C5-C6 and this fracture configuration is felt to be unstable. Fractures through the posterior elements of C-4 non-displaced. Interview on 08/25/2025 at 2:00 p.m. with S2 DON revealed Resident #1 was at the facility for 5 days (07/21/2025 through 07/26/2025), on respite care. S2 DON revealed on 07/23/2025 Resident #1 was agitated and kept trying to get out of his wheelchair to ambulate. S2 DON revealed Resident #1 was becoming more difficult to handle. S2 DON stated on 07/24/2024 at 4:30 a.m. Resident #1 was heard hollering by S5 CNA and was found in his room on the floor. S5 CNA stayed with Resident #1 while S6 CNA summoned S3 LPN and S4 LPN. Resident #1 complained of head and neck pain and was sent to the hospital for evaluation. S2 DON stated Resident #1 was diagnosed with fractures to C-4 and C-5 and returned back to the facility on [DATE] at approximately 3:00 p.m. Telephone interview on 08/26/2025 at 8:20 a.m. with S5 CNA revealed on 07/24/2024 S7 CNA came and got her to help with Resident #1, because he had fallen. S5 CNA stated they called for S3 LPN. S5 CNA stated Resident #1 had been up by the nurse's station earlier in the shift saying he wanted to go home. Telephone interview on 08/26/2025 at 8:24 a.m. with S3 LPN revealed she provided care for Resident #1 on 07/24/2025 for the 7:00 p.m. to 7:00 a.m. shift. S3 LPN stated at approximately 4:30 a.m. S6 CNA came to the nurse's station and stated Resident #1 had fallen. S3 LPN stated when she and S4 LPN entered Resident #1's room he was lying on the floor between the bed and air conditioner. S3 LPN stated she assessed Resident #1 and helped him back to bed with the assistance of S5 CNA and S7 CNA .S3 LPN stated Resident #1 complained of head and neck pain. S3 LPN stated Resident #1 had been restless all night and kept trying to get out of the bed. S3 LPN stated Resident #1 had fallen earlier in the morning on 07/24/2025 at approximately 2:00-2:30 a.m. S3 LPN stated S4 LPN and S6 CNA helped her to put Resident #1 back in the bed after the first fall. S3 LPN stated she did not notify the physician or responsible party that resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN stated she did not document the fall or tell S1 DON that Resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN confirmed she should have notified the physician and documented that Resident #1 had fallen at 2:00-2:30 a.m. on 07/24/2025. During the interview S3 LPN confirmed the following: Resident #1 complained of neck and head pain rated a 10 after the 4:30 a.m. fall; S3 LPN waited 3 hours to send Resident #1 to the hospital after 2 unwitnessed falls. S3LPN failed to administer Resident #1 pain medications that were ordered and available at the facility.Telephone interview on 08/26/2024 at 8:45 a.m. with S6 CNA revealed she was on Resident #1's hall speaking with S5 CNA when they heard Resident #1 yell for help. S6 CNA stated when they entered Resident #1's room he was lying on the floor. S6 CNA stated S3 LPN, S4 LPN and S5 CNA assisted Resident #1 off the floor onto the bed. S6 CNA stated Resident #1 had complained of back and neck pain at this time and was moaning and groaning.Interview on 08/26/2025 at 9:16 a.m. with S7 CNA revealed she was the CNA assigned to Resident #1 on 07/24/2025 7:00 p.m.-7:00 a.m. shift. S7 CNA stated Resident #1 fell twice on the 7:00 pm to 7:00 a.m. shift on 07/24/2025. S7 CNA stated the first fall was at approximately 2:30 a.m. and the second fall was 4:30 a.m. S7 CNA stated she was outside on break during the first fall and S6 CNA called her cell phone and said your resident (Resident #1) fell. S7 CNA revealed she went back into the facility to Resident #1's room, and S3 LPN, S4 LPN, S5 CNA, and S6 CNA had gotten him off the floor back in the bed. S7 CNA stated she had went to check on Resident #1 after his first fall and he was on the floor hollering. S7 CNA stated she called for S5 CNA and she summoned the S3 LPN. S7 CNA stated Resident #1 complained of his neck hurting and was groaning in pain. S7 CNA stated she told S3 LPN that Resident #1 was complaining of his neck hurting. S7 CNA stated she was told by S3 LPN to be quiet and let Resident #1 say if he was hurting. S7 CNA stated Resident #1 did not go to the hospital until much later, but continued to complain of neck pain. Telephone interview on 08/26/2025 at 11:45 a.m. with S4 LPN revealed Resident #1 had fallen twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S4 LPN stated she did not remember the time of the first fall. S4 LPN revealed S3 LPN was the nurse for Resident #1 and she assisted her with the first fall. S4 LPN revealed she did not assist with the second fall that occurred at 4:30 a.m., but did complete the incident report. Interview on 08/26/2025 at 1:05 p.m. with S1 Administrator, S2 DON and S8 Corporate Nurse revealed they were unaware that Resident #1 had fallen twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S1 Administrator, S2 DON and S8 Corporate Nurse confirmed the following: S3 LPN should have notified the physician and the responsible party of both falls, documented the first fall; and called the ambulance promptly and administered pain medications as necessary to Resident #1.Telephone interview on 08/26/2025 at 2:36 p.m. with S9 Hospice CNA revealed she arrived to the facility at 6:30 a.m. on 07/24/2025. S9 Hospice CNA stated she was getting ready to bathe Resident #1 and Resident #1 was grimacing and said his neck was hurting. S9 Hospice CNA stated a nurse came in the room and said Resident #1 had fallen. Interview and record review on 08/26/2025 at 1:05 p.m. with S2 DON of Resident #1's 07/2025 Medication Administration Record and Narcotic Log confirmed no documentation of pain medication given on 07/24/2025. The Immediate Jeopardy was removed on 08/28/20205 at 3:25 p.m. The facility implemented and acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Plan of Removal: Actions the facility will take:S3 LPN was suspended from work on 08/27/2025 due to the following reasons: neglecting to notify the MD of the fall, neglecting to document on the incident and neglecting to send the resident to the ER promptly. To establish a baseline a pre-test has been developed for each nurse to complete prior to the in-service. This pre-test contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The pre-test also addresses administration of prn pain medications, if indicated.Education/Training Plan-In-services were initiated for all nurses by the DON and/or ADON on 08/27/2025 and will be completed by 08/28/2025. The in-service covers the following:-The requirements to notify the MD of each and every fall, regardless of injury. This notification should be documented in the medical record.-The requirements to document each and every fall in the medical record. The documentation should include a description of the incident and assessment of the resident.-The importance of promptly sending the resident to the emergency room, when indicated based on the assessment, or as ordered by the MD.-The importance of assessing for pain with falls and administering prn pain medication, if ordered and indicated.-Nurses were reminded to always notify the DON or ADON with any questions or concerns. They were also instructed to immediately notify the DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address the following:-The definition of neglect-examples of neglect will be reviewed, which will include the following, at a minimum; Failing to notify the MD of a fall with injury, failing to document a fall, failing to document as assessment following a fall, and failing to promptly send the resident to the ER.Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions:To ensure residents are promptly cared for following a fall and no neglect has occurred, a QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure the MD was notified, an assessment was documented, the resident was sent to the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure residents are promptly cared for, falls are addressed and no neglect has occurred, and additional QAPI Monitor has been created. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to neglect, the DON or designee will interview a random sample of at least 3 nurses 3 x a week for 6 weeks, and them monthly thereafter until compliance is reached. This interview will contain questions related to neglect, notification of MD with falls, documentation of falls in the medical record, documentation of assessments related to falls and sending a resident to the ER promptly when ordered or as required.The effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide care and services that met professional standards of quality for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents, by failing to ensure physician orders were followed timely for the management of pain, and timely hospital transfer after a fall.Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 complained of neck pain after being found on the floor by S3 LPN. S3 LPN failed to notify the physician of the fall and failed to administer pain medications that were ordered and available to give. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and complained of neck, back, and head pain at a 10 out of 10 on the pain scale at that time. Resident #1 was not transferred to the hospital for evaluation until 3 hours after transfer orders had been given to S3 LPN. On 07/24/2025 at 1:20 p.m. the hospital notified the facility that Resident #1 had a fracture of his C-4, C-5 and C-6.S1 Administrator was notified of the Immediate Jeopardy situation on 08/27/2025 at 2:45 p.m.This deficient practice continued at a potential for more than minimal harm for all residents in the facility. The census was 89.Findings: Review of a facility's policy titled Code of Ethics with no revision date, revealed in part.2. Facility maintains accurate and reliable clinical documentation to insure that all patient care services are medically necessary and conform with all requirements for the delivery of quality patient care services. Review of a facility's policy titled Code of Conduct, with no revision date, revealed in part.The Code of Conduct is in effect at this facility to protect the rights and safety of all employees and patients. Any employee guilty of any of the following will be subject to immediate dismissal: (21). Inefficiency, inability and/or gross or repeated negligence in the performance of assigned duties. Review of Resident #1's medical record revealed an admit date of 07/21/2025 with diagnoses that included in part.Heart Disease Unspecified, Dementia in other Diseases, Mood Disturbance, Anxiety and Type II Diabetes Mellitus. Review of Resident #1's Discharge MDS with an ARD of 07/26/2025 revealed a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #1's MDS revealed he required supervision or touching assistance with oral hygiene, personal hygiene; partial/moderate assistance with toileting hygiene, bathing and set-up or clean up assistance with eating. Resident #1 used a manual wheelchair for mobility had no impairments to upper/lower extremities. Review of Resident #1's care plan with a target date of 10/19/2025 revealed in part.1. Physical mobility impaired with interventions that included to assist with bed mobility, transfers, locomotion as necessary or requested, monitor for decline in mobility and notify physician of changes.2. Self-care deficit with interventions that included for resident to receive person-centered care; needs with assist with bathing, hygiene, dressing, and grooming.3. High Risk for falls related to Cerebrovascular Accident and Heart Disease with interventions that included turn bars on bed times two to assist with mobility, assist with transfers as needed, keep assistive devices in reach, keep bed in lowest position with wheels locked, and keep call light in reach. Review of an incident report dated 07/24/2025 at 4:30 a.m. by S4 LPN revealed in part .Nursing Description: This nurse was notified by CNA that resident was lying on the floor. As this nurse entered the room this nurse observed resident lying on the floor on his back between the bed and the air conditioner. Resident stated he didn't know what happened or how he got on the floor. No injuries noted anywhere to residents body upon full body assessment. Range of Motion within normal limits. Resident stated he was having some back, head and neck pain. Daughter notified of incident and transfer of resident to ER to be evaluated and treated. Immediate Action Taken: Full body assessment, Vital signs taken, pain assessment, assisted back into bed x 3 person assist to wait on ambulance to transfer to hospital. Level of Pain-10. Review of Resident #1's Medication Administration Record and Narcotic Log revealed no documentation of pain medicine administered on 07/24/2025. Resident #1 had Tramadol HCL 50 Milligrams by mouth every 12 hours as needed for moderate to severe pain ordered and available. Review of Resident #1's nursing progress notes dated 07/24/2025 at 7:40 a.m. by S2 DON revealed in part.ambulance here to transport resident to the hospital per stretcher due to pain from fall. Nursing progress note dated 07/24/2025 at 1:20 p.m. revealed in part. report received from the hospital regarding resident. Nurse reports CT of the head clear but neck shows C-4 and C-5 fracture and resident will be coming back to the nursing home in a C-collar and to follow up with neurosurgery in 2 weeks. Family aware and has been at the hospital with resident. Review of Resident #1's x-ray dated 07/24/2025 revealed in part.CT of Cervical Spine without contrast. History: Neck pain, fall. Impression: Osteoporosis, mild anterior subluxation C4-C5 and prior anterior and posterior bony fusion C5-C7. Transverse fracture through the body of C5 with additional transverse fractures extending through the fused posterior elements of C5-C6 and this fracture configuration is felt to be unstable. Fractures through the posterior elements of C-4 non-displaced. Interview on 08/25/2025 at 2:00 p.m. with S2 DON revealed Resident #1 was at the facility for 5 days (07/21/2025 through 07/26/20205), on respite care. S2 DON stated on 07/24/2024 at 4:30 a.m. Resident #1 was heard hollering by S5 CNA and was found in his room on the floor. S5 CNA stayed with Resident #1 while S6 CNA summoned S3 LPN and S4 LPN. Resident #1 complained of head and neck pain and was sent to the hospital for evaluation. S2 DON stated Resident #1 was diagnosed with fractures to C-4 and C-5 and returned back to the facility on [DATE] at approximately 3:00 p.m.Telephone interview on 08/26/2025 at 8:20 a.m. with S5 CNA revealed on 07/24/2024 S7 CNA came and got her to help with Resident #1, because he had fallen. S5 CNA stated they called for S3 LPN. Telephone interview on 08/26/2025 at 8:24 a.m. with S3 LPN revealed she provided care for Resident #1 on 07/24/2025 for the 7:00 p.m. to 7:00 a.m. shift. S3 LPN stated at approximately 4:30 a.m. S6 CNA came to the nurse's station and stated Resident #1 had fallen. S3 LPN stated when she and S4 LPN entered Resident #1's room he was lying on the floor between the bed and air conditioner. S3 LPN stated she assessed Resident #1 and helped him back to bed with the assistance of S5 CNA and S7 CNA. S3 LPN stated Resident #1 complained of head and neck pain. S3 LPN stated Resident #1 had been restless all night and kept trying to get out of the bed. S3 LPN stated Resident #1 had fallen earlier in the morning on 07/24/2025 at approximately 2:00-2:30 a.m. S3 LPN stated S4 LPN and S6 CNA helped her to put Resident #1 back in the bed after the first fall. S3 LPN stated she did not notify the physician or responsible party that resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN stated she did not document the fall or tell S1 DON that Resident #1 had fallen between 2:00-2:30 a.m. on 07/24/2025. S3 LPN confirmed she should have notified the physician and documented that Resident #1 had fallen at 2:00-2:30 a.m. on 07/24/2025. During the interview S3 LPN confirmed the following: Resident #1 complained of neck and head pain rated a 10 after the 4:30 a.m. fall; S3 LPN waited 3 hours to send Resident #1 to the hospital after 2 unwitnessed falls. S3LPN failed to administer Resident #1 pain medications that were ordered and available at the facility. Telephone interview on 08/26/2024 at 8:45 a.m. with S6 CNA revealed she was on Resident #1's hall speaking with S5 CNA at approximately 2:30 a.m. on 07/24/2025 when they heard Resident #1 yell for help. S6 CNA stated when they entered Resident #1's room he was lying on the floor. S6 CNA stated S3 LPN, S4 LPN and S5 CNA assisted Resident #1 off the floor onto the bed. S6 CNA stated Resident #1 had complained of back and neck pain at that time and was moaning and groaning. Interview on 08/26/2025 at 9:16 a.m. with S7 CNA revealed she was the CNA assigned to Resident #1 on 07/24/2025 7:00 p.m.-7:00 a.m. shift. S7 CNA stated Resident #1 fell twice on the 7:00 pm to 7:00 am shift on 07/24/2025. S7 CNA stated the first fall was at approximately 2:30 a.m. and the second fall was 4:30 a.m. S7 CNA stated she was outside on break during the first fall and S6 CNA called her cell phone and said your resident (Resident #1) fell. S7 CNA revealed she went back into the facility to Resident #1's room, and S3 LPN, S4 LPN, S5 CNA, and S6 CNA had gotten him off the floor back in the bed. S7 CNA stated between 3:30 a.m.-4:30 a.m. she had went to check on Resident #1 and he was on the floor hollering. S7 CNA stated she called for S5 CNA and she summoned the S3 LPN. S7 CNA stated Resident #1 had complained of his neck hurting and was groaning in pain. S7 CNA stated she told S3 LPN that Resident #1 was complaining of his neck hurting. S7 CNA stated she was told by S3 LPN to be quiet and let Resident #1 say if he was hurting. S7 CNA stated Resident #1 did not go to the hospital until much later, but continued to complain of neck pain. Telephone interview on 08/26/2025 at 11:45 a.m. with S4 LPN revealed Resident #1 had fallen twice on the 7:00 p.m. to 7:00 a.m. shift on 07/24/2025. S4 LPN stated she did not remember the time of the first fall. S4 LPN revealed S3 LPN was the nurse for Resident #1 and she assisted her with the first fall. S4 LPN revealed she did not assist with the second fall. S4 LPN confirmed she did the incident report on Resident #1 on 07/24/2025 at 4:30 a.m.Interview on 08/26/2025 at 1:05 p.m. with S1 Administrator, S2 DON and S8 Corporate Nurse revealed they were unaware that Resident #1 had fallen twice on 07/24/2025. S1 Administrator, S2 DON and S8 Corporate Nurse confirmed S3 LPN should have notified the physician and the responsible party of both falls, documented the first fall; and administered pain medications as necessary to Resident #1 but had not. Telephone interview on 08/26/2025 at 2:36 p.m. with S9 Hospice CNA revealed she arrived to the facility at 6:30 a.m. on 07/24/2025. S9 Hospice CNA stated she was getting ready to bathe Resident #1 and Resident #1 was grimacing and said his neck was hurting. S9 Hospice CNA stated a nurse came in the room and said Resident #1 had fallen and was complaining of neck pain. Interview and record review on 08/26/2025 at 1:05 p.m. with S2 DON of Resident #1's 07/2025 Medication Administration Record and Narcotic Log confirmed no documentation of pain medication given on 07/24/2025. The Immediate Jeopardy was removed on 08/28/20205 at 3:25 p.m. The facility implemented and acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Plan of Removal: Actions the facility will take:S3 LPN was suspended from work on 08/27/2025 due to failing to maintain professional standards of care by not notifying the MD following and unwitnessed fall, not assessing the resident, not administering pain medications that were ordered and available and waiting 3 hours to send the resident to the ER. To establish a baseline a pre-test has been developed for each nurse to complete prior to the in-service. This pre-test contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The pre-test also addresses administration of prn pain medications, if indicated.The DON will complete A Performance Evaluation for each nurse beginning 08/28/2025. Nurses on FMLA will have the Performance Evaluation completed upon return to workEducation/Training Plan-In-services were initiated for all nurses by the DON and/or ADON on 08/27/2025 and will be completed by 08/28/2025. The in-service covers the following:-The requirements to notify the MD of each and every fall, regardless of injury. This notification should be documented in the medical record.-The requirements to document each and every fall in the medical record. The documentation should include a description of the incident and assessment of the resident.-The importance of promptly sending the resident to the emergency room, when indicated based on the assessment, or as ordered by the MD.-The importance of assessing for pain with falls and administering prn pain medication, if ordered and indicated.-Nurses were reminded to always notify the DON or ADON with any questions or concerns. They were also instructed to immediately notify the DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address professional standards of practice related to the following: -It is professional standards of practice to notify the MD of falls-It is professional standards of practice, following a fall, to administer pain medications when a resident is in pain and has pain medication ordered. If no pain medication is ordered, the MD should be notified so orders can be obtained. -It is professional standard of practice to promptly send a resident to the ER when ordered or required based on assessment. -Resident Rights will be reviewed with each nurse as well. Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions: A QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure Professional Standards are maintained following a fall, by ensuring the MD was notified, an assessment was documented, the resident was sent to the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.An additional QAPI Monitor has been created to ensure Professional Standards are maintained following a fall by ensuring that falls have been addressed in the medical record. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to Professional Standards, the DON or designee will interview a random sample of at least 3 nurse, 3 x a week for 6 weeks, and then monthly thereafter until compliance is reached. This interview will contain questions related to Professional Standards, notification of MD with falls, assessing residents with falls, administering pain medications if needed and available and promptly sending residents to the ER when ordered or required.To further ensure Professional Standards are maintained, the DON or ADON will complete Performance Evaluations on 4 nurses weekly for 6 weeks, and then monthly thereafter until compliance is reached. The Corporate nurse will oversee the plan of removal and plan of correction and will also ensure that follow-up regarding the specific areas will be conducted. The effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.