**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the resident's Responsible Party (RP), Medical Director and staff, the facility failed to notify the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed until 11/18/24 and the results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). Failure to notify the physician delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, bed sores, and increased risk for mortality. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This deficient practice affected 1 of 5 residents reviewed for notification of change (Resident #1). Immediate jeopardy began on 11/17/24 when the facility failed to notify the Medical Director that the STAT x-ray of Resident #1's left hip could not be completed as ordered on 11/17/24. The immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a 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. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). An Unwitnessed Fall Report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA) #1 that Resident #1 was on the floor next to her bed sitting on her bottom. The on-call provider and responsible party (RP) were notified. She was assessed, and no injuries were noted. Vital signs were within normal limits. Resident #1 reported no pain or discomfort. She was then assisted back to her bed. Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that on 11/17/24 around 11:00 AM, NA #1 told her that Resident #1 had fallen in her room. Nurse #1 went to the room and saw Resident #1 on her bottom next to her bed. Although Resident #1 was nonverbal, she could shake/nod her head to yes and no questions. Nurse #1 asked if she was ok, and she said yes. She then assessed Resident #1, including her extremities (limbs, hands, and feet), and asked if she hit her head. Resident #1 said no. She was then put back into bed with Nurse #1's assistance. Nurse #1 took vital signs and notified her supervisor at the time (name unknown). Nurse #1 was instructed to complete all documentation related to the fall and then called Resident #1's RP. The RP came later (45 minutes or so) and said Resident #1 complained of pain. Nurse #1 assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying on her right side. When she pressed on it, Resident #1 winced with pain, and there was a bruise. She contacted the On-Call Provider again and told her that the newly onset pain had not been discovered until just then. She was instructed to order an x-ray STAT. Nurse #1 stated she gave Resident #1 some Tylenol and then she left for the night at 7:00 PM. A 72 Hour Post Fall Documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip. The RP was interviewed on 12/18/24 at 1:56 PM. She revealed that when she arrived at the facility on 11/17/24, about 45 minutes after the fall, Resident #1 complained of pain. The RP indicated she reported the pain to Nurse #1. An On-Call NP note dated 11/17/24 at 2:32 PM revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. Now, Resident #1 reported left hip pain with tenderness to palpation. A STAT x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours. Physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:05 PM. A telephone interview was conducted with Nurse #1 on 12/19/24 at 6:05 PM. She revealed that radiology told her they would get to the facility on [DATE] as soon as they could. Nurse #1 indicated she did not notify the On-Call NP that the x-rays were not yet performed when she finished her shift at 7:00 PM on 11/17/24. Nurse #1 could not provide a reason as to why she did not notify the On-Call NP of the STAT x-ray delay. A Medical Progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status. A Health Status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility to perform the STAT x-rays ordered on 11/17/24. Review of the x-ray results dated 11/18/24 revealed an acute nondisplaced transverse left femur fracture. The x-rays were taken at 9:23 AM and reported to the facility at 12:54 PM. Review of a health status dated 11/18/24 at 2:59 PM and completed by Nurse #2 revealed that the results were back from the STAT x-rays. The RP and NP were notified. During an interview with the Medical Director on 12/20/24 at 12:57 PM, he revealed that the expectation of a STAT x-ray was for it to be performed on the same day it was ordered. If a STAT x-ray was delayed until the next day, he should have been notified. The Director of Nursing (DON) was interviewed on 12/30/24 at 11:49 AM. She revealed that if a STAT x-ray was not performed within 2-4 hours after it was ordered or before a shift was completed, then Nurse #1 should have contacted the on-call provider for further instructions on whether to wait or receive other orders. An interview was conducted with the Administrator on 12/31/24 at 12:00 PM. He revealed that if a STAT order was not completed the same day, Nurse #1 should have notified the on-call provider to receive further instruction on how to move forward. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. Review of physician orders for Resident #1 revealed that on 11/19/24 an orthopedic surgery consultation for a left hip/leg fracture was ordered. The Transportation Scheduler was interviewed on 1/7/25 at 4:20 PM. She revealed that she had received a consultation order from the NP on 11/19/24 to schedule an orthopedic appointment for Resident #1. The Transportation Scheduler stated she did not receive an order as soon as possible (ASAP) for the appointment from the NP, but she called that day (11/19/24) to schedule. The appointment was originally scheduled for 11/26/24. The Transportation Scheduler indicated she was notified on 11/22/24 to get Resident #1 an immediate orthopedics appointment for that day, but she could not recall who the request came from. Review of Resident #1's medical record revealed that there was no documentation for an orthopedics consultation scheduled for 11/26/24. During a telephone interview with NA #3, who worked with Resident #1 during the overnight shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she stated that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. NA #3 recalled when she arrived for her shift, she was notified by the off coming NA #5 that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. NA #3 did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. NA #3 further stated she made sure not to change or move Resident #1 during the shift unless necessary. A telephone interview was conducted with NA #2 on 12/19/24 at 10:53 AM. NA #2 confirmed she worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop. The DON was interviewed on 12/30/24 at 11:49 AM. She revealed that if Resident #1 was in any discomfort after the fall on 11/17/24, NA #2 and NA #3 should have notified the nurse on duty or the provider. The NAs could have performed a Stop N Watch, which meant they were not allowed to assess Resident #1's pain, but they could have completed charting in her medical record that would alert the DON, unit managers, and the providers. The Administrator was interviewed on 12/31/24 at 12:00 PM. He revealed that NA #2 and NA #3 should have completed a Stop N Watch task as well as notified the charge nurse that they thought Resident #1 had some discomfort during their shifts. A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results reported on 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. He was unaware that an orthopedic appointment had been scheduled for the following week and not sooner. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. During a follow-up telephone interview with the Medical Director on 12/20/24 at 11:13 AM, he revealed that the nurses always put the printout of the x-ray results in his mailbox or the provider communication book to review. The Medical Director stated that he relied on the paperwork in his mailbox or provider communication book for further evaluation or orders. He further stated that he did not see Resident #1's x-ray results in the provider's communication book until 11/22/24. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge summary dated [DATE] revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the emergency department (ED) for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived at the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The on-call medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The medical provider was not notified the stat x-ray could not be obtained on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The residents' responsible party and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the daughter who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The facility failed to notify the Medical Director (MD) that the orthopedic consult could not be scheduled ASAP. The facility failed to notify the MD when the resident's pain was not manageable on night shift for the following dates, 11/20/2024 and 11/21/2024, when Resident #1 grabbed the aide and said stop. The MD was not aware of the fracture until he saw Resident #1 on 11/22/2024 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/2024 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/2024. On 12/27/2024 the Director of Nursing and Nurse Managers reviewed residents who have fallen during the last 30 days to confirm that the Medical Director had been notified. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/3/2025. On 12/27/2024 the Director of Nursing and Nurse Managers reviewed 30 days of diagnostic and laboratory testing to ensure they were obtained as ordered and the Medical Director had been notified. The audit included reading 30 days of progress notes to identify any residents that may have been in pain and were not addressed. Any opportunities identified during this audit will be corrected by the nurse managers by 1/3/2025. On 12/20/2024 the Director of Nursing/Staff Development Coordinator began in person education for all nursing staff on the facility policy and procedures for physician notification to include notification of physician for any complaints of unrelieved pain by residents to be reported to the physician immediately. Education also included notification to the physician of any delays in physician orders including stat orders and delay in any physician ordered appointments, consultations, and X-rays this is to include the weekends and after hours. Licensed nurses were also educated on utilization of the MD communication book to report diagnostic reports and other non-emergent resident issues. All nurse aides were also educated on the process of notification to licensed nurse of any identified resident issues such as pain or other resident concerns and use the electronic medical record, which is to document the pain and/or concerns of the resident in their electronic medical record. The licensed nurses will review the information and report to the medical provider. The licensed nurses will document in the residents' electronic medical record the notification to the medical provider and the plan of care. The Nurse Managers will review the residents electronic medical record daily and the documentation to ensure the medical provider was notified. Education will be provided for all new nursing staff and agency staff prior to the beginning of their first shift. Education will be completed by 1/4/2025 by the Director of Nursing/Staff Development Coordinator. This education will become a part of the new hire orientation process for newly hired nursing staff. The Staff Development Coordinator will track the education for all staff who did not receive the education to ensure they receive the education prior to their first assigned shift. The Staff Development Coordinator was notified of her responsibilities on 12/20/2024. Nurse Aides can report directly to the nurse or use the computer system which serves as an alert system within the resident's electronic record which nurse aides can send alerts to the nurse electronically. Once a computer system alert is triggered the nurse can see it instantly on the clinical dashboard for continued assessment to be done. The Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a fracture and/or a significant change of condition. The Licensed Nurse will call the Medical Director with any results of fractures and/or a significant change of condition. The Licensed Nurse will place this information in the Medical Directors' communication book after making verbal notification to the medical providers for additional follow-up by the Medical Director and in-house NP. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person. The Director of Nursing or designee will complete in person review with any staff that receive education by telephone to assure their understanding of the education received. The Staff Development Coordinator will be responsible for tracking which employees have received their education. The Staff Development Coordinator was made aware of this responsibility on 12/20/24. On 1/3/2024 the Director of Nursing and Administrator completed an Ad-Hoc QAPI to ensure that all components of the credible allegation were completed and followed. The QAPI included the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional Director of Clinical Services, Admissions Director, Unit Managers, Maintenance Director and Discharge Planner. Effective 1/3/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged date of IJ removal: 1/5/2025 An onsite validation was conducted on 01/09/25. A review of in-service records revealed that all nursing staff were educated on the facility's policy and procedures for physician notification to include any complaints of unrelieved pain by residents to be reported to the physician immediately. Education also included notification to the physician of any delays in physician orders including STAT orders and delay in any physician ordered appointments, consultations, and X-rays, this is to include the weekends and after hours. Licensed nurses were also educated on utilization of the physician communication book to report diagnostic reports and other non-emergent resident issues. All nurse aides were also educated on the process of notification to the licensed nurse of any resident experiencing issues such as pain or other resident concerns and use of the electronic medical record, which is to document the pain and/or concerns of the resident in their electronic medical record. Interviews conducted with nurses and nurse aides during the onsite validation were completed and the staff were able to verbalize knowledge of the policy and procedures for notification. The physician communication book was reviewed for verification of physician notification. The immediate jeopardy removal date of 01/05/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and facility staff, Nurse Practitioner (NP), Medical Director, and Responsible Party (RP), and Orthopedic Surgeon interviews, the facility failed to protect a resident's right to be free of neglect as evidenced by the following: they failed to notify the physician at the onset of pain and when an x-ray could not be completed STAT (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 and reported pain in her left hip. The x-ray was completed on 11/18/24 and revealed an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The NP failed to communicate and collaborate with the Medical Director when the x-ray results were received on 11/18/24 and the facility failed to recognize the seriousness of the injury and identify the need for urgent orthopedic evaluation and surgical intervention. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedic consultation scheduled for 11/26/24. The facility failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). The Medical Director (MD) was not aware of the fracture or the orthopedic consult scheduled for 11/26/24 until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. The resident was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 1 sampled residents reviewed for neglect (Resident #1). Immediate jeopardy began on 11/18/24 when the facility neglected to provide the necessary care and services for Resident #1 when x-ray results verified the resident sustained a transverse left femur fracture. The immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a 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: This tag is cross referenced to: F580: Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed 11/18/24 and the results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). Failure to notify the physician delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, bed sores, and increased risk for mortality. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This deficient practice affected 1 of 5 residents reviewed for notification of change (Resident #1). F684: Based on record review and interviews from the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (with no delay) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1). F714: Based on record review, and staff, Medical Director (MD) and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the MD when Resident #1 was diagnosed on [DATE] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture following an unwitnessed fall on 11/17/24. The NP did not consult with the MD before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and MD delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This failure affected 1 of 3 reviewed for accidents (Resident #1). The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable 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: An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024. The stat x-ray was not obtained on 11/17/2024. The nursing staff failed to notify the medical provider that the stat x-ray could not be obtained on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's RP and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the daughter who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/2024 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/2024. The facility failed to notify the physician of an acute change in condition requiring emergent orthopedic medical treatment (x-ray results positive for fracture). The facility failed to notify the physician that an x-x-ray ordered stat was not going to be done stat. The facility failed to notify the physician that the orthopedic consult could not be scheduled ASAP. The facility failed to notify the physician when the resident's pain was not manageable on night shift on 11/20/2024 and 11/21/2024 when resident grabbed the aide and said stop. The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after a fall on 11/17/2024 and identify the urgent need for orthopedic evaluation and surgical intervention. A STAT x-ray was ordered but not completed until 11/18/2024 and confirmed the fracture. The Nurse Practitioner ordered scheduled and as needed opioid pain medication and an orthopedic consultation on 11/19/2204 but failed to collaborate with the MD he was attempting to treat the fracture in- house. The facilities neglect led to delayed treatment of Resident #1's left intertrochanteric femur fracture on 11/18/2024 causing Resident #1 to be sent to the hospital 11/22/2024. Resident #1 had surgery on 11/23/2024 to repair the left femur fracture. To assist in identifying other residents who may have been affected by this deficient practice on 12/20/24 the Nurse Practitioner and Medical Director reviewed the previous 45 days of labs and radiology reports to ensure that all abnormalities have been addressed. On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to assess residents to include active and passive range of motion and pain assessment. This review also included examination of all recent incident reports to identify any patterns or recurring issues related to falls or delayed medical interventions. The Director of Nursing and Regional Director of Clinical Services completed a review of all pain scales on 1/4/25 to assist in identifying any resident with unrelieved pain. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/25. On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to validate the Medical Director had been notified. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/2025. 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: On 12/20/24 the Director of Nursing/Staff Development Coordinator began in-person education for all facility staff in all departments including agency and contract staff. Education included review of policy regarding abuse/neglect. - Recognizing signs of abuse and neglect - Examples of neglect, including not providing necessary care and services. - Reporting of abuse and neglect - Facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately. - Notification to physician of any delays in physician orders including stat orders and delay in any physician ordered appointments and x-rays. - Education to certified nurse aides on reporting identified pain and other abnormal events identified during delivery of care. Any nursing staff member that did not receive education on 12/20/2024 will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All newly hired licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 12/20/2024. The DON or designee will verify the understanding of education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. In person education was completed on 12/27/2024 by the Director of Nursing to current medical providers including on-call providers, Nurse Practitioners and Medical Director. Education consisted of communication between all providers should be clear, concise and collaborative. Communication should include a discussion of treatment plans and seeking advice when necessary. Providers should participate in decision making in a timely manner. On 1/3/2025 the Medical Director and the Physician Extenders agreed to meet with the Director of Nursing weekly to discuss abnormal labs, radiology or test results as a team. On 1/3/2025 the Regional Director of Clinical Services informed the Staff Development Coordinator and/or the Director of Nursing to complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy removal: 1/5/2025 An onsite validation was conducted on 01/09/25. A review of in-service records revealed that all facility staff were educated on the facility's policy and procedures for abuse and neglect. This in-service training included: Recognizing signs of abuse and neglect, examples of neglect, including not providing necessary care and services, reporting of abuse and neglect, facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately, notification to physician of any delays in physician orders including STAT orders and delay in any physician ordered appointments and x-rays and education to nurse aides on reporting identified pain and other abnormal events identified during delivery of care. Interviews conducted with staff verified they had received training on abuse and neglect. The immediate jeopardy removal date of 01/05/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff, the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (immediately) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1). Immediate jeopardy began on 11/18/24 when the facility failed to recognize the seriousness of the injury and identify the need for urgent orthopedic evaluation when x-ray results verified the resident sustained a transverse left femur fracture. The immediate jeopardy was removed on 1/9/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a 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. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had adequate vision/hearing, usually understood/understands, and was severely cognitively impaired. She did not have any falls since the previous assessment, and there was no pain presence or pain medication regimen in place at the time of the review period. Resident #1 was 62 inches tall and weighed 89 pounds. Review of physician orders for Resident #1 revealed that a pain assessment using 0-10 (0 = no pain, 10 = excruciating pain) scale or non-verbal scoring tool every shift was ordered on 11/9/24. Review of an unwitnessed fall report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA)#1 that Resident #1 was on the floor next to her bed sitting on her bottom. Resident #1 denied hitting her head. The On-Call Provider and RP were notified. She was assessed, and no injuries were noted. Vital signs were within normal limits. Resident #1 reported no pain or discomfort. She was then assisted back to her bed. Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the RP arrived at the facility. An On-Call NP note dated 11/17/24 at 2:32 PM revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. Now, Resident #1 reported left hip pain with tenderness to palpation (a method of feeling with the fingers or hands during a physical examination). Nurse #1 reports right facial swelling and concern for facial droop. A neurological check was performed by the NP via video and there were no acute deficits noted. A STAT x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed (PRN) for pain. Neurological checks should be performed every 4 hours. Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:04 PM. On the same day, Tylenol 500mg tablet given every 6 hours as needed for pain was also ordered. Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that on 11/17/24 around 11:00 AM, NA #1 told her that Resident #1 had fallen in her room. Nurse #1 went to the room and saw Resident #1 on her bottom next to her bed. Although Resident #1 was nonverbal, she could shake/nod her head to yes and no questions. Nurse #1 asked if she was ok, and she said yes. She then assessed Resident #1, including her extremities (limbs, hands, and feet), and asked if she hit her head. Resident #1 said no. She was then put back into bed with Nurse #1's assistance. Nurse #1 took vital signs and notified her supervisor at the time (name unknown). Nurse #1 was instructed to complete all documentation related to the fall and then called Resident #1's RP. The RP came later (45 minutes or so) and said Resident #1 complained of pain. Nurse #1 assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying on her right side. When she pressed on it, Resident #1 winced with pain, and there was a bruise. She contacted the On-Call NP again and told her that there was new onset pain. The On-Call NP ordered an x-ray STAT. Nurse #1 stated she gave Resident #1 some Tylenol and then she left for the night at 7:00 PM. A follow-up telephone interview was conducted with Nurse #1 on 12/19/24 at 6:05 PM. She revealed that radiology told her they would get to the facility on [DATE] as soon as they could. Nurse #1 did not notify the On-Call Provider that the x-rays were not yet performed when she finished her shift at 7:00 PM on 11/17/24. Nurse #1 could not provide a reason as to why she did not notify the On-Call Provider of the STAT x-ray delay. During a telephone interview with the Medical Director on 12/20/24 at 12:57 PM, he revealed that the expectation of a STAT x-ray was for it to be performed on the same day it was ordered. The Director of Nursing (DON) was interviewed on 12/30/24 at 11:49 AM. She revealed that if a STAT x-ray was not performed within 2-4 hours after it was ordered or before a shift was completed, then Nurse #1 should have contacted the On-Call Provider for further instructions on whether to wait or receive other orders. The RP was interviewed via telephone on 12/18/24 at 1:56 PM. She revealed that Nurse #1 called her on 11/17/24 when Resident #1 fell and said she was fine. She visited 45 minutes later, and when asked if anything hurt, Resident #1 would say her left hip. The RP was told by Nurse #1 that an x-ray was ordered. She waited until 8:00 PM, but no one came. During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he revealed that when he arrived for the night shift on 11/17/24, he was instructed by the day shift nurses to pay more attention to Resident #1 due to her trying to get up without assistance. Resident #1 needed assistance with transfers and was very unsteady on her feet. Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation. Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility for Resident #1 to perform the STAT x-rays ordered on 11/17/24. Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. Review of the x-ray results dated 11/18/24 revealed an acute transverse left femur fracture. The x-rays were taken at 9:23 AM and reported at 12:54 PM. Review of a 72-hour post fall documentation note dated 11/18/24 at 2:18 PM and completed by Nurse #2 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip. Review of the November 2024 medication administration record (MAR) revealed that Nurse #2 administered 500mg of as needed Tylenol to Resident #1 on 11/18/24 at 2:54 PM due to a pain level of 7. Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/18/24. Resident #1 was not alert and oriented and was nonverbal but able to shake her head yes or no when asked a question. She stated Resident #1 had bruising on her left hip, and an x-ray was ordered. On 11/18/24, it was found that Resident #1 had a left hip/leg fracture. Nurse #2 would ask Resident #1 how she was feeling during medication pass on 11/18/24 and if she was hurting, and she would nod yes if in pain. When working with her and turning her in bed, Nurse #2 noticed that Resident #1 would grimace some. It seemed she had pain from between a 4 to 7 out of 10 on the pain scale on 11/18/24. During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he stated he did not recall if he received any special instructions or was notified of the fracture when he arrived for the night shift on 11/18/24. Resident #1 was nonverbal but would shake her head yes or no for responses. During the week of 11/18/24, he indicated that he could not recall if Resident #1 had any significant signs or symptoms of pain/discomfort. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she spoke to the RP on 11/19/24, and she wanted Resident #1 to be sent out to the hospital. The Unit Manager instructed her to speak to the NP, who then told her that Resident #1 was not a surgical candidate due to her low body mass. The Unit Manager indicated there was a non-verbal scoring tool with pain assessments on the MAR, and all nurses should have performed pain assessments during each shift. Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for a left hip/leg fracture was ordered. An order note dated 11/19/24 at 10:16 AM by Nurse #2 revealed that new orders were received for an orthopedic consultation of Resident #1's left femur fracture after a fall. Review of a health status note dated 11/19/24 at 11:43 AM by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. A consultation for orthopedics was ordered. Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that the note read in part: Current status of the resident's injuries or reports of pain from the fall: Acute transverse, nondisplaced intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Interventions are currently in place to prevent additional falls: keep wheelchair beside bed, call bell within reach, bed in lowest/locked position, and Nurse Aides rounding every 2 hours. Resident's response to new interventions remains in the bed, Tylenol given for pain. Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/19/24. The nurse stated she asked Resident #1 how she was feeling during medication pass on 11/19/24 and if she was hurting, and she would nod yes if in pain. On 11/19/24, an order for Tramadol was added. Review of a health status note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol (treats moderate to moderately severe pain). The RP was made aware. On 11/19/24, a physicians order for Tramadol (opioid) 25mg twice daily due to the resident having increased pain. During an interview via telephone on 12/18/24 at 1:56 PM the RP indicated they visited on 11/18/24 and found out about the left hip/leg fracture x-ray results. She requested to speak to the NP, but she was not contacted until 11/19/24. He (the NP) told her that Resident #1 had a broken hip and would not send her out because she was not a surgical candidate due to her small body frame and the fracture could possibly heal on its own. On 11/19/24, the RP stated she told the Unit Manager that Resident #1 was still in pain, and the RP wanted her to be sent out to the hospital. The RP stated she could not rate Resident #1's pain level due to her dementia but when she (the resident) reached for something she would say her left hip was hurting. When the RP asked if they could send Resident #1 to the hospital, the Unit Manager told her that the hospital would send her right back. The Unit Manager then ordered stronger pain medication. The RP stated her main concern was that Resident #1 was not sent to the hospital immediately after the fall. During a telephone interview with the RP on 12/18/24 at 10:28 AM, she revealed on 11/19/24 when she spoke to the NP over the phone, he told her that he would not send Resident #1 to the hospital due to her small body frame, and it would be difficult for the surgeons to work on her. The RP recalled the facility scheduled an orthopedic appointment originally for 11/26/24. During a follow-up telephone interview with the RP on 12/20/24 at 9:56 AM, she revealed that when she spoke to the NP over the phone on 11/19/24, he never spoke to her about the risks of not sending Resident #1 out to the hospital. Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. The note indicated staff were to provide closer supervision and that fall protocols were in place. Laboratory results and radiology were reviewed. The Night Nurse Supervisor was interviewed via telephone on 12/21/24 at 7:48 AM. She revealed that she did not assess Resident #1 for pain at all on 11/18/24, 11/19/24, or 11/20/24 She stated that she took the information in the 72-hour post fall documentation notes from the previous shift and copied the details into the notes she wrote just so that some kind of documentation was completed during her shift. The Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done it herself. Resident #1 was nonverbal, so she could not verbally provide a pain scale rating. During a telephone interview with NA #3, who worked with Resident #1 during the night shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she revealed that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. When she arrived for her shift, she was notified by the off coming NA that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. She did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. She made sure not to change or move Resident #1 during the shift unless necessary. Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall protocols were already in place. Laboratory results and radiology reviewed. A telephone interview was conducted with NA #2 on 12/19/24 at 10:53 AM. She worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop. Review of the MAR for November 2024 revealed that pain assessments were completed with a check mark from 11/19/24 - 11/22/24 without a numerical value or location for pain or a non-verbal pain scoring tool result in the medical record. Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics was made for today (11/22/24). A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she thought Resident #1 was not in pain the week after the fall because there was one day (date unknown) that she got out of bed into her wheelchair. However, for most of that week after the 11/17/24 fall, Resident #1 remained in bed, even though she was usually up daily. Every time she (the Unit Manager) asked if Resident #1 was in pain, she shook her head no. The RP told nursing staff that Resident #1 was in pain, but when staff asked her themselves, she would shake her head no. On 11/22/24, after the Medical Director saw the x-ray results and evaluated Resident #1, he wanted her to be sent out to an orthopedic appointment that same day. The RP was interviewed via telephone on 12/18/24 at 10:28 AM and 1:56 PM. She indicated Resident #1 remained in bed the entire week until 11/22/24, the day she went to the hospital. The Scheduler called the RP on 11/22/24 and told her that the orthopedics appointment was rescheduled for that same day. No reason was provided. The orthopedics office saw the fracture, and Resident #1 was then sent to the emergency department (ED). The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Resident #1 would be suitable for surgery due to asymptomatic bradycardia. The NP indicated on 11/19/24 he requested Resident #1 be sent to the first available appointment at an orthopedics office to determine if she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP indicated that he did not send Resident #1 to the emergency department (ED) because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to the emergency department (ED) for surgery. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused (adequate blood flow). Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge summary dated [DATE] revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the ED for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. The Orthopedic Surgeon, who performed the left hip surgery for Resident #1 on 11/23/24 in the hospital, was interviewed on 1/2/25 at 5:22 PM. He revealed that the healing and the treatment of Resident #1's left hip/leg fracture would not change with the delay of surgery. However, the risk of complications would go up if there was a delay. Such complications could be deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. The Orthopedic Surgeon stated that if Resident #1 was lying completely still, then the left hip pain could be well tolerated. However, if she was transferred to a chair or back to bed or rolling in bed, that could be significantly painful for her. In general, the standard of care was that if someone broke a long bone (such as the femur), they would need to be evaluated by an orthopedic specialist, who would then make the final decision for surgery within 24-48 hours after the injury. An injury like this would need an immediate transfer to the hospital. If she came to the clinic to be seen, she would have been sent directly to the ED, and they would not let her go home and wait for surgery. If this type of fracture was not treated within 24-48 hours, there are good outcome studies that were done showing a 30% perioperative mortality rate. That mortality rate would decrease if the injury was treated with surgery within 48 hours. The DON was interviewed on 12/30/24 at 11:58 AM. She revealed that nurses should have used a non-verbal pain tool or a pain scale when assessing Resident #1 for pain. She believed that the nurses chose N/A in the MAR when performing the pain assessments because Resident #1 denied pain. If a STAT x-ray was not done within 2-4 hours or before a shift was completed, then the nurse should have contacted the on-call provider for further instructions whether to wait or complete other orders. Resident #1 was noted during that week without pain or discomfort. The providers made their decision, and if any pain or discomfort was observed, the providers and managers would have agreed on further steps. The DON stated Resident #1 was not neglected, and the NP made his judgement call to keep her at the facility. During an interview with the Administrator on 12/30/24 at 12:31 PM, he revealed that he could not speak on this issue due to not having a clinical background. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable 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: An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The residents' RP and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the RP who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The NP made a determination to treat the injury in-house because he considered the resident to not be a good surgical candidate. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after the fall on 11/17/24, identify the urgent need for orthopedic evaluation and surgical intervention, obtain the x-ray stat as ordered by the medical provider. In addition, the facility also failed to explain to the RP the risk of not sending the resident out for treatment versus managing the fracture in-house without a physician and/or orthopedic consultation. The delay in orthopedic medical management care and treatment put the resident at risk for complications such as DVT, PNA and bed sores. On 12/27/24 the Director of Nursing, Unit Managers and Regional Director of Clinical Services, reviewed the last 30 days of diagnostic results and progress notes for all residents to identify any instances of delay in carrying out orders, changes in condition, abnormal results, refusals or other clinical conditions that had not been properly identified and acted upon. If there were instances identified, the Unit Manager completed proper assessment and follow-up with resident, medical providers and responsible party as needed. 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: The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for Licensed Nurses, including agency nurses, on recognizing when to seek medical treatment for residents with fracture and changes in condition and notification to the Physician/Medical Director following an incident or change of condition and when receiving ordered diagnostic test results. Requirements for notification included reporting of abnormal labs and x-ray results, if an order is not to be carried out as ordered by the physician or nurse practitioner, refusal of treatment plan by the resident or responsible party. Education also included knowing the risk and benefits of not sending a resident out for treatment when needed and how to effectively communicate this information to the RP or resident if they are responsible for making their own healthcare decisions. Risks include worsening condition, delayed treatment plan, increased pain or discomfort and complications associated with the disease process. The Director of Nursing will ensure that no staff member works without receiving this education. The Staff Development Coordinator is responsible for tracking that all staff received the required education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/8/2025 by the Staff Development Coordinator. The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers initiated in-person training for all Licensed Nurses, including agency nurses, to ensure they understand the requirements for orders received for diagnostic tests. The requirements included: If the diagnostic test is ordered stat and the mobile diagnostic company is unable to perform the study stat or in an acceptable time at the direction of the medical provider the resident is to be sent to the hospital. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/4/2025. The Staff Development Coordinator will be responsible for tracking all staff to make sure they have received the required education. The Staff Development Coordinator was informed of her responsibility on 12/27/24. This education will also become a part of the new hire orientation process for all newly hired licensed nurses. On 12/27/24, the Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for all Licensed Nurses, including agency nurses, on the procedure for handling abnormal x-ray results. The training emphasized that abnormal results must be reported to the Medical Director for further orders. Education will be completed by 1/4/2025. Any staff who did not receive the in-person training will be educated before their next scheduled shift. The Staff Development Coordinator is responsible for tracking that all staff receive the required education. This training will also be included in the new hire orientation for all newly[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Medical Director and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the Medical Director when Resident #1 was diagnosed on [DATE] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (leg) fracture following an unwitnessed fall on 11/17/24. The NP did not consult with the Medical Director before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and Medical Director delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This failure affected 1 of 3 reviewed for accidents (Resident #1). Immediate jeopardy began on 11/18/24 when the NP failed to collaborate and communicate with the Medical Director regarding medical management when x-ray results confirmed Resident #1 had an acute nondisplaced intertrochanteric femur fracture. Immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a 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 #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was severely cognitively impaired, had adequate hearing/vision, could speak clearly, and usually understood/understands. Review of an Unwitnessed Fall Report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA) #1 that Resident #1 was on the floor next to her bed sitting on her bottom. She was assessed, and no injuries were noted. Vital signs (VS) were within normal limits (WNL). Resident #1 reported no pain or discomfort and was then assisted back to her bed. Review of a 72 Hour Post Fall Documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the responsible party (RP) arrived at the facility. Review of On-Call Provider progress note dated 11/17/24 at 4:15 PM and completed by the on-call provider revealed that Resident #1 had a fall at 11:00 AM on 11/17/24. No injuries were reported, and Resident #1 denied pain. The RP visited the facility and now Resident #1 reported left hip pain with tenderness to palpation. A neurological check was performed via video and there were no acute deficits noted. A STAT (immediately) x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours. Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:04 PM. Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation. Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility to perform the STAT x-ray ordered for Resident #1 on 11/17/24. Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. Review of a health status note dated 11/18/24 at 3:00 PM and completed by Nurse #2 revealed Resident #1's x-ray results of the left hip were an acute nondisplaced intertrochanteric (where the hip and thigh meet) femur fracture. Review of Resident #1's radiology results report in the electronic medical record revealed an entry on the x-ray results that noted the Medical Director reviewed the report on 11/18/24 at 6:29 PM. During a telephone interview with the Medical Director on 12/20/24 at 11:13 AM, he revealed that the nurses always put the printout of x-ray results in his mailbox or provider book to review. The Medical Director stated on 11/18/24 he had cleared all the lab and x-ray results from the computer without looking at the x-ray report for Resident #1. He did not review the x-ray results of any resident if he did not place the original order. He stated that he relied on the paperwork in his mailbox or provider book for further evaluation/orders. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. Review of a health note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol. The RP was made aware. Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for a left hip/leg fracture was ordered. Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. Staff to provide closer supervision and fall protocols were in place. Laboratory results and radiology reviewed. Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall protocols were already in place. Laboratory results and radiology reviewed. Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics that had been made for today. A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. A telephone interview was conducted with the Unit Manager on 1/3/25 at 8:33 AM, and she revealed that the NP did consult with her and the Director of Nursing (DON) on 11/18/24 about the decision to keep Resident #1 in the facility and order an orthopedic consultation. The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Resident #1 would be suitable for surgery due to asymptomatic bradycardia (asymptomatic). The NP indicated on 11/19/24 he requested Resident #1 be sent to the first available appointment at an orthopedics office to determine if she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP indicated that he did not send Resident #1 to the ER because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to the ER for surgery. During a follow-up telephone interview with the NP on 12/20/24 at 8:09 AM, he revealed that he did not recall why the MD was not consulted prior to 11/22/24. The NP stated he made the decision to keep Resident #1 in the facility from consultations with the unit supervisor and the DON. During a follow-up telephone interview with the NP on 1/2/25 at 3:34 PM, he revealed that he was not trained to communicate with the Medical Director on specific topics. The NP and the Medical Director communicate on things that require additional assessments or moderate to severe issues (for example: a suspected arterial blockage in the lower extremities). The NP stated the only time he would communicate to the Medical Director about x-rays, or a fracture, was if he had a question about the treatment. During a follow-up telephone interview with the Medical Director on 12/20/24 at 8:27 AM, he revealed the NP consulted with him quite often, but he should have consulted with the Medical Director about the fracture when he found out on 11/18/24. The Medical Director stated that the NP had lots of experience and was qualified to look at x-rays and make decisions. However, in this case, the NP made the wrong decision. He should have sent Resident #1 out when the x-ray results were received. The Medical Director indicated that he had seen Resident #1 on 11/20/24, and she denied pain. He was unaware of the fracture on that date, and he was unaware that an x-ray was ordered by the On-Call Provider. He became aware of the fracture on 11/22/24 from the provider communication book. When he saw Resident #1 on 11/22/24, and she said she was in pain, he went to look at the communication report and found out about the fracture on that day. The fracture report was not in the communication book the days prior. During an additional telephone interview with the Medical Director on 1/2/25 at 3:09 PM, he revealed that the NP could have made the decision on his own to wait for surgery for Resident #1 because he had a lot of experience and was an independent practitioner. The NP made those types of decisions daily and well. The Medical Director stated that if the NP was comfortable managing those type of situations (fractures), then he did not need to consult with the Medical Director. The Medical Director indicated that he expected the NP to communicate with him when he was unsure/unclear about something or had a question, which the NP did regularly. The Medical Director indicated he and the NP spoke daily. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge summary dated [DATE] revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the ER for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. During an interview with the DON on 12/30/24 at 12:03 PM, she revealed that she was unaware of the medical providers' communication protocol. During a follow-up telephone interview with the DON on 1/6/25 at 8:54 AM, the DON recalled the NP giving the order for the orthopedic consultation and an explanation why Resident #1 may not have been a surgical candidate but did not ask for her opinion. An interview was conducted with the Administrator on 12/30/24 at 12:34 PM, and he revealed that he could not speak on the medical provider collaboration issue due to not having a clinical background. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the responsible party (RP) arrived to the facility. The on-call medical provider was called at 2:14 PM and at that time the medical provider gave orders for a stat x-ray. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 at 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's responsible party (RP) and Nurse Practitioner (NP) were informed of the results on 11/18/2024 at 2:59 pm. The NP made a determination to treat the injury in-house, but did not consult with the Medical Director regarding this treatment plan before making the decision to treat in house because he considered the resident to not be a good surgical candidate. The Medical Director (MD) saw the resident on 11/20/24 and 11/21/24 but was unaware of the fracture because of the lack of communication and coordination from the facility and the NP. On 12/20/2024, the MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD on 12/20/2024. On 12/20/2024, the Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of treatment should have been for the resident. On 1/4/25 the Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition. The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting. On 1/4/2025, the Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers on 1/4/25. The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person. This education was completed on 1/4/2025 by the Regional Director of Clinical Services. Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy Removal: 1/5/2025 An onsite validation was conducted on 01/09/25. The in-service conducted by Regional [NAME] President with the Medical Director, Nurse Practitioners, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition was reviewed. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition. Interviews completed with the Medical Director and Nurse Practitioner verified knowledge of the new process for collaborating and consulting following a significant change in condition. The immediate jeopardy removal date of 01/05/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to implement a broad-based approach COVID-19 testing for staff and residents on 10/13/24 when residents tested positive for COVID-19 on two resident halls. The facility had been in outbreak status since 10/08/24 when a staff member tested positive and only residents/staff with symptoms, roommates of residents that tested positive and staff that requested or were symptomatic tested for COVID-19. Broad-based COVID-19 testing per the Centers for Disease Control and Prevention (CDC) guidance was not implemented until 10/23/24. Before broad-based testing was implemented on 10/23/24, a total of 4 staff members and 22 residents had tested positive for COVID-19. Results of the broad-based testing from 10/23/24 through 10/25/24 yielded one (1) staff member and 6 additional residents positive for COVID-19. In addition, 11of 14 staff members failed to wear surgical masks covering both their mouth and nose for source control to help prevent transmission while working in the facility during the COVID-19 outbreak and one staff member (Nurse Aide #6) entered a resident room under transmission-based precautions for COVID-19 without wearing eye protection. The facility's infection control policy and procedures for outbreak testing did not conform with CDC guidance. had not initiated the administration of any 2024-2025 COVID-19 vaccinations for residents. The resident census at the time of the survey was 129. The facility had their first 2024-2025 COVID-19 vaccination clinic on 10/16/24 through10/18/24. These cumulative practices and system failures occurred during a COVID-19 outbreak and had the high likelihood for continued transmission of COVID-19 to residents and staff and a serious adverse outcome. Immediate Jeopardy began on 10/13/24 when COVID positive residents were identified on the 200-hall and 400-hall and broad-based testing of staff and residents was not initiated. Immediate jeopardy was removed on 10/25/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of E (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. The findings included: A. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: i. Employee and patient testing according to current standards Per the CDC guidelines dated 6/24/24, The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach is preferred if all potential contacts cannot be event identified or managed with contact tracing or if contact tracing fails to halt transmission. If additional cases are identified, strong consideration should be given to shifting to broad based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach testing should continue on affected units or facility wide every 3-7days until there are no new cases for 14 days. If antigen testing is used more frequent testing (every three days) should be considered. A review of the facility document titled COVID-19 Contact Tracing Investigation revealed the following: - The COVID outbreak started on 10/08/24 when the facility Social Worker tested positive for COVID. - The Receptionist tested positive on 10/10/09/24. - On 10/13/24 four residents on the 200-hall (Resident #98, Resident #126, Resident #442, and Resident #443) and 1 resident on the 400-hall (Resident #5) tested positive for COVID. - On 10/14/24 two residents on the 400-hall (Resident #90 and Resident#92) and 1 resident on the 700 hall (Resident #67) tested positive for COVID. - On 10/15/24 one resident on the 200-hall (Resident #68) and one resident on the 700-hall (Resident #3) tested positive for COVID. - On 10/17/24 one resident on the 200-hall (Resident #29), one resident on the 300-hall (Resident #55), one resident on the 400-hall (Resident #111), and two residents on the 700-hall (Resident #107 and Resident #116). - On 10/18/24 one resident on the 300-hall (Resident #39) and two residents on the 700-hall (Resident #4 and Resident #119) tested positive. - On 10/21/24 one resident on the 300-hall (Resident #13) tested positive. - On Tuesday, 10/22/24, two more residents and one staff member tested positive. - On Wednesday, 10/23/24, one additional resident and one staff member tested positive. On 10/23/24 at 11:09 AM an interview was conducted with the Infection Preventionist (IP)/Assistant Director of Nursing /Staff Development Coordinator, and she stated residents were tested when they were symptomatic or the roommate of a COVID positive resident. She further stated staff were tested when they requested or if they were symptomatic. The IP stated the facility Social Worker tested positive for COVID on 10/8/24 and on 10/09/24 the Receptionist tested positive for COVID. She stated on 10/13/24 five residents on the 200 hall and one resident on the 400-hall tested positive. On 10/14/24 there were 2 more residents on the 400-hall who tested positive for COVID and 1 resident on the 700-hall. On 10/15/24 another resident on the 700-hall and 1 resident on the 200-hall tested positive. On 10/17/24 a total of 5 more residents tested positive - 1 on the 200-hall, 1 on the 300- hall, 1 on the 400-hall and 2 on the 700-hall. On 10/18/24 another resident on the 300-hall and 2 residents on the 700-hall tested positive. She stated on Monday, 10-21-24, there were19 COVID+ residents and zero COVID+ staff. On Tuesday, 10/22/24 two more residents and 1 staff tested COVID+. On Wednesday, 10/23/24, 1 additional resident and 1 staff tested positive. The IP stated residents were tested on ly when they were symptomatic or if they were roommates of a resident who tested positive. She stated a COVID outbreak was when 6 or more residents and/or staff were positive. The Infection Preventionist stated she had spoken with her corporate clinical nurse consultant who had informed her that she did not have to report the COVID outbreak to the Health Department as they had in the past because the facility reported to National Healthcare Safety Network (NHSN). She said she reported this outbreak to the health department on 10/18/24 when the number of COVID+ residents reached 18. The IP stated she felt the spread of COVID throughout the building was largely due to noncompliant residents and the agency staff working at different facilities and getting exposed from numerous sources. The IP stated she felt they did all the protocols they should have initiated. The IP stated COVID+ residents were quarantined for 10 days and then they're off of quarantine and they do not re-test those residents after the 10-day quarantine. The interview further revealed the facility had a COVID-19 vaccine clinic In an interview with Nurse Aide (NA) #6 on 10/22/24 at 12:43 PM she stated she had not been tested for COVID by the facility. On 10/23/24 at 11:09AM the IP stated the facility had a COVID vaccine clinic from 10/16/24 through 10/18/24 and had one scheduled for that week (the week of 10/21/24) but cancelled it due to the survey. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 2:06 PM and she stated she expected all nurses (staff and agency) to follow the standards of nursing and to follow the infection prevention/infection control practices. The DON deferred questions regarding testing and education to the IP. A follow up interview with the DON was conducted on 10/25/24 5:00 PM revealed all residents in the facility and all staff members entering the facility were tested for COVID beginning on 10/23/24. The facility identified 6 more COVID+ residents on Wednesday, 10/23/24 and one staff member on Friday, 10/25/24. No positive cases were identified on Thursday 10/24/24. B. The facility policy titled Infection Prevention and Control Committee, updated 08/02/2024, revealed the Infection Prevention and Control Committee was responsible for implementing established program plans and standards of practice that promoted, monitored, and maintained an environment that reduced the risk of transmission and acquisition of center-acquired infections. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: a. Source control (well-fitting face mask/face covering): - For those with suspected or confirmed respiratory infection - For those who have had close contact with someone with COVID-19 for 10 days after contact - For those who reside or work in an area of the facility experiencing COVID-19 outbreak with uncontrolled transmission, or - When otherwise recommended by public health authorities - Even if not otherwise required by the facility, individuals should always be allowed to wear source control based on personal preference. c. Respiratory Hygiene/cough etiquette d. Visual alerts posted to inform current infection control practices f. Appropriate staff use of PPE, when indicated On 10/21/24 at 7:45 AM an interview and observation was conducted upon entry with Receptionist #1, and she informed the survey team masks were in use due to COVID-19 infection in the facility. Receptionist #1 was wearing mask during the interview. A box of yellow surgical masks and a box of black N-95 masks were available on the reception desk. There was no signage at the entrance to alert staff and visitors of a COVID outbreak, visual alerts for infection control practices or instructions about when to use personal protective equipment and hand hygiene. On 10/22/24 at 12:26 PM in an interview with Receptionist #2 she stated the front door was kept locked, so all visitors had to ring the bell to enter. She was wearing a mask covering her nose and mouth during the interview. She further stated visitors were directed to sign-in at the digital kiosk. Receptionist #2 stated that while she did not talk about the COVID status in the facility, she did talk to visitors about protecting themselves and also helping to protect the residents. She stated and offered the visitors a mask, either a surgical, KN95 or N95. Receptionist #2 stated it was not mandatory for visitors to wear masks while in facility. Receptionist #2 added she was unsure of what the mask policy was for staff working in the facility. On 10/21/24 at 3:08 PM an observation revealed Nurse Aide (NA) #2 walking down the 700-hall without wearing a mask. An interview was conducted with the Director of Nursing (DON) on 10/21/24 at 3:19 PM after she was observed removing her mask to speak to a resident in the Unit 2 common area. The DON stated she removed her mask to talk to the resident because he was hard of hearing. She further stated the purpose of the masks was to stop the spread of COVID. An observation on 10/22/24 at 10:38 AM revealed a housekeeper enter and exit 2 rooms on the 600-hall with a mask worn under his chin not covering his mouth and nose. An observation on 10/22/24 at 10:41 AM revealed Nurse #5 was reviewing medication administration records while seated in the Unit 2 common area. Nurse #5 was wearing a surgical mask tucked under her chin and the other nurse had on an N95 mask as well as a face shield. On 10/22/24 at 1:42 PM an observation and interview were conducted with Nurse #6 while she prepared to pass medications on the 600-hall. There were no COVID positive residents on the 600-hall. She was observed wearing a surgical mask below her nose. Nurse #6 stated when working on a COVID hall staff wore masks and the facility preferred for staff to wear N95 masks during the COVID outbreak. An interview was conducted with NA#3 on 10/22/24 at 1:45 PM as she entered the 600-hall from the therapy department hall. She was not wearing a face mask. NA #3 stated she was assigned to obtain weights on residents throughout the facility who were due weights. NA #3 added she was not assigned to weigh any residents with COVID. She said since the COVID outbreak masks were to be worn by staff and staff could wear the mask of their preference. On 10/22/24 at 1:52 PM an observation and interview were conducted with NA #4 on the 600 Hall. Her mask was under her nose. NA #4 stated she did not think the facility had an outbreak. NA #4 further stated an outbreak was when 50 or more residents were positive for COVID. She added the type of mask staff wore was an individual preference. On 10/23/24 at 10:04 AM Nurse #8 was observed as she prepared to administer medications on the 200-hall (a hall where there were COVID positive residents). Her surgical mask did not cover her mouth or nose. On 10/23/24 at 10:43 AM Nurse #8 was observed as she stood at a medication cart across from a room with droplet precaution signage on the 200-hall. Nurse #8 was wearing her surgical mask below her chin, not covering her mouth or nose. On 10/23/24 at 10:49 AM the Medical Director was observed walking down the 200-hall to the 400- hall then to 600-hall with his surgical mask under his nose. On 10/23/24 at 5:20 PM the IP brought staff folders to the conference room with no mask on. On 10/22/24 at 1:59 PM an observation and interview were conducted with Nurse #7 while she was walking through the Unit 2 common area. Nurse #7 was wearing a surgical mask, which covered her nose and mouth, and she stated the facility was considered in a COVID outbreak. She further stated masks were required, either surgical or N95. Nurse #7 added masks should be worn for the duration of the shift and should cover both the nose and mouth to keep from breathing in or out droplets. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Precautionary Measures Policy Name Transmission Based Precautions- General Practice Effective date 12/01/21 revealed the facility initiates transmission-based precautions to protect other patients, employees and visitors from the spread of a confirmed or suspected infection or contagious disease. The TBPs will be based on the type of pathogens, knowledge of the natural history of certain diseases and studies of epidemiology. The TBP measures will be the least restrictive possible for the patient under the circumstances. Measures included: 19. If protective attire is determined necessary, when donning the protective attire follow these steps: a. Wash hands or perform hand hygiene with alcohol-based hand rub b. Put on gown c. Apply mask over mouth and nose, (1) Pinch the metal band above the nose to make the mask fit to the contour of the face. (2) The mask must be replaced if it becomes moist or after 20 minutes (3) Do not touch the mask once it is positioned until it is removed (4) Remove the mask when leaving the room and discard immediately, (5) Do not reuse the mask. d. Put on goggles or face shield if required. Place over eyes and adjust to fit. e. Put on gloves. An observation on 10/22/24 at 12:43 PM was conducted of NA #6 as she passed lunch trays to residents on the 200-hall. Prior to entering a COVID+ resident's room (room [ROOM NUMBER]), she sanitized her hands and then donned PPE which consisted of an N95 mask, gown and gloves. She did not wear eye protection as she entered the room. When NA #6 exited the room, she was asked why she had not donned eye protection. NA #6 pointed towards the top of her head and patted a pair of goggles. NA #6 explained that she had been busy, moving fast to get the lunch trays passed out and had forgotten to put them on. NA #6 stated she was an agency NA, and it was her first time working in the facility. When asked if she had been made aware of the COVID outbreak in the facility, she confirmed the DON told her that morning. An interview was conducted on 10/23/24 at 11:09 AM with the Infection Preventionist (IP) and she stated she educated staff in all departments related to COVID protocol. The IP stated masks were mandatory during COVID outbreaks. She stated education for donning and doffing personal protection equipment (PPE) was provided during orientation, during yearly competencies, and in-services as needed. When informed of observations of staff not wearing their masks over both their nose and mouth, she stated she tried to make rounds periodically throughout the day to check to make sure staff were using PPE correctly. She stated when she saw staff not wearing their masks correctly, she reminded them to cover both their nose and mouth with the mask. She stated all staff were fit-tested for N95 masks and had been instructed on the proper application of masks and PPE. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 2:06 PM and she stated she expected all nurses (staff and agency) to follow the standards of nursing and to follow the infection prevention/infection control practices. The DON deferred questions regarding testing and education to the IP. In an interview with the Nurse Practitioner (NP) on 10/23/24 at 3:53 PM she stated staff not wearing masks properly can increase the transmission of COVID from staff to staff and from staff to resident. She stated none of her residents who tested COVID+ had been hospitalized . On 10/22/24 at 2:14 PM an interview was conducted with the Administrator, and he stated it was his expectation that any staff member caring for a COVID+ resident wear an N95 mask. C. The facility policy titled Infection Prevention and Control Committee, updated 08/02/2024, revealed the Infection Prevention and Control Committee was responsible for implementing established program plans and standards of practice that promoted, monitored, and maintained an environment that reduced the risk of transmission and acquisition of center-acquired infections. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: i. Employee and patient testing according to current standards A review of the CDC's policy for COVID testing dated June 2024 revealed the following guidance for nursing homes: - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. - Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. - Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. - Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. -In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. - If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. - If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. - If antigen testing is used, more frequent testing (every 3 days), should be considered. An interview was conducted with the IP on 10/23/24 at 11:09 AM and she stated there was a lot of back and forth about the infection control policy with the new facility ownership. She stated all staff receive PPE and infection control training during orientation, yearly during competency training and in-services as needed. The Administrator was notified of immediate jeopardy on 10/23/24 at 5:47 PM. The facility provided the following credible allegation of IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. On 10/23/2024, during the annual certification survey for [NAME] Health and Rehabilitation, it was noted that the facility had multiple residents affected by COVID. These residents were noted to be located on more than one hallway throughout the facility. During the survey it was noted that multiple staff did not employ appropriate source control throughout the facility. The facility did not initiate broad-based testing on all staff and residents with the increase in COVID cases throughout the facility. It is also noted that the facilities policy did not meet the CDC's guidance related to testing. On 10/23/24, the Director of Nursing and Infection Preventionist completed broad-based testing on all staff and residents within the facility. The facility will complete testing on all residents and staff twice per week until there is a 14-day interval of no new positive cases. The Infection Preventionist was notified on 10/24/24 and will be responsible for continuing testing until resolution of the outbreak. Specify action the entity will take to alter the process or system to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator/Infection Preventionist, and the Unit Managers regarding Special Droplet Contact Precautions when a resident tested positive for COVID-19. All staff, including medical director and Nurse Practitioner, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room. All staff, including medical director and nurse practitioner will wear a gown when entering the room, remove before exiting the room. All staff, including medical director and nurse practitioners, will wear an N95 when entering the room and remove before exiting the room. All staff, including the medical director and nurse practitioner will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room. All staff, including the medical director and nurse practitioner will wear gloves when entering the room and remove them before leaving the room. Education completed 10/23/2024. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding source control to include wearing face mask throughout the building during outbreak status regardless of if they are in a covid positive room or not. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding Special Droplet Contact Precautions when a resident test positive for COVID-19. All staff, including the medical director and nurse practitioners, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room. All staff, including the medical director and nurse practitioner, will wear a gown when entering the room, remove before exiting the room. All staff including the medical director and nurse practitioner will wear an N95 when entering the room and remove before exiting the room. All staff, including the medical director and nurse practitioners will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room. All staff, including the medical director and nurse practitioners, will wear gloves when entering the room and remove them before leaving the room. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person. This education will be by 10/24/24. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly [NAME] Personal Protective Equipment. The gown will fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. Then fasten behind neck and waist. Once the gown is fastened, the mask or respirator will be secure with ties or elastic bands at middle of head and neck and ensure the flexible band to nose bridge fits properly. The fit of the mask should be snug to the face and below chin. All staff, including the medical director and nurse practitioners will then Fit-check respirator by gently exhaling while blocking any paths for air to escape. If air is escaping, reposition the respirator and check again until you feel no air escaping. All staff, including the medical director and nurse practitioners will then place goggles or face shield over their face or eyes and adjust to fit. Then the staff will don the glove and extend to cover wrist of isolation gown. Education completed 10/23/2024. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly Doff Personal Protective Equipment. All staff, including the medical director and nurse practitioners will use a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove. All staff, including the medical director and nurse practitioners will then discard gloves in a waste container. All staff, including the medical director and nurse practitioners will then remove goggles or face shield from the back by lifting head band or earpieces. Otherwise, discard in a waste container. All staff, including the medical director and nurse practitioners will unfasten the gown ties and take the gown off by taking care that sleeves don't contact your body when reaching for ties. The gown will then need to be pulled away from neck and shoulders, touching inside of gown only. All staff, including the medical director and nurse practitioners, will then remove the mask or respirator by grasping the bottom ties or elastics, then the ones at the top, and remove without touching the front and discarding in a waste container. All staff, including the medical director and nurse practitioners, will then wash their hands or use an alcohol-based hand sanitizer immediately after removing all personal protective equipment. Education completed 10/23/2024. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly [NAME] Personal Protective Equipment with current staff. The gown will fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. Then fasten behind neck and waist. Once the gown is fastened, the mask or respirator will be secure with ties or elastic bands at middle of head and neck and ensure the flexible band to nose bridge fits properly. The fit of the mask should be snug to the face and below chin. All staff, including the medical director and nurse practitioners will then Fit-check respirator by gently exhale while blocking any paths for air to escape. If air is escaping, reposition the respirator and check again until you feel no air escaping. All staff, including the medical director and nurse practitioners will then place goggles or face shield over their face or eyes and adjust to fit. All staff, including the medical director and nurse practitioners will don the glove and extend to cover wrist of isolation gown. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person. Education will be completed by the Staff Development Coordinator or Director of Nursing. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly Doff Personal Protective Equipment with current staff. All staff, including the medical director and nurse practitioners will use a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove. All staff, including the medical director and nurse practitioners will then discard gloves in a waste container. The staff will then remove goggles or face shield from the back by lifting head band or earpieces. Otherwise, discard in a waste container. All staff, including the medical director and nurse practitioners will unfasten the gown ties and take the gown off by taking care that sleeves don't contact your body when reaching for ties. The gown will then need to be pulled away from neck and shoulders, touching inside of gown only. All staff, including the medical director and nurse practitioners will then remove the mask or respirator by grasping the bottom ties or elastics, then the ones at the top, and remove without touching the front and discarding in a waste container. All staff, including the medical director and nurse practi[TRUNCATED]