**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews the facility failed to protect a resident's privacy for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone. The staff allowed a prison inmate who was watching the live stream to view the resident while the resident was naked from the waist up and while care was provided; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized and have feelings of worthlessness, powerlessness and dehumanization through people that were not caregivers viewing them naked and while care was provided without consent. Immediate jeopardy began on 10/4/24 when Resident #2's privacy was violated. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included anxiety, Alzheimer's, dementia, and mood disturbance. Review of Resident #2s quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of video footage provided by the Sheriff Department revealed the following events took place on 10/04/24 at 10:30 PM. The video revealed NA #1 and NA #2 located in a facility in the resident's room on live stream video through a cell phone with a prison inmate. The inmate was observed talking into a telephone receiver in an open area with several other inmates behind him. The inmate was looking at the live stream. The video was reviewed on 12/4/24 at 4:45 PM. The following was found and documented by the time mm:ss (minutes colon seconds) where mm represents minutes and ss represents seconds. -:01 Video starts with NA #1 walking down the facility hallway towards Resident #2's room. No residents were shown at this time. -:33 NA #1 entered Resident #2's room. -:45 NA #1 laid the cell phone down. The video showed several inmates walking around the inmate while he was speaking to NA #1 and Resident #2 was visible sitting in the wheelchair with NA #1 and NA #2 present in the resident's room. NA #2 was observed undressing Resident #2 and taking off her shirt. It was observed that multiple inmates and a guard walked by the inmate during this time. -:53 NA #2 was observed jerking the resident's shirt out of Resident #2's hands aggressively. Residents #2's bare shoulders were observed to be showing. -2:09 NA #1 pointed the live stream video at Resident #2 and Resident #2 was visible in the wheelchair with her shirt removed and NA # 1 was trying to remove her bra from her right arm; both breasts were showing. The inmate stated, come on man, come on man. The inmate stated, I got to go, bye. NA #1 states no we're talking. The inmate replies, that s . just p . me off. NA #2 comes in the live video frame and was laughing. During this time multiple inmates were behind the inmate in an open public area. -3:02 NA #1 was holding the cell phone and pointed it to NA #2 smiling and laughing into the camera. NA #2 acknowledged again she is on a live video stream call with the inmate. -3:07 NA #2 was viewed fastening Resident #2's gown behind her back and the inmate states, y'all are crazy., y'all crazy as hell. Y'all two together is trouble. -3: The inmate stated, you just put anything on camera you need to stop that s NA #1 replied I don't give a damn. -4:29 NA #1 was observed standing on the right side of the bed and NA #2 was on the left between the resident's beds with Resident #2 sitting in the mechanical lift sling suspended. NA #1 had the phone live streaming Resident #2 and laughing. The privacy curtain was not pulled between the two beds. The roommate was not visualized at this time. -4:42 NA #1 turned the cell phone camera, and Resident #2 was suspended in the mechanical lift. Inmates were passing by behind the inmate that was watching. -5:01 Resident #2 was being transferred to her bed in the mechanical lift and there was another resident in the room in the opposite bed. The privacy curtain was not pulled while Resident #2 was being transferred. -6:01 NA #1 laid the cell phone down still showing care and rolled Resident #2 aggressively on to her left side by jerking up by the lift pad. Resident #2's face was away from the camera with her full brief exposed. The inmate stated, damn, don't roll her out of bed. NA #1 looked back at the video and laughed. NA #2 was still present in the room on the other side of the bed assisting with Resident #2. Two inmates were observed in the back in the open area. -6:08 NA #1 stated, patient confidentiality and moved the phone to the side of the bed pointing towards the end wall not viewing the resident but still live streaming while giving care to the resident. -7:17 NA #1 stated to resident, open your legs girl. NA # 1 stated more that was not discernable. -8:45 NA #1 and NA #2 exited the resident's room and walked down the facility hall and continued to talk to the inmate on the cell phone. -9:46 Video ends. A phone interview conducted with the Lieutenant of Criminal Investigations on 12/2/24 at 11:30 AM revealed he had obtained video footage of an inmate and NA #1 having a video call where NA #1 had shown the inmate view of an elderly resident in a wheelchair. The Lieutenant stated he had reported the concerns to Adult Protective Services (APS) and was concerned NA #1 had exploited Resident #2. A follow up phone interview with Lieutenant of Criminal Investigations on 12/05/24 at 9:20 AM explained the video occurred on 10/4/24 and the video call app used was Home WAV which is a video call that is recorded of both parties. The Lieutenant indicated when a video call occured the inmate had a phone receiver to hear the conversation but had a computer size screen mounted on the wall to see who they are face calling. The Lieutenanr stated other inmates were unable to hear the conversation but could visually see the video because the screen is in a non-private area with other inmates present. An interview conducted with NA #1 on 12/02/24 at 2:35 PM revealed she had worked in the facility for two years. NA #1 further revealed she had completed an in-service on resident privacy and video and telephone calls were prohibited in care areas. NA #1 stated she had never taken any pictures or videos of any resident in the facility. A phone interview conducted with Nurse Aide (NA) #2 on 12/4/24 at 6:00 PM revealed she had been employed by the facility for approximately two years. NA #2 further revealed she had been educated on residents' privacy. NA #2 stated she had never observed any staff or had taken a video or picture of a resident. NA #2 indicated if she was to observe a staff member record a resident that she would report it to the Administrator. NA #2 denied any staff videoing Resident #2 while giving care. An interview conducted with the Director of Nursing (DON) and Administrator on 12/02/24 at 2:45 PM revealed they both had been recently employed at the facility. The interview revealed no staff had reported concerns about staff having their phones out in care areas and taking pictures or video footage of a resident. Both indicated nursing staff had been in-service at hire, annually, and anytime on resident privacy and person phones were not allowed to be out in resident rooms. The video was shared with facility staff on 12/4/24 at 5:45 PM. Those present were the Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI (quality assurance and performance improvement). The facility staff cried. After the video was reviewed, Resident #2, NA #1, and NA #2 were identified by the DON. It was further revealed nursing staff were not allowed to have personal cell phones in care areas and it was not permitted to record any audio or image of a resident. The DON stated NA #1 failed to protect the privacy of Resident # 2 and NA #2 failed to report the exploitation and privacy of Resident #2. An interview conducted with Resident #2's Responsible Party (RP) on 12/5/24 at 3:15 PM revealed the facility had notified the family of the video on 12/04/24. The RP further revealed she was upset this had happened to Resident #2 but was glad it was being investigated and hoped justice would be served to NA #1 and NA #2. An interview conducted with the Administrator on 12/9/24 at 4:00 PM revealed she had been employed by the facility for a short period of time but assisted with the initial investigation. The Administrator further revealed NA #1 and NA #2 had denied being in any video or on a telephone call with a resident present. The Administrator further revealed she expected nursing staff to not break confidentiality and protect residents' privacy. The Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI were notified of immediate jeopardy on 12/5/24 at 12:35 PM. The Administrator was not present. The facility provided the following immediate jeopardy removal plan. The facility failed to maintain privacy for Resident # 2 while personal care was provided. NA # 1 used her personal cell phone while in the residents' room to facetime with a male inmate which allowed Resident # 2 to be observed sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed without her consent. The observation was provided in real time through the use of a wall mounted screen in a common area of an incarceration center while other people in the prison were also observed walking past the screen. On 12/2/24 at 1:35pm, the DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director (MD) of allegation. Because the resident was unknown at this time and the presence of a witness was unknown, the facility was unable to make notifications to Resident #2's resident representative or initiate immediate suspension of NA #2. On 12/2/24 at 2:15pm, the Social Worker (SW) notified the local police department and adult protective services (APS). A police report number was obtained. On 12/2/24 at 3:30pm, the Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS). On 12/2/24 at 4:00pm, the Administrator completed an observational round of facility residents and staff to ensure that resident's right to privacy is maintained. Observations include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space. No additional concerns identified. On 12/2/24 and on 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure to maintain privacy for a resident while personal care was being provided. Root cause analysis determined that the facility failed to implement an effective system to ensure strict enforcement and monitoring measures to prohibit cellular phones and video recording devices in resident care areas. On 12/4/24 at 3:30pm, additional information was provided to the facility to include identification of resident (Resident #2) and addition of a witness (NA #2). In response to this new information, the DON immediately suspended NA #2, notified Resident #2 resident representative(s) and the MD and the VPRQA notified local law enforcement and APS with updated information to initial 12/2/24 reports. The VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and resident was pleasantly confused at baseline. On 12/4/2024 the VPCQA, VPCO and DON attempted to obtain information regarding the location of the prison. Upon receipt of this information, the facility plans to inquire on the security of the recording and ensure that Resident #2 is protected from any additional violation of privacy by others who are unauthorized to have such information. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/24, all current facility staff were in-serviced on the Resident Rights Policy, CMS guidance 483.10(h) and the Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc.,10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained. Effective 12/2/2024, questionnaires were also completed following in-servicing with current facility staff to validate competency of education received and to identify if additional incidences of resident privacy had been violated. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/2024 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete observational rounds of facility residents and staff to ensure that resident's right to privacy is maintained. Observations to include 1) care being provided only by authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space. On 12/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit as above. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/05/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided psych evaluation follow up for Resident #2 regarding the incident. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook review were executed. The facility showed evidence of communication with the sheriff's office that the video was encrypted and secured with only authorized person could access and view the footage. The IJ removal date if 12/05/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and family, Lieutenant of Criminal Investigations and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone, the resident was naked from the waist up, the staff and the prison inmate watching the live stream spoke with profanity and vulgarity without any regard for the resident; the staff did not explain care as it was provided to the resident; the staff were physically aggressive during care; the staff allowed an inmate who was watching the live stream to view the resident and speak to the resident; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being abused by caregivers in their home environment making them feel worthless, angry, dehumanized and powerless. Immediate jeopardy began on 10/4/24 when Resident #2 was abused. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included anxiety, Alzheimer's disease, dementia, and mood disturbance. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with two-person for bed mobility and transfers. The MDS further revealed Resident #2 had adequate hearing and vision and was able to understand others. The MDS indicated no behaviors of rejection and care. Review of Resident #2's care plan dated 04/07/23 revealed the resident had an activities of daily living (ADL) self-care performance deficient due to Alzheimer's disease, impaired cognition, and muscle weakness. The goal was for Resident #2 to maintain its current level of function through the review date. Resident #2's care plan revised on 08/19/24 revealed the resident was resistive to care and refused to see the dentist and other medical directors at time due to dementia. The goal was for the resident to cooperate with care through the next review date. Interventions included for Resident #2 to make decisions about treatment regime and to give clear explanation of all care activities prior to an as they occur during each contact. Review of video footage provided by the Sheriff Department revealed the following events took place on 10/04/24 at 10:30 PM. The video revealed NA #1 and NA #2 located in a facility in the resident's room on live stream video through a cell phone with a prison inmate. The inmate was observed talking into a telephone receiver in an open area with several other inmates behind him. The inmate was looking at the live stream. The video was reviewed on 12/4/24 at 4:45 PM. The following was found and documented by the time mm:ss (minutes colon seconds) where mm represents minutes and ss represents seconds. -:01 Video starts with NA #1 walking down the facility hallway towards Resident #2's room. No residents were shown at this time. -:33 NA #1 entered Resident #2's room. -:45 NA #1 laid the cell phone down and shook her rear in the camera as the inmate states, that damn ass is fat. Look at that ass. That mother f . is fat. The video showed several inmates walking around the inmate while he was speaking to NA #1 and Resident #2 was visible sitting in the wheelchair with NA #1 and NA #2 present in the resident's room. NA #2 was observed undressing Resident #2 and taking off her shirt. It was observed that multiple inmates and a guard walked by the inmate during this time. Staff were not observed to be explaining their actions related to care to the resident. -:53 NA #2 was observed jerking the resident's shirt out of Resident #2's hands aggressively. Residents #2's bare shoulders were observed to be showing. NA #2 was not observed to explain care to the resident. -1:28 NA #1 picked up the cell phone and spoke to the inmate walking throughout the resident's room. -2:07 NA #2 was observed waving and smiling at the inmate through the cell phone acknowledging the inmate. -2:09 NA #1 pointed the live stream video at Resident #2 and Resident #2 was visible in the wheelchair with her shirt removed and NA # 1 was trying to remove her bra from her right arm; both breasts were showing. The inmate stated, come on man, come on man. NA #1 pointed the live stream video at NA #2, and she is observed smiling and laughing. The inmate stated, I got to go, bye. NA #1 states no we're talking. The inmate replies that s . just p . me off. NA #2 comes in the live video frame and was laughing. During this time multiple inmates were behind the inmate in the open public area. -3:02 NA #1 was holding the cell phone and pointed it to NA #2 smiling and laughing into the camera. NA #2 acknowledged again she is on a live video stream call with the inmate. -3:07 NA #2 was viewed fastening Resident #2's gown behind her back and the inmate stated, y'all are crazy., y'all crazy as hell. Y'all two together is trouble. Staff did not explain the care being provided to the resident. -3:32 NA #1 stated, this mother f . about to hit this resident in the head and proceeded to state it's not going to hurt her; she isn't going to bruise because she is black. The inmate stated, you just put anything on camera you need to stop that s NA #1 replied I don't give a damn. -4:05 NA #1 stated, Resident #2 (Name of resident) say hey to him, and put the camera in the resident's face while sitting in the lift sling starting to be lifted. Resident #2 was moving her mouth and breathing heavy. NA #1 and NA #2 did not explain to the resident they were putting her into a mechanical lift. NA #1 stated, she is trying to focus on going into the lift. She is scared as hell. The inmate stated, are yall about put her in the bed? NA #1 replied hell yeah she will be falling like a mother f . I know I am not lifting her up. While the inmate was speaking to NA #1 another inmate was observed behind him in the open area. -4:29 NA #1 was observed standing on the right side of the bed and NA #2 was on the left between the resident's beds with Resident #2 sitting in the mechanical lift sling suspended. NA #1 had the phone live streaming Resident #2 and laughing. The privacy curtain was not pulled between the two beds. A roommate was not visualized at that time. -4:42 NA #1 had the phone pointed towards her and stated, who the f . shoes she got on (NA #2's nickname.) NA #1 and NA #1 started to laugh, and NA #1 stated, this is not this ladies' shoes. NA #1 turned the cell phone camera, and Resident #2 was suspended in the mechanical lift with neither aide beside her. Inmates were passing by behind the inmate that was watching. -5:01 Resident #2 was being transferred to her bed in the mechanical lift and there was another resident in the room in the opposite bed. The privacy curtain was not pulled while Resident #2 was being transferred. -5:09 Resident #2 was still in the mechanical lift sling and NA #1 put the camera in the resident's face and stated, say hey. Resident's face was scrunched up. The inmate stated, why you looking so mean? speaking about the resident's facial expression. NA #1 stated, she is mad, but she doesn't even understand what we are saying. -5:18 NA #1 laid the phone down while she was still being shown on live video stream and the inmate stated, put that camera down a little more let me see that mother f (inaudible words). NA #1 grabbed the phone and lowered it showing off her rear. The inmate stated, that mother f NA #1 and NA #2 began to laugh. -6:01 NA #1 laid the cell phone down still showing care and rolled Resident #2 aggressively on to her left side by jerking up by the lift pad. The care was not explained to the resident. Resident #2's face was away from the camera with her full brief exposed. The inmate stated, damn, don't roll her out of bed. NA #1 looked back at the video and laughed. NA #2 was still present in the room on the other side of the bed assisting with Resident #2. Two inmates were observed in the back in the open area. -6:08 NA #1 stated, patient confidentiality and moved the phone to the side of the bed pointing towards the end wall not viewing the resident but still live streaming while giving care to the resident. -6:16 Resident #2 stated, oh, oh, while NA #1 assisted the resident and NA # 1 stated, you aren't about to fight me. -6:20 Resident #2 grabbed NA #1's left pant leg and NA #1 stepped back and then stepped forward, and the resident swatted at NA #1. NA #1 looked at the camera and laughed while continuing care. The inmate stated, what happened why did you move the phone? NA #1 stated, because she is trying to fight me. F . she is trying to fight us. I am not going to get my ass whooped by an old lady. -7:17 NA #1 stated to resident open your legs girl. NA # 1 stated more that was not discernable. -7:30 NA #1 stated good night (residents name) . After you fought like a mother f . Then stated God d NA #2 stated go to sleep (residents name). -7:40 NA #2 was observed taking off two sets of gloves and the inmate asked, why you put on two gloves? NA #1 stated this mother f be sh . like hell. NA #2 stated and pissin'. NA #1 agreed and stated, pissin' like hell. -7:54 NA #1 picked up phone and turned towards Resident #2 and showed the resident in bed with covers up to her neck and stated, good night boo. Resident #2 had facial grimacing. -7:58 NA #2 stated the way she pissed is like she can hold her piss all day. NA #1 replied and stated, yeah, she can hold her piss all day. Like a waterfall. NA #2 replied yep. -8:15 NA #1 stated, I'm fixing to clock out. NA #1 had the cell phone pointed towards her with NA #2 following her. NA #2 stated it's not even 11 o'clock where the f . are you going? NA #1 replied, I'm ready to go I'm tired as a mother f .,. The NAs walked towards the resident's door to leave. -8:45 NA #1 and NA #2 exited the resident's room and walked down the facility hall and continued to talk to the inmate on the cell phone. -9:46 Video ends. A phone interview conducted with the Lieutenant of Criminal Investigations on 12/2/24 at 11:30 AM revealed he had obtained video footage of an inmate and NA #1 having a video call where NA #1 had shown the inmate view of an elderly resident in a wheelchair and completed a phone call where NA #1 discussed abusing residents and not leaving bruises on them. The Lieutenant stated he had reported the concerns to Adult Protective Services (APS) and was concerned NA #1 had exploited Resident #2. A follow up phone interview with Lieutenant of Criminal Investigations on 12/05/24 at 9:20 AM explained the video occurred on 10/4/24 and the video call app used was Home WAV which is a video call that is recorded of both parties. The Lieutenant indicated when a video call occured the inmate had a phone receiver to hear the conversation but had a computer size screen mounted on the wall to see who they are face calling. The Lieutenanr stated other inmates were unable to hear the conversation but could visually see the video because the screen is in a non-private area with other inmates present. An interview conducted with NA #1 on 12/02/24 at 2:35 PM revealed she had worked in the facility for two years. NA #1 further revealed she had completed an in-service on abuse and neglect and was educated to report abuse or neglect to the administrator. NA #1stated she had never taken any pictures or videos of any resident in the facility. A phone interview conducted with Nurse Aide (NA) #2 on 12/4/24 at 6:00 PM revealed she had been employed by the facility for approximately two years. NA #2 further revealed she had been educated on abuse upon hire, yearly, and randomly. NA #2 stated she had never observed any staff or had taken a video or picture of a resident. NA #2 indicated if she was to observe a staff member record a resident that she would report it to the Administrator. NA #2 denied any staff videoing Resident #2 while giving care. An interview conducted with the Director of Nursing (DON) and Administrator on 12/02/24 at 2:45 PM revealed they both had been recently employed at the facility. The interview revealed no staff had reported concerns about staff having their phones out in care areas and taking pictures or video footage of a resident. Both indicated nursing staff had been in-service at hire, annually, and anytime on resident privacy and person phones were not allowed to be out in resident rooms. The video was shared with facility staff on 12/4/24 at 5:45 PM. Those present were the Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI (quality assurance and performance improvement). Facility staff were crying. After the video was reviewed, Resident #2, NA #1, and NA #2 were identified by the DON. It was further revealed NA #1 and NA #2 had been in-serviced on abuse and neglect and reporting upon hire, annually, and during any abuse investigations. It was indicated Resident #2 was not alert and oriented and could be combative and resistive to care. The DON revealed she expected staff to walk away and get help if the resident becomes frustrated or combative. It was further revealed nursing staff were not allowed to have personal cell phones in care areas and it was not permitted to record any audio or image of a resident. The DON stated NA #1 failed to protect the privacy of Resident # 2 and NA #2 failed to report the exploitation and privacy of Resident #2. An interview conducted with Resident #2's Responsible Party (RP) on 12/5/24 at 3:15 PM revealed the facility had notified the family of the video on 12/04/24. The RP further revealed she was upset this had happened to Resident #2 but was glad it was being investigated and hoped justice would be served to NA #1 and NA #2. An interview conducted with the Administrator on 12/9/24 at 4:00 PM revealed she had been employed by the facility for a short period of time but assisted with the initial investigation. The Administrator further revealed NA #1 and NA #2 had denied being in any video or on a telephone call with a resident present. The Administrator further revealed she expected nursing staff to prevent abuse and neglect and report. The Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI were notified of immediate jeopardy on 12/5/24 at 12:35 PM. The Administrator was not present. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to protect a resident's right to be free from mental and sexual abuse (Resident #2). On 10/4/24 Resident #2 was shown in compromised positions during an audiovisual phone call from Nursing Assistant (NA) #1 with a male individual who was witnessing the audiovisual through the use of a wall mounted screen in a common area of an incarceration center while other people in the prison were observed walking past the screen. During the audiovisual surveillance, NA #1 was observed to show Resident #2 to the male through her phone camera, the resident sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed. There were two NAs witnessed in the video, NA #1 and NA #2. The NA's did not explain to the resident before each step of care was provided; NA # 1 shoved the resident to turn on her side aggressively; NA # 1 and the inmate talked inappropriately, using vulgar language including f**k and sh*t, about the resident and to the resident while NA # 1 and the inmate carried on their own private, foul mouthed (including discussion of NA #1's buttocks), conversation in the presence of the resident. On 12/2/2024 at 1:30pm, the Director of Nursing (DON), [NAME] President of Clinical Operations (VPCO) and [NAME] President of Risk and Quality Assurance (VPRQA) were notified by a surveyor during a recertification and complaint survey that a complaint was received from the community alleging an inappropriate photo or video of an unknown elderly female, partially unclothed and a female identified as NA #1was witnessed. On 12/2/24 at 1:35pm, the DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director (MD) of allegation. Because the resident was unknown at this time and the presence of a witness was unknown, the facility was unable to make notifications to Resident #2's resident representative or initiate immediate suspension of NA #2. On 12/2/24 at 2:15pm, the Social Worker (SW) notified the local police department and adult protective services (APS). A police report number was obtained. On 12/2/24 at 3:30pm, the Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS). On 12/2/24 at 4:00pm, the Administrator completed an observational round of facility residents and staff to ensure that resident rights to privacy and freedom from abuse is maintained. Observations included 1) care being provided only by authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space and 5) observations t ensure residents have no physical signs or behaviors indicative of potential abuse. No additional concerns identified. On 12/2/2024 and on 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure protect a resident's right to be free from abuse. Root cause analysis determined that the facility failed to implement an effective system to ensure strict enforcement and monitoring measures to prohibit cellular phones and video recording devices in resident care areas. Effective 12/2/2024, licensed nurses completed resident abuse questionnaires with cognitively intact residents and body audits with cognitively impaired residents to identify any additional concerns of resident abuse. No additional concerns reported or observed. On 12/4/24 at 4:00pm, the DON, VPCO and VPRQA were notified of additional information and observed video surveillance provided by the survey team identifying Resident #2 as a resident of the facility and of mental and sexual abuse by NA #1 in the presence of NA #2. The DON immediately suspended NA #2 pending investigation. The VPRQA notified police and provided additional information and left a message with APS. The DON notified Resident #2's resident representative (RP) and MD was provided updated information received. On 12/4/2024 at 6:00pm, the VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and was pleasantly confused at baseline. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/2024, all current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection. Identification examples included; physical, mental, sexual, verbal, neglect, exploitation and signs of mental or emotional abuse such as, sudden unexplained changes in behavior, changes in eating habits, withdrawal from care, fear of certain persons or expressions of guilt or shame and staff obligation of reporting abuse immediately to the Administrator and prevention of abuse by the immediate intervention of removing the harm or potential for harm from the resident by removing the perpetrator or threat. Education of proper resident care includes examples such as ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse. To protect resident's right to privacy, the facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas, especially while providing personal care. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc., 10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained and resident's remain free from abuse. Effective 12/2/2024, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/2024 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete ongoing daily observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained, including strict prohibition of staff cellular phone use or any type of audio or video device use in resident care areas. Observations to include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas, 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space, 5) observations of any form of physical, sexual or emotional abuse which include but are not limited to; a. ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified; b. residents are free from offensive comments, profanities or other form of verbal abuse and c. observations to ensure residents are not exhibiting signs of mental anguish such as tearfulness, withdrawal, fear, guarding, aggressiveness and other unusual changes in resident behaviors. On 2/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit and observe resident and staff interactions as above. Effective 12/4/24, the facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care to further ensure residents are free from abuse. Updates include improved interview process, a minimum of two professional references, screening of social media content for inappropriate content and improved screening of background checks. Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms. With the guidance of our legal counsel, a template including a set of questions will be used during the interview process which include the categories of background, interpersonal skills and qualifications and a template for reference checks will be used. Screening of social media platforms will be used via internet search to provide information related to a candidate's personal character. The Human Resource (HR) Director will process and review criminal background checks and forward to the Administrator or DON for approval if a criminal record is identified. The Administrator or DON will consider all screening results to make a final determination. However, the facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/5/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook review were executed. The immediate jeopardy removal date of 12/5/24 was validated.

Based on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews, the facility failed to develop and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents (Resident #2). While Resident # 2 was being abused, neither of the two nurse aides (NA #1 and NA #2) in the room identified the abuse, intervened to stop the abuse, and neither of the two nurse aides reported the abuse immediately to licensed staff or administrative staff. Immediate jeopardy began on 10/4/24 when Resident #2 was abused without staff identification, intervention or reporting. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect, and Exploitation, with a revised date of 10/22/24, read in part it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. As read in section 1: Policy Explanation and Compliance Guidelines, reads 1a.) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This tag is cross referred to F600 Based on observation, record review, and family, Lieutenant of Criminal Investigations and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone, the resident was naked from the waist up, the staff and the prison inmate watching the live stream spoke with profanity and vulgarity without any regard for the resident; the staff did not explain care as it was provided to the resident; the staff were physically aggressive during care; the staff allowed an inmate who was watching the live stream to view the resident and speak to the resident; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being abused by caregivers in their home environment making them feel worthless, angry, dehumanized and powerless. Immediate jeopardy began on 10/4/24 when Resident #2 was abused. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The Director of Nursing (DON), [NAME] President of Clinical Operations (VPCO), and [NAME] President of Risk and QAPI (VPRQA) were notified of immediate jeopardy on 12/5/24 at 1:45 PM. The Administrator was not present. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to follow their abuse policy in the areas of identification, prevention, and reporting when NA #2 witnessed NA #1 conduct an audiovisual phone call where NA #1 showed Resident #2 in compromised positions during a recorded call NA #1 was having with a male individual who was witnessing Resident #2 through the use of a wall mounted screen in a common area of an incarceration center. During the audiovisual conversation NA #1 was observed to show Resident #2 to the male individual through her phone camera, the resident sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed. NA #2 failed to intervene to stop the audiovisual device and protect the resident from ongoing mental abuse, and did not immediately get licensed staff or administrative staff to intervene and stop it, nor did she notify administration, or a supervisor. On 12/4/24 at 4:00pm, the DON, VPCO and VPRQA were first made aware of the presence of NA #2 during the incident on 10/4/2024. The DON immediately suspended NA #2 pending investigation. The VPRQA notified police and provided additional information and left a message with APS. The DON notified Resident #2's resident representative (RR) and MD was provided updated information received. On 12/4/2024 at 6:00pm, the VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and was pleasantly confused at baseline. On 12/4/2024 the VPCQA, VPCO and DON attempted to obtain information regarding the location of the prison. Upon receipt of this information, the facility plans to inquire on the security of the recording and ensure that Resident #2 is protected from any additional violation of privacy by others who are unauthorized to have such information. On 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure to protect a resident's right to be free from abuse when NA #2 did not identify, prevent or report the incident on 10/4/2024. Root cause analysis determined that the facility failed to 1) implement an effective system to ensure staff knowledge of the Abuse, Neglect and Exploitation Policy to include detailed examples of how to identify, prevent and report abuse and validation of staff understanding and 2) the facility failed to enforce a strict NO TOLERATION for cell phone use and video recording device use in resident care areas per the Cell Phone Policy. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/2024, all current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection. Identification examples included; physical, mental, sexual, verbal, neglect, exploitation and signs of mental or emotional abuse such as, sudden unexplained changes in behavior, changes in eating habits, withdrawal from care, fear of certain persons or expressions of guilt or shame and staff obligation of reporting abuse immediately to the Administrator and prevention of abuse by the immediate intervention of removing the harm or potential for harm from the resident by removing the perpetrator or threat. Education of proper resident care includes examples such as ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse. To protect resident's right to privacy, the facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas, especially while providing personal care. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc., 10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained and resident's remain free from abuse. Effective 12/2/24, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/24 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/24, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/24 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete ongoing daily observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained, including strict prohibition of staff cellular phone use or any type of audio or video device use in resident care areas. Observations to include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas, 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space, 5) observations of any form of physical, sexual or emotional abuse which include but are not limited to; a. ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified; b. residents are free from offensive comments, profanities or other form of verbal abuse and c. observations to ensure residents are not exhibiting signs of mental anguish such as tearfulness, withdrawal, fear, guarding, aggressiveness and other unusual changes in resident behaviors. On 2/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit and observe resident and staff interactions as above. Effective 12/4/24, the facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care to further ensure residents are free from abuse. Updates include improved interview process, a minimum of two professional references, screening of social media content for inappropriate content and improved screening of background checks. Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms. With the guidance of our legal counsel, a template including a set of questions will be used during the interview process which include the categories of background, interpersonal skills and qualifications and a template for reference checks will be used. Screening of social media platforms will be used via internet search to provide information related to a candidate's personal character. The Human Resource (HR) Director will process and review criminal background checks and forward to the Administrator or DON for approval if a criminal record is identified. The Administrator or DON will consider all screening results to make a final determination. However, the facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/5/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided evidence of an Ad Hoc meeting discussion of the root cause analysis of the facility failure to implement effective systems of their abuse policy. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook reviewed. The facility's IJ removal date of 12/05/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, family, nurse practitioner (NP), physician (MD), and staff interviews, the facility failed to notify the MD of a resident who experienced pain following a fall for 1 of 3 residents investigated for notification of changes (Resident #94). Resident #94 sustained a fall on 6/2/2023 and reported the fall and right hip pain to Physical Therapist (PT) #1 on 6/3/2023. PT #1 reported the fall and the hip pain to a nurse. Resident #94 reported the fall and right hip pain when she was assessed by NP#2 on 6/5/2023. NP#2 ordered an x-ray of the right hip, which revealed a fractured femur (the long bone in the leg). Resident #94 was sent to the hospital on 6/6/2023 at 12:30 AM and had a partial hip replacement surgery on 6/7/2023. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported the fall and right hip pain to PT #1 and the MD was not notified. Immediate Jeopardy was removed on 7/26/2023when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 documented that Resident #94 was alert and oriented to person and situation. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. A physical therapy evaluation conducted by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. PT #1 documented that Resident #94 required moderate assistance to stand with right-sided leaning noted. The note documented the physical therapist notified the nurse (unnamed) and was told nursing would order an x-ray. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that Nurse #1 or any other staff notified the physician of Resident #94's fall and subsequent pain or that an x-ray was ordered on 6/3/2023. An interview was conducted with NA #4 by phone on 7/25/2023 at 11:10 AM. NA #4 reported she provided Resident #94 with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2, 6/3, 6/4, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she remembered Resident #94's family member requesting a walker during her shift (3:00 PM to 11:00 PM) on 6/4/2023 but denied the family member reporting Resident #94 was experiencing pain. There was no evidence in the medical record that Nurse #2, Nurse #8, or any other staff notified the physician of Resident #94's fall and subsequent pain or that an x-ray was ordered on 6/4/2023. NP#1 was interviewed on 7/20/2023 at 12:14 PM. NP #1 reported that a review of the on-call logs revealed no calls came from the facility to report a fall or pain for Resident #94 on 6/2, 6/3, or 6/4/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 reported she went to get the nurse, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 explained Resident #94 was unable to move in bed without yelling out in pain. NA #3 reported she went to get Nurse #6 and when she returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearable painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. NP #2 reported she had not received notification of the fall or reports of pain prior to 6/5/2023. NP #2 reported she would have ordered an x-ray on 6/3/2023 of Resident #94's hip if she had been notified of the fall with pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell, landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An orthopedic trauma operative (surgical) report dated 6/7/2023 documented Resident #94 had a right partial hip replacement performed on that date for a right hip fracture. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP was available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 on 6/2, 6/3, or 6/4/2023. The MD reported that delaying treatment for a fractured large bone could have resulted in many complications for Resident #94. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to Nurse #1 that Resident #94 had a fall and was experiencing pain. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to notify the physician and/or the resident representative after Resident #94 reported to the Physical Therapist on 6/3/23 that she had fallen in her room on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. On 7/21/23, the Director of Nursing spoke to Nurse #1, and she denied any knowledge of Resident #94 reporting that she had fallen or that the physical therapist or any other staff member reporting to her that Resident #94 had fallen. In addition, Nurse #1 was asked if Resident #94 requested pain medication or had signs or symptoms of pain and Nurse #1 reported no. On, 7/20/23, the Therapy Director spoke to the physical therapist that was working on 6/3/23 and she reported that Resident #94 had reported to her that she had fallen on 6/2/23 while attempting to go to the bathroom. The physical therapist reported that the roommate also reported that the resident had fallen on the previous day (6/2/23). On 6/5/23, after the Nurse Practitioner reported that Resident #94 reported a fall on 6/2/23, the Director of Nursing completed a follow up interview and Resident #94 reported that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff. On 6/5/23, Unit Manager #1 and the Admissions Director spoke to Resident #94's family member who reported that on 6/2/23, Resident #94 had reported to him that she had fallen on the way to the bathroom and that she was having a lot of pain. The family member reported that he reported that Resident #94 was having pain to the charge nurse. On 6/5/23, during the Nurse Practitioner initial assessment, Resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. On 7/17/23, the facility investigation by the Director of Nursing revealed that the Nurse Practitioner was informed of Resident #94's fall on 6/2/23 during her initial assessment on 6/5/23 by the resident. In addition, further review of the medical record revealed that there was no fall nursing assessment documentation or physician/physician extender notification documentation by the licensed nurse of the 6/2/23 fall until 6/5/2023. The Director of Nursing completed the interviews on 7/21/23. The interviews revealed that the licensed nurses and the certified nursing assistants that worked on 6/2/23, 6/3/23, and 6/4/23 reported that Resident #94 did not report to them that she had fallen on 6/2/23. The licensed nurses, certified nursing assistants, and certified medication aide interviews by the Director of Nursing of staff that who worked on 6/2/23, 6/3/23, and 6/4/23 per the nursing assignment sheets revealed that Resident #94 did not report the fall to the assigned licensed nurse, certified nursing assistant or certified medication aide. On 7/17/23, Nurse #3 (Weekend Supervisor) interview with the Director of Nursing revealed that Resident #94 did not express pain concerns and she did not observe signs or symptoms of excruciating pain on 6/3/23 and 6/4/23. Nurse # 3 also reported that Resident #94 as well as the other nursing staff to include the physical therapist who worked on 6/3/23 and 6/4/23, did not report that Resident #94 has fallen on 6/2/23. Nurse #3 reported that Resident #94's family member did not report to her that the resident was having pain and that the resident had fallen on 6/2/23. All current residents are also at risk as a result of this deficient practice. Starting 7/21/23, the Director of Nursing/the Unit Managers and designee will complete an audit of the medical records to include review of progress notes, outside provider notes, incident reports, medication administration records, physician orders, and nursing shift reports of all the current residents for the last 60 days to ensure the physician/ physician extenders and resident representatives have been notified of any resident falls or changes in condition and identified concerns have been address by 7/25/23. Starting 7/21/23 the Director of Nursing / designee will complete interviews of the alert current residents to ensure resident concerns to include incident and accidents, pain management, medication/ treatments and other resident care concerns have been identified and reported to the physician/ physician extenders in the last 60 days by 7/25/23. Starting 7/21/23, the Director of Nursing/ designee will complete interviews of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, housekeeping/laundry, agency, new hire and prn staff to ensure all resident changes in condition or any reported concerns in the last 60 days have been reported to the DON, Unit Manager and/or the Nursing supervisor by 7/25/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 7/21/23, the Staff Development Coordinator/ designee will complete education by 7/25/23 of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, therapy department, housekeeping/laundry, agency, new hire and prn staff related to ensuring resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/families reported concerns have been reported to the licensed nurse and to the physician and/or DON, Unit Managers and nursing supervisor. Starting 7/21/23, the Staff Development Coordinator/ designee will complete education with the licensed nurses to include agency, new hire, and prn licensed nurses related to immediate notification and documentation of resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/ families reported concerns to the physician/ physician extenders and resident representatives and document in the medical record by 7/25/23. After hours the licensed nurse will notify the on-call provider and document in the medical record. Starting 7/21/23, the Staff Development Coordinator was made aware by the Director of Nursing that she will be responsible for verifying that the education has been completed by the required staff members by using the facility personal roster and the nursing, dietary, therapy and housekeeping/laundry staffing schedules to include new hires, agency and prn staff and ongoing education by 7/25/23. No staff will be allowed to work until they have received this education. The SDC/ designee which includes the DON, Unit Managers, and Nursing supervisors will be responsible for providing all of the education. On 7/25/23, The Director of Nursing educated the therapy manager to ensure that all therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist report resident observed and reported falls to the therapy manager and the Director of Nursing immediately. Starting 7/25/23, the therapy manager will educate the therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist related to ensuring resident observed and reported falls are immediately reported to the therapy manager and the Director of Nursing. Therapy staff to include prn and new hire staff will not be allowed to until they receive this education. Effective 7/21/2023 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/27/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility's documentation to support the Credible Allegation for F580 was reviewed. The facility's Director of Nursing (DON) evaluated the named resident after she was notified the resident complained of pain due to a fall on 6/5/2023 and a pain assessment was completed. The Nurse Practitioner assessed the named resident on 6/5/2023 and sent her to the hospital for evaluation due to right hip pain due to a fall the previous Friday, 6/2/2023. The facility completed chart reviews for all residents and interviews were conducted with all cognitively intact residents and family members of residents that were not able to be interviewed. An in-service education which included the facility's policy for staff to notify the supervisor, provider, and responsible party of any falls. The education also included the nurse who was responsible for the resident would complete a post fall review with all resident falls. The facility provided the education all staff (nursing, housekeeping, therapy, dietary, and all agency staff) receive when they are oriented to the facility. Staff were interviewed to ensure their understanding of the education. The facility completed the assessment of the named resident, review and monitoring of all resident's charts and interviews with residents and family members of residents, and education of all staff by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and resident, family member, Physical Therapist (PT) #1, Nurse Practitioner #2, Director of Rehab Services, Physician (MD), and staff interviews, the facility neglected to protect a resident from the right to be free from deprivation of goods and services related to pain management and initiating medical care and treatment after a fall on 6/2/2023 for 1 of 4 residents investigated for abuse/neglect (Resident #94). Nurse Practitioner (NP) #2 completed Resident #94's admission assessment on 6/5/2023 and Resident #94 reported the fall on 6/2/2023 and pain in her right hip since the fall. An x-ray of the right hip revealed a right femoral neck fracture (type of hip fracture of the thigh bone). Resident #94 was sent to the hospital on 6/6/2023 and had a partial hip replacement surgery on 6/7/2023. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported right hip pain after a fall and was not assessed by nursing staff to determine what medical care and services were needed. Immediate Jeopardy was removed on 7/26/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 at 2:03 PM documented that Resident #94 was alert and oriented to person and situation. Resident #94 was always continent of bowels and bladder and required a wheelchair for mobility. Resident #94 was oriented to her room and demonstrated correct use of the call light. A review of the admission medication orders dated 6/2/2023 did not include orders for pain medication. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 was unable to identify the NAs who put her back in bed. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 denied that a nurse assessed her after the fall and reported she had not received pain medication. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 explained that she couldn't recall if the lights were on in the bathroom. Resident #94 reported she was wearing slippers on her feet, and she fell against the wall opposite to the bathroom door and hit her right hip. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported I screamed every time I was touched or moved after the fall. I never got pain medication. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. Resident #94 said her pain was 10 out of 10 all the time, they did not do anything for it. Resident #94 explained she had an x-ray that showed her right hip was fractured and she was sent to the hospital. Resident #94 reported she cried about the right leg pain every time someone came into her room and that it was horrible pain. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member reported that the nurse got acetaminophen (an over-the-counter pain reliever) and administered the medication to Resident #94. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. The family member explained that an x-ray wasn't ordered until Monday 6/5/2023 after NP #2 examined Resident #94. A pain assessment was ordered on 6/2/2023 to be conducted 3 times per day. A review of the medication orders for Resident #94 revealed no scheduled or as needed pain medications were prescribed for her 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. The medication administration record for June 2023 was reviewed. No administration of acetaminophen was documented for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. No nursing assessments related to pain after a fall were conducted on 6/2/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift (7:00 AM to 3:00 PM) on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. The pain assessment for the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 was recorded by Nurse #2 and she documented a pain level of 0. (0-10 with 10 being the most intense pain). An interview was conducted on 7/21/2023 at 12:04 PM with NA #7 and she reported she provided care to Resident #94 on 6/2/2023 for the afternoon shift. NA #7 reported Resident #94 experienced urinary incontinence, but she did not report pain and she did not report a fall during her shift. When asked if she had assisted Resident #94 off the floor after a fall, NA #7 reported that no, she had not picked Resident #94 up off the floor after a fall. Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2, 6/3, 6/4, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Night shift (11:00 PM to 7:00 AM) 6/2/2023 pain assessment was recorded as 0 by Nurse #9. An interview was conducted with Nurse #9 by phone on 7/21/2023 at 11:33 AM. Nurse #9 explained that she did not frequently work Resident #94's hallway (C), but she was assigned to that hallway on 6/2/2023. Nurse #9 indicated Resident #94 did not report pain when she performed the pain assessment or at any other time during the shift, and Nurse #9 stated, No, if a resident reported pain, I would have written a note or addressed it in the pain assessment. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94 or that an x-ray was ordered on 6/2/2023. Day shift on 6/3/2023 pain assessment recorded by Nurse #1 documented a pain level of 0'. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3/2023 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. NA #6 was interviewed on 7/19/2023 at 1:05 PM. NA #6 reported that he was not assigned to Resident #94, but had provided care to her roommate, Resident #50 for day shift on 6/3/2023. NA #6 reported that he found out Resident #94 fell on 6/5/2023. NA #6 was interviewed again on 7/20/2023 at 12:01 PM and he reported he worked day and evening shift on 6/2/2023, 6/3/2023 and 6/4/2023 and he had not picked up Resident #94 from the floor on 6/2/2023 and if Resident #94 had reported pain, he would have reported the pain. The weekend supervisor Nurse #3 was interviewed by phone on 7/20/2023 at 1:39 PM. Nurse #3 reported she worked 6/3/2023 and 6/4/2023 from 7:00 AM until 11:00 PM and no staff reported that Resident #94 was experiencing pain. A physical therapy evaluation performed by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. The note documented the physical therapist notified the nurse (unnamed) Resident #94 was having pain in her right hip. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. The Director of Rehabilitation was interviewed on 7/25/2023 at 8:59 AM by phone. The Director of Rehabilitation reported that PT #1 clocked in to work on 6/3/2023 at 3:46 PM. An occupational therapy evaluation dated 6/3/2023 was reviewed. The evaluation note documented that Resident #94 had pain that interfered or limited functional activity (no location) and that nursing would address pain management. The note documented that Resident #94 reported she had a fall on 6/2/2023 and she had pain in her right leg. The Occupational Therapist (OT) #1 was interviewed on 7/25/2023 at 9:19 AM by phone. OT #1 reported she also assessed Resident #94 on 6/3/2023 and Resident #94 reported she had fallen on 6/2/2023. OT #1 explained that she did not report to the nurse because Resident #94 had told her that the NA staff had helped her get up off the floor. OT #1 indicated that Resident #94 did not have pain during the evaluation, but she had not gotten Resident #94 out of bed. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94, or that an x-ray was ordered on 6/3/2023. The pain assessment for day shift on 6/4/2023 was recorded by Nurse #8 as 0. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she was assigned to Resident #94 during the day shift on 6/4/2023 and reported Resident #94 had not expressed she was in pain at all to her when Nurse #8 conducted the pain assessment on 6/4/2023. Nurse #8 reported she remembered Resident #94's family member requesting a walker during the day shift on 6/4/2023. Nurse #8 reported she recalled that Resident #94 was very pleasant and not in any pain. Nurse #8 reported that no staff reported a fall to her. The pain assessment for night shift on 6/3/2023 and 6/4/2023 were recorded by Nurse #7 as 0. Nurse #7 was interviewed by phone on 7/21/2023 at 3:15 PM. Nurse #7 reported that Resident #94 had not complained of pain when Nurse #7 conducted the pain assessment during 6/3/2023 or 6/4/2023 on the night shifts. Nurse #7 explained that Resident #94 had an order to administer acetaminophen at 6:00 AM daily and she did administer the medication to her. Nurse #7 reported the resident had not complained of pain, and she had received scheduled acetaminophen at 6:00 AM on 6/3 and 6/4/2023. NA #5 was interviewed on 7/21/2023 at 11:33 AM. NA #5 reported she was assigned to Resident #94 on 6/4/2023 for the night shift. NA #5 was unable to recall if Resident #94 required incontinence care during her shift and reported that Resident #94 did not complain of pain to her during the night shift. There was no evidence in the medical record that any staff notified the physician of Resident #94's fall and subsequent pain, completed an assessment or that an x-ray was ordered on 6/4/2023. The pain assessment day shift on 6/5/2023 recorded by Nurse #6 documented a pain level of 0. Nurse #6 was interviewed on 7/21/2023 at 12:10 PM. Nurse #6 reported she was the nurse who admitted Resident #94 on 6/2/2023 and she was also assigned to her during the day shift on 6/5/2023. Nurse #6 reported Resident #94 did not report pain to her when Nurse #6 conducted the pain assessment on 6/5/2023, and if she had reported pain, there were facility standing orders she could have activated for administering acetaminophen to Resident #94. Nurse #6 explained that because Resident #94 did not report pain to her, she did not activate the standing orders. During an interview conducted on 7/21/2023 at 4:49 PM, NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 explained she went to get Nurse #6, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 was unable to move in bed without yelling out in pain. NA #3 explained that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearably painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. An interview was conducted with NA #4 by phone on 7/25/2023 at 11:10 AM. NA #4 reported she provided Resident #94 with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. There was no evidence in the medical record that pain medication was ordered on 6/5/2023. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell, landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An orthopedic trauma operative (surgical) report dated 6/7/2023 documented Resident #94 had a right partial hip replacement performed on that date for a right hip fracture. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP is available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 6/2/2023, 6/3/2023, 6/4/2023 or 6/5/2023. The MD reported that delaying treatment for a fractured large bone could have resulted in many complications for Resident #94 and would have been very painful for Resident #94, and he was not aware she did not have an order for pain medication. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to an unknown nurse that Resident #94 had a fall and was experiencing pain. The DON stated she interviewed Resident #94 on 6/5/2023 after the NP evaluation and Resident #94 reported she had fallen and gotten herself up off the floor and did not report the fall to staff. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain and assessed Resident #94. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that Resident #94 was free from neglect. The facility failed to notify the physician of resident changes in condition related to an unwitnessed fall on 6/2/23 until 6/5/23 which resulted in a delay of provision of necessary medical care, treatment, and services for a right hip fracture. The facility failed to address resident pain from 6/2/23 to 6/5/23 that would be associated with a hip fracture. The facility staff failed to follow up on resident reported pain resulting in resident unaddressed pain from 6/3/23 to 6/5/23. Review of Resident #94's Medication Administration revealed no documentation of pain medication being provided to the resident from 6/2/23 through 6/6/23. The facility failed to complete all the facility admission assessments on 6/2/23 for a new admission to ensure preventative measures are in place. There was no evidence from record review and staff interviews that nursing staff completed an assessment of the resident after the fall on 6/2/23 until she was seen by the Nurse Practitioner on 6/5/23. Resident #94's roommate stated she reported Resident #94's fall on 6/2/23 to Nurse #2 on 6/2/23. Nurse #2 denied knowledge of the fall on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. Review of the medical record revealed that Nurse #1 did not complete any documentation related to the fall and did not complete a nursing assessment of Resident #94. On 6/5/23, during the Nurse Practitioner initial assessment, resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. The Nurse Practitioner assessed the resident and noted pain/discomfort to the right hip area, but no bruising was noted. The Nurse Practitioner also noted swelling to the right hip and reported that it appeared that the hip was dislocated. New orders for stat x-ray was given to the nursing staff and to send the resident to the emergency room if x ray results reveal a fracture. On 6/5/23, Resident #94 reported to the Director of Nursing that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff on 6/2/23. On 6/5/23, the right hip x-ray was obtained. On 6/5/23 at 11:45pm, the licensed nurse received the x ray results which revealed an acute right hip fracture. On 6/6/23 at about 12:30am resident #94 was transported to the emergency room by Emergency Transportation per stretcher for further evaluation. On 6/6/23, Resident #94 was admitted to the hospital and a right hemiarthroplasty was performed on 6/7/23. On 7/20/23, the 3-11 nursing supervisor and the Staff Development Coordinator interviewed Resident #94 and she reported that two black females came into her room and picked her up and put her back in bed after the fall on 6/2/23. Resident #94 reported that she could not remember who they were. All the current residents are at risk as a result of this deficient practice. Starting 7/21/23, Social Services will interview the alert and interviewable residents to ensure that any concerns related to resident abuse/neglect have been identified and addressed by 7/25/23. Starting 7/21/23 a skin assessment will be completed by the Unit Managers on all the current residents to identify any bruising, redness, or swelling that has not been reported or that might require further investigation by 7/25/23. On 7/24/23, the Activities Director will meet with the Resident Council President to request a short Resident Council Meeting to review resident rights and reporting Abuse/Neglect. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Starting 7/21/23, the Staff Development Coordinator/ Unit Manager/ Director of Nursing/ Nursing supervisor will educate facility staff to include licensed nurses, certified nursing assistants (CNA), certified medication aide (CMA), dietary, housekeeping/ laundry, therapy staff, maintenance, administrative staff, agency and prn staff on the abuse policy and procedures to include examples of Abuse/neglect, abuse prevention, reporting and identifying Abuse and Neglect. The staff will also be made aware that all reports of Abuse and Neglect to include resident care concerns, fall concerns, unaddressed pain, and resident bruising should be reported to the Administrator immediately 7 days a week regardless of the time of the event. The Administrator contact information will be posted at each nursing station, at the time clock and at the receptionist desk. The Staff Development Coordinator and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, CNA, and CMA receive the Abuse and Neglect education through validation by the facility employee roster and nursing, housekeeping/laundry, therapy, and dietary schedules. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing after 7/25/23 to include new hires and prn staff. Effective 7/21/23, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/27/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility provided documentation to support their credible allegation for Abuse, Neglect and Exploitation. The named resident was assessed by the Nurse Practitioner on 6/5/2023 and sent to the hospital for evaluation of pain from a fall sustained on 6/2/2023. The facility also provided documentation of their investigation of the residents fall. The facility interviewed all alert and oriented residents regarding any issues regarding abuse and neglect and completed skin assessments for each resident by 7/25/2023. The facility also had a resident council meeting to review all residents' rights regarding abuse and neglect. The facility provided documentation of audits of resident interviews and skin assessments to ensure continued monitoring for abuse and neglect. All staff (dietary, housekeeping, maintenance, therapy, and nursing) received an in-service education regarding abuse, neglect, and exploitation by 7/25/2023. A sample of staff across these disciplines revealed understanding of the in-service provided for abuse and neglect. The facility further provided the in-service education provided to all facility staff, new orientees, and agency staff before they are allowed to work in the facility. The facility completed the initial skin assessments and interviews, monitoring of all residents, and education for abuse and neglect by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, family, nurse practitioner, physician, and staff interviews, the facility failed to effectively manage pain for a resident after she experienced a fall and reported pain for 1 of 5 residents investigated for pain management (Resident #94). Resident #94 experienced pain that caused her to yell and scream. The pain affected her ability to go to the bathroom and she became incontinent. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported hip pain to Physical Therapist (PT) #1 and nursing did not effectively manage her pain. Immediate Jeopardy was removed on 7/26/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 documented that Resident #94 was alert and oriented to person and situation. Resident #94 was always continent of bowels and bladder and required a wheelchair for mobility. Resident #94 was oriented to her room and demonstrated correct use of the call light. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 was unable to identify the NAs who put her back in bed. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 denied that a nurse assessed her after the fall and reported she had not received pain medication. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 explained that she couldn't recall if the lights were on in the bathroom. Resident #94 reported she was wearing slippers on her feet, and she fell against the wall opposite to the bathroom door and hit her right hip. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported I screamed every time I was touched or moved after the fall. I never got pain medication. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. Resident #94 said her pain was 10 out of 10 all the time, they did not do anything for it. Resident #94 explained she had an x-ray that showed her right hip was fractured and she was sent to the hospital. Resident #94 reported she cried about the right leg pain every time someone came into her room and that it was horrible pain. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member reported that the nurse got acetaminophen (an over-the-counter pain reliever) and administered the medication to Resident #94. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. The family member explained that an x-ray wasn't ordered until Monday 6/5/2023 after NP #2 examined Resident #94. A pain assessment was ordered on 6/2/2023 to be conducted 3 times per day. A review of the medication orders for Resident #94 revealed no scheduled or as needed pain medications were prescribed for her 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. Standing orders for the facility, which included acetaminophen, were not transcribed to Resident #94's medical record. The medication administration record for June 2023 was reviewed. No administration of acetaminophen was documented for Resident #94 on 6/2, 6/3, 6/4, or 6/5/2023. No nursing assessments related to pain after a fall were conducted on 6/2/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift (7:00 AM to 3:00 PM) on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. An interview was conducted on 7/21/2023 at 12:04 PM with NA #7 and she reported she provided care to Resident #94 on 6/2/2023 for the afternoon shift. NA #7 reported Resident #94 experienced urinary incontinence, but she did not report pain and she did not report a fall during her shift. The pain assessment for the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 was recorded by Nurse #2 and she documented a pain level of 0. (0-10 with 10 being the most intense pain). Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Night shift (11:00 PM to 7:00 AM) 6/2/2023 pain assessment was recorded as 0 by Nurse #9. An interview was conducted with Nurse #9 by phone on 7/21/2023 at 11:33 AM. Nurse #9 explained that she did not frequently work Resident #94's hallway (C), but she was assigned to that hallway on 6/2/2023. Nurse #9 indicated Resident #94 did not report pain when she performed the pain assessment or at any other time during the shift, and Nurse #9 stated, No, if a resident reported pain, I would have written a note or addressed it in the pain assessment. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94 or that an x-ray was ordered on 6/2/2023. Day shift (7:00 AM to 3:00 PM) on 6/3/2023 pain assessment recorded by Nurse #1 documented a pain level of 0'. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3/2023 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. NA #6 was interviewed on 7/20/2023 at 12:01 PM and he reported he worked day and evening shift on 6/2/2023, 6/3/2023 and 6/4/2023 and if Resident #94 had reported pain, he would have reported the pain. The weekend supervisor Nurse #3 was interviewed by phone on 7/20/2023 at 1:39 PM. Nurse #3 reported she worked 6/3/2023 and 6/4/2023 from 7:00 AM until 11:00 PM and no staff reported that Resident #94 was experiencing pain. A physical therapy evaluation performed by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. The note documented the physical therapist notified the nurse (unnamed) Resident #94 was having pain in her right hip. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. The Director of Rehabilitation was interviewed on 7/25/2023 at 8:59 AM by phone. The Director of Rehabilitation reported that PT #1 clocked in to work on 6/3/2023 at 3:46 PM. An occupational therapy evaluation dated 6/3/2023 was reviewed. The evaluation note documented that Resident #94 had pain that interfered or limited functional activity (no location) and that nursing would address pain management. The note documented that Resident #94 reported she had a fall on 6/2/2023 and she had pain in her right leg. The Occupational Therapist (OT) #1 was interviewed on 7/25/2023 at 9:19 AM by phone. OT #1 reported she also assessed Resident #94 on 6/3/2023 and Resident #94 reported she had fallen on 6/2/2023. OT #1 explained that she did not report to the nurse because Resident #94 had told her that the NA staff had helped her get up off the floor. OT #1 indicated that Resident #94 did not have pain during the assessment, but she had not gotten Resident #94 out of bed. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94, or that an x-ray was ordered on 6/3/2023. The pain assessment for day shift on 6/4/2023 was recorded by Nurse #8 as 0. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she was assigned to Resident #94 during the day shift on 6/4/2023 and reported Resident #94 had not expressed she was in pain at all to her when Nurse #8 conducted the pain assessment on 6/4/2023. Nurse #8 reported she remembered Resident #94's family member requesting a walker during the day shift on 6/4/2023. Nurse #8 reported she recalled that Resident #94 was very pleasant and not in any pain. Nurse #8 reported that no staff reported a fall to her. The pain assessment for night shift on 6/3/2023 and 6/4/2023 were recorded by Nurse #7 as 0. Nurse #7 was interviewed by phone on 7/21/2023 at 3:15 PM. Nurse #7 reported that Resident #94 had not complained of pain when Nurse #7 conducted the pain assessment during 6/3/2023 or 6/4/2023 on the night shifts. Nurse #7 explained that Resident #94 had an order to administer acetaminophen at 6:00 AM daily and she did administer the medication to her. Nurse #7 reported the resident had not complained of pain, and she had received scheduled acetaminophen at 6:00 AM on 6/3 and 6/4/2023. NA #5 was interviewed on 7/21/2023 at 11:33 AM. NA #5 reported she was assigned to Resident #94 on 6/4/2023 for the night shift. NA #5 was unable to recall if Resident #94 required incontinence care during her shift and reported that Resident #94 did not complain of pain to her during the night shift. There was no evidence in the medical record that any staff notified the physician of Resident #94's fall and subsequent pain, completed an assessment or that an x-ray was ordered on 6/4/2023. The pain assessment day shift on 6/5/2023 recorded by Nurse #6 documented a pain level of 0. Nurse #6 was interviewed on 7/21/2023 at 12:10 PM. Nurse #6 reported she was the nurse who admitted Resident #94 on 6/2/2023 and she was also assigned to her on 6/5/2023. Nurse #6 reported Resident #94 did not report pain to her when Nurse #6 conducted the pain assessment., and if she had reported pain, there were facility standing orders she could have activated for administering acetaminophen to Resident #94. Nurse #6 explained that because Resident #94 did not report pain to her, she did not activate the standing orders. During an interview conducted on 7/21/2023 at 4:49 PM, NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 explained she went to get Nurse #6, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 was unable to move in bed without yelling out in pain. NA #3 explained that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearably painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. An interview was conducted with NA #4 on 7/25/2023 at 11:10 AM. NA #4 reported she provided her with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. There was no evidence in the medical record that pain medication was ordered on 6/5/2023. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. It was unknown if Resident #94 received pain medication during transport to the hospital for evaluation on 6/6/2023. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell, landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP is available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 6 /2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. The MD reported that delaying treatment for a fractured large bone would have been very painful for Resident #94, and he was not aware she did not have an order for pain medication. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to an unknown nurse that Resident #94 had a fall and was experiencing pain. The DON stated she interviewed Resident #94 on 6/5/2023 after the NP evaluation and Resident #94 reported she had fallen and gotten herself up off the floor and did not report the fall to staff. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain and assessed Resident #94. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to notify the physician and/or the resident representative after Resident #94 reported to the Physical Therapist on 6/3/23 that she had fallen in her room on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. On 7/21/23, the Director of Nursing spoke to Nurse #1, and she denied any knowledge of Resident #94 reporting that she had fallen or that the physical therapist or any other staff member reporting to her that Resident #94 had fallen. In addition, Nurse #1 was asked if Resident #94 requested pain medication or had signs or symptoms of pain and Nurse #1 reported no. On, 7/20/23, the Therapy Director spoke to the physical therapist that was working on 6/3/23 and she reported that Resident #94 had reported to her that she had fallen on 6/2/23 while attempting to go to the bathroom. The physical therapist reported that the roommate also reported that the resident had fallen on the previous day (6/2/23). On 6/5/23, after the Nurse Practitioner reported that Resident #94 reported a fall on 6/2/23, the Director of Nursing completed a follow up interview and Resident #94 reported that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff. On 6/5/23, Unit Manager #1 and the Admissions Director spoke to Resident #94's family member who reported that on 6/2/23, Resident #94 had reported to him that she had fallen on the way to the bathroom and that she was having a lot of pain. The family member reported that he reported that Resident #94 was having pain to the charge nurse. On 6/5/23, during the Nurse Practitioner initial assessment, Resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. On 7/17/23, the facility investigation by the Director of Nursing revealed that the Nurse Practitioner was informed of Resident #94's fall on 6/2/23 during her initial assessment on 6/5/23 by the resident. In addition, further review of the medical record revealed that there was no fall nursing assessment documentation or physician/physician extender notification documentation by the licensed nurse of the 6/2/23 fall until 6/5/2023. The Director of Nursing completed the interviews on 7/21/23. The interviews revealed that the licensed nurses and the certified nursing assistants that worked on 6/2/23, 6/3/23, and 6/4/23 reported that Resident #94 did not report to them that she had fallen on 6/2/23. The licensed nurses, certified nursing assistants, and certified medication aide interviews by the Director of Nursing of staff that who worked on 6/2/23, 6/3/23, and 6/4/23 per the nursing assignment sheets revealed that Resident #94 did not report the fall to the assigned licensed nurse, certified nursing assistant or certified medication aide. On 7/17/23, Nurse #3 (Weekend Supervisor) interview with the Director of Nursing revealed that Resident #94 did not express pain concerns and she did not observe signs or symptoms of excruciating pain on 6/3/23 and 6/4/23. Nurse # 3 also reported that Resident #94 as well as the other nursing staff to include the physical therapist who worked on 6/3/23 and 6/4/23, did not report that Resident #94 has fallen on 6/2/23. Nurse #3 reported that Resident #94's family member did not report to her that the resident was having pain and that the resident had fallen on 6/2/23. All current residents are also at risk as a result of this deficient practice. Starting 7/21/23, the Director of Nursing/the Unit Managers and designee will complete an audit of the medical records to include review of progress notes, outside provider notes, incident reports, medication administration records, physician orders, and nursing shift reports of all the current residents for the last 60 days to ensure the physician/ physician extenders and resident representatives have been notified of any resident falls or changes in condition and identified concerns have been address by 7/25/23. Starting 7/21/23 the Director of Nursing / designee will complete interviews of the alert current residents to ensure resident concerns to include incident and accidents, pain management, medication/ treatments and other resident care concerns have been identified and reported to the physician/ physician extenders in the last 60 days by 7/25/23. Starting 7/21/23, the Director of Nursing/ designee will complete interviews of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, housekeeping/laundry, agency, new hire and prn staff to ensure all resident changes in condition or any reported concerns in the last 60 days have been reported to the DON, Unit Manager and/or the Nursing supervisor by 7/25/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 7/21/23, the Staff Development Coordinator/ designee will complete education by 7/25/23 of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, therapy department, housekeeping/laundry, agency, new hire and prn staff related to ensuring resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/families reported concerns have been reported to the licensed nurse and to the physician and/or DON, Unit Managers and nursing supervisor. Starting 7/21/23, the Staff Development Coordinator/ designee will complete education with the licensed nurses to include agency, new hire, and prn licensed nurses related to immediate notification and documentation of resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/ families reported concerns to the physician/ physician extenders and resident representatives and document in the medical record by 7/25/23. After hours the licensed nurse will notify the on-call provider and document in the medical record. Starting 7/21/23, the Staff Development Coordinator was made aware by the Director of Nursing that she will be responsible for verifying that the education has been completed by the required staff members by using the facility personal roster and the nursing, dietary, therapy and housekeeping/laundry staffing schedules to include new hires, agency and prn staff and ongoing education by 7/25/23. No staff will be allowed to work until they have received this education. The SDC/ designee which includes the DON, Unit Managers, and Nursing supervisors will be responsible for providing all of the education. On 7/25/23, The Director of Nursing educated the therapy manager to ensure that all therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist report resident observed and reported falls to the therapy manager and the Director of Nursing immediately. Starting 7/25/23, the therapy manager will educate the therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist related to ensuring resident observed and reported falls are immediately reported to the therapy manager and the Director of Nursing. Therapy staff to include prn and new hire staff will not be allowed to until they receive this education. Effective 7/21/2023 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/227/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility provided documentation to support the Credible Allegation for F697. The facility's Nurse Practitioner assessed the named resident and sent her to the hospital for evaluation of a right subcapital fracture. The facility further provided documentation of pain assessment for all residents in the facility. The facility further provided auditing of pain assessments, pain documentation, pain medication management, and pain care plan updates for all residents in the facility. An in-service education was completed with the nursing and therapy staff regarding resident pain identification, signs of pain, management of pain medication, documentation of pain, and update of the care plan. The facility further provided the education that will be provided to all new hires and agency staff regarding pain management before being allowed to work in the facility. Facility nursing staff were interviewed regarding their understanding of the education provided. The assessment of the named resident and all other residents; the auditing of pain assessments, documentation, medication management, and care plan update; and the education of staff were completed by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.