**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 12 residents (Residents #1) reviewed for accidents/hazards. 1.The facility failed to remove a mechanical lift that was missing a metal clip from service from 04/15/25-04/25/25. 2. The facility failed to ensure CNA A and CNA B safely transferred Resident #1. CNA A and CNA B placed Resident #1 in the lift and did not secure the sling resulting in the resident falling out of the sling on 4/15/25. This fall caused an orbital fracture to the face of Resident #1. An IJ was identified on 04/25/25. The IJ template was provided to the facility on [DATE] at 2:31 PM. While the IJ was removed on 04/26/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of falls, a loss of quality of life, severe injuries, hospitalization, and death. Findings included: Record review of a facility face sheet dated 4/25/25 for Resident #1 indicated that she was a 83 -year-old female admitted to the facility on [DATE] with diagnoses including hypertension (a condition where the force of blood pushing against the artery walls is consistently too high), hyperlipidemia (an elevated level of lipids-like cholesterol and triglycerides-in your blood), advanced Alzheimer's dementia (lose the ability to communicate), and Major Depressive Disorder (a mood disorder characterized by persistent low mood, loss of interest or pleasure in most activities). Record review of a quarterly MDS Staff Assessment of Mental Status dated 01/13/25 for Resident #1 indicated she was dependent on two or more helpers to complete activities. Record review of the discharged MDS assessment dated [DATE] reflected a Staff Assessment for Mental Status section reflected Resident #1 had memory problem and her cognitive skills for daily decision making was severely impaired and she was dependent on two or more helpers to complete activities. Record review of a comprehensive care plan dated 02/28/25 for Resident #1 indicated the problem was that she had an ADL self- care performance deficit, her goal was to maintain her dignity, the intervention was she was totally dependent on two staff for transferring with a mechanical lift. Record review of incident report dated 04/15/25 reflected, CNA's reported the resident fell from [mechanical] lift when she was raised in the air. CNA stated the resident fell hitting the left side of her face on the [Mechanical lift] leg. Resident unable to give description. Resident extremities moving per baseline for this resident, alert and non-verbal per baseline. Negative vocalization occasional moan or grown, low level of speech with a negative quality, Facial expression detail- sad, frightened, frown, mental status disoriented, injuries report- post incident bruise face, fracture face. Record review of facility investigation of fall investigation of Resident #1 undated reflected, Resident was being transferred by CNAs x2 when the sling came loose from the lift causing her to fall to the floor. She hit the left side of her face on the leg of the [mechanical]lift. EMS was called and resident was transferred to ER for evaluation. She was found to have a fx of the left orbital bone. Resident returned with new order for Tylenol #3 (used to treat mild to moderate pain) and antibiotics (a group of drugs that treat bacterial infections). CNAs wrote detailed accounts of the incident and were placed on suspension pending investigation. [mechanical] lift and sling were examined. Sling was intact, no tearing, in very good condition. Lift was found to be in working order. Both CNAs state they were transferring the resident from the wheelchair to the bed when the sling detached causing the resident to slide out of the sling. [CNA B] was maneuvering the lift and [CNA A] was guiding the resident towards the bed. Education was completed by [Sic]with CNAs including demonstration/return demonstration to reinforce proper use of [mechanical]lift and skills check off completed. [CNA A] and [CNA B] came in for [mechanical] training including demonstration/return demonstration and Skills check off on 4/17/25 Record review of progress notes dated 04/15/25 reflected, CNAx2 came out into the hall next to residents room and stated they had an emergency situation. Upon entering the room resident noted on the floor underneath the [mechanical] lift and left side of body and face was resting on the [mechanical] lift leg. Resident was alert and non-verbal per baseline. Resident never lost consciousness. Unable to get vitals due to position and contractures. Resident has minimal amount of bleeding from unknown origin. Left face is swollen and blue in color. Pillow and ice slid under the residents face without moving her neck/head. 911 called and [family] notified. ADON at the bedside, DON and doctor notified. Record review of hospital visit summary dated 04/15/25 reflected, Reason for visit, fall, diagnoses closed fracture of left orbit, closed head injury, skin tear of left hand without complication. During an interview and observation on 04/25/25 at 10:36 AM, CNA A, she stated on 04/15/25 between 1:00 PM and 1:20 PM, she and CNA B were preparing to put Resident #1 in bed for a rest after lunch. She stated CNA B had the sling under Resident #1 when she went into the room and CNA B hooked the sling up to the lift. She stated once the resident was high enough out of the chair, she moved the wheelchair and as she moved toward the other side of the bed, CNA B moved the mechanical lift toward the bed. She stated she saw Resident #1's head falling out of the sling, then she fell out of the side of the sling to the floor and hit her face on the base of the lift. CNA A stated prior to Resident #1 being lifted she did not notice the lift was missing the metal clip. She stated the lift used on 04/15/25 was still in the shower room. Observation of the lift revealed there were six hook point options to put the sling on the lift. Observation revealed one of the hook points had several layers of medical tape and the other five hooks had a metal clip. She stated the clip was on the lift to help secure the sling on the hook. CNA A stated the tape was not on the lift the afternoon of 04/15/25 at the time of incident . She stated she did not know who or why the tape was put on the lift. She stated she had an in-service training on the mechanical lift about three or four months prior to this incident. She stated the training consisted of how to open the legs of the lift, which sling should be use on the residents, and to make sure the sling was secure before lifting. She stated it was the responsibility of both CNA's to ensure the sling was secure. She stated she lasted used the lift on 04/25/25. She stated the resident was at risk of injury when equipment was not reported to not be working properly. During a telephone interview on 04/26/2025 at 12:45 PM, CNA B stated on 04/15/25 around 1:00 PM after lunch she and CNA A were getting Resident #1 ready to lay down. She stated CNA A hooked up the top of the sling and she hooked up the bottom of the sling. She stated she operated the lift to lift the resident up out of the wheelchair. She stated when the lift was at the highest level was when Resident #1 fell. She stated Resident #1 fell and hit the left side of her face, around her left eye on the bottom of the lift. She stated when Resident #1 fell she made the sound ou, ou. She stated she had received in-service training on the lift a few months prior to the incident, she did not know the exact date. She stated she received another in-service training again after the incident on 04/17/25. She stated prior to the incident she had not noticed the metal clip missing from the lift. She stated she was a PRN worker and usually worked at night and had not had a reason to get the people up out of bed. She stated the Resident's risk of injury was greater because the lift had not inspected prior to use. She stated it was the responsibility of both CNA A and her to ensure Resident #1 was secure in the lift. During an interview on 04/25/25 at 11:15 AM RN C, stated one of the CNA's notified her that Resident #1 had fall. She stated when she entered the room, she observed Resident #1 on the floor and her head was on the base part of the lift, her face was partially on the lift. She stated after the resident was sent to the hospital; she saw that there was a clip missing off the lift. She stated she thought the sling broke but when she checked it there was nothing wrong with the sling. She stated she saw the Administrator and Operations Director looking at the lift and they put a sign on the lift that said, Do Not Use. She stated it was the responsibility of both CNA's to ensure the sling was secure and the equipment was working properly before use. She stated the resident was at risk of injury when the equipment was not used properly or in proper working order. During an interview on 4/25/25 at 11:42 AM with Operations Director, he stated after the incident with Resident #1 on 04/15/25, he inspected the mechanical lift used by the two CNA's. He stated there was a clip missing from the lift. He stated the clip did not cause the lift to be unusable. He stated he did not put the tape on the lift, but he would try to find out. He stated prior to the incident he had not been made aware that the clip was missing from the lift. He stated he looked at the lifts quarterly to ensure they were in working order. He stated he did not keep a log of when or how often the lifts were inspected. He stated he could not say if the clip had been missing from the lift during his last inspection. He stated he would think the CNA's would inspect the lift before using each time. He stated the clip was a secondary safety measure to ensure the loop on the sling was on the lift properly. He stated when the lift was not used properly the resident could be injured. During an observation on 4/25/25 at 1:25 PM revealed CNA's Q and R were observed taking the mechanical lift with the missing metal clip into the room of a resident. The mechanical lift had been identified earlier by CNA A. CAN's Q and R locked the wheelchair, they discussed which color whey should use on the sling to lift the resident up, the staff explained to the resident they were raising her up, they used the lift raise the resident out of her chair and place her on her bed. During an interview on 4/25/2025 1:50 PM the Administrator stated during his investigation of the incident it was determined if the strap on the sling was put on properly it would not have come off. He stated both CNA's would have been responsible to ensure the sling was secure before lifting the resident out of the chair. He stated both CNA's had training on how to use the lift prior to this incident. He stated he would search for the training documents. He stated the Operations Director put the tape on the lift, when informed the Operations Director stated he did not put the tape on the lift, he stated maybe one of the CNA's had put the tape on the lift. He stated even with the tape on the lift, it was still usable, the tape did not hinder the function of the lift. He stated the Operations Director checked the lifts quarterly. He stated he was not aware there was no documentation of the lifts being checked. He stated the resident had been at risk of injury when staff did not report to him or the Operations Director the metal clip was missing from the lift. He stated the resident was also put at risk when the staff did not securely hook the sling onto the lift prior to lifting the resident. Attempted phone call to POA of Resident #1 on 04/25/25 at 3:15 PM, message left for return phone call. Follow-up interview with the Administrator on 04/26/25 at 4:15 p.m. The Administrator stated the previous DON was not as organized as he would have liked, and he had been unable to locate the lift service trainings for CNA A and CNA B. During an interview on 04/30/2025 at 1:20 PM with the Senior Sales Rep for [[mechanical]Mechanical lift] revealed if the metal clip was not on the lift the sling would not be secure. She stated the clip was essential to securing the sling on the lift. She stated if there was any part missing on the lift to secure the sling the [mechanical] lift should not have been used by the facility staff. She stated if the lift was used without the clip the resident would not be secured in the lift and could cause an injury. Record review of undated [mechanical] HPL500 manual reflected, Daily Check List: [[mechanical]Mechanical lift Company] strongly recommends the following checks be carried out on a daily basis and before using lift. Examine the sling hooks on the spreader bar for excessive wear. If in doubt-do not use. Maintenance [Mechanical lift [mechanical]Company] recommends regular inspection and maintenance. Record review of facility Safe Resident Handling/Transfers dated 03/22/2017 revised 06/21/2024 reflected, It is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. 7. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. 10. Two staff members must be utilized when transferring residents with a mechanical lift. 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. 15. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. Record review of facility Employee Lifting Policy dated 05/30/2024 reflected All staff will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated. Procedure 4. If a lifting device is required, the manufacturer guidelines will be used to determine the type of lifting device and size of sling that should be utilized. Equipment Storage and Readiness 1. It is the responsibility of the nursing unit to assure that the equipment is ready for use. The nurse manager will determine/assign who will be responsible for seeing that the equipment is in proper working order and has been electrically charged. An IJ was identified on 04/25/25. The IJ template was provided to the Administrator on 04/25/25 at 2:31 PM. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 04/25/25 at 6:00 PM and reflected the following: What corrective actions have been implemented for the identified residents? o All malfunctioning equipment is removed from circulation until it has been serviced and returned to proper working conditions (immediate) 4/25/25. Four [mechanical]lifts are in good working order and in use. o All [mechanical] lifts were inspected (immediate) and quarterly by the maintenance director to ensure safe use of equipment. 4/25/25 o The two individuals involved were suspended from duty until a thorough investigation had been completed. 4/15/25 to 4/18/25. o In-service and skills check-off performed for the two aides involved in this incident 4/18/25. How were other residents at risk to be affected by this deficient practice identified? All residents requiring assistance in transfers are identified as possible candidates for this deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? All malfunctioning equipment is removed from service until returned to proper working condition as determined by maintenance director and manufacturer recommendations. This will be completed by 4/28/25. ADONs will perform Skills check-off on direct care staff (RNs, LVNs, CMAs, CNAs) that work with [mechanical] lifts and transfers prior to the start of their shift. No direct care staff will be allowed to work their shift without displaying proper technique of transfers and [mechanical] lifts. This will be completed by 4/28/25. How will the system be monitored to ensure compliance? o Maintenance will perform quarterly checks on all equipment and log findings. These logs will be reviewed and addressed by the Administrator during the monthly QAPI meeting with the next meeting being 5/20/25. o All direct care staff will perform a skills check of [mechanical] lift and transfers quarterly. The ADONs will observe, evaluate and maintain a log sheet proving mastery. This will be completed by 4/28/25. o Any discrepancies noted throughout monitoring period will immediately be reviewed by Quality Assurance Team. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/25/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of the facility's Plan of Removal included the following: During an interview on 04/26/25 at 12:30 PM with the Administrator he stated the malfunctioned lift was removed from the building and taken to the storage building outside on 04/25/25. He stated all [mechanical] lifts had been inspected on 04/25/25 and there were no other lifts missing metal clips. He stated all the equipment checks was put into a logbook. He stated the ADONs had conducted the skills checkoffs with CNA staff, med aides, and nurses prior to their shifts. Interviews with the following staff from 04/25/25 at 12:45 PM to 3:19 PM, both in person and by phone, who worked all shifts and days of the week revealed they had been in-serviced that both staff using the lift were responsible to ensure the lift and sling were in good condition, the resident was secure prior to moving the resident, to report broken equipment to the administrator and operations director: CNA B, CNA D, CNA E, CNA F, CNA G CNA H, Student Aide I, LVN J, CMA K, LVN L, CNA M, CMA N, RN O, CNA P, LVN/ADON Q, and the Administrator. Record review of QAPI meeting dated 05/25/25 reflected the facility would be checking the mechanical lifts quarterly and it would be documented, and the logs would be checked during QAPI meetings. Record review of maintenance logs dated 05/25/25 reflected five mechanical lifts had been checked and one lift was taken out of service and placed in the storage building until it could be repaired. Observation of the four lifts in service revealed no missing metal clips, and no other missing parts, Record review of facility in-service documents dated 04/25/25 reflected staff had been in-serviced on the use of the mechanical lift and had shown understanding by demonstration and the areas had been checked off list. An IJ was identified on 04/25/25. The IJ template was provided to the facility on [DATE] at 2:31 PM. While the IJ was removed on 04/26/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for accidents. The facility failed to provide Resident #1 with ADL care in a safe manner, allowing Resident #1 to fall off her bed on 5-21-2024 between 4:00-4:30 PM, while her shirt was being changed by a staff member. An immediate Jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems. This failure resulted in actual harm due to facility staff not following proper transfer protocol which caused Resident #1 to fall and incur a fracture, placing residents who required two-person transfers at risk of serious injury, harm, impairment, or death. Findings Included: Record review of Resident #1's Face Sheet dated 6-4-2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Alzheimer's Disease with late onset, and secondary diagnosis of Dementia, Cerebral Infarction (Stroke), and Need for Assistance with Personal Care. Record review of Resident #1's Comprehensive MDS Assessment, dated 3-25-2024, revealed Resident #1 had a BIMS Score of 11 indicating moderate cognitive impairment. Section GG revealed Resident #1 was Dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for upper body/lower body dressing, bathing, and Chair-to-bed transfers. Because of Resident #1's medical conditions or safety concerns, Resident #1 was coded for there to be no attempt made by staff to move Resident #1 from Lying to sitting on side of bed. Resident #1 had a diagnosis of stroke, brain and spinal cord dysfunction, amputation, hip and knee replacement, fractures, and other multiple traumas. Record review of Resident#1's Care Plan, dated 4-5-2024, indicated Resident #1 had an ADL self-care performance deficit and required maximum assistance for lying in bed to sitting on the side of the bed by staff. Resident #1 also had a right hip fracture which placed Resident #1 at risk for pain, informing staff to be alert for nonverbal pain cues (changes in vital signs, emotions, and behavior). Listen to reports of family members regarding my pain. The right hip fracture put Resident #1 at risk for falls and impaired physical mobility. The care plan stated for staff to follow facility fall protocol. Resident #1 had a fall on 5-4-2023 causing a right hip fracture. Resident #1's Care Plan reflected Right hip fracture status post reduction percutaneous pinning placing at risk for pain, limited ROM, mobility, peripheral neurovascular dysfunction, impaired gas exchange, impaired physical mobility, impaired skin integrity, infection, Knowledge deficit, further injury, and falls Impaired physical mobility evidenced by: Inability to move purposefully within the physical environment, imposed restrictions. On 6-4-2024, at 5:30 PM, record review of Resident #1's MAR, revealed LVN A gave Resident #1 one 50-milligram tablet of Tramadol, for pain, on 5-21-2024 at 4:16 PM. Record review of Resident #1's Nursing Notes dated 5-21-2024 revealed the following: 7:00 PM, Nurse Note Text: N/O received from MD for STAT L knee X-Ray. Dx: Pain & to change PRN Tramadol to Tramadol 50mg TID. MAR updated & XR ordered. 10:23 PM - Nursing Note Text: This writer informed by staff that resident fell in her room on her knee during transfer. Resident crying for pain on left leg. Upon MD assessment, resident given additional pain medication and new order for STAT X-ray. Pain medication administered and MD order obtained. BP 152/72 P 79 SPO2 99% RR 20 Temp. 97.7 DON, MD and POA notified. 10:40 PM - Nurse Note Text: XR results positive for Comminuted fracture of the left distal femur just above the femoral condyles. MD notified. Order given to send resident out for evaluation & treatment. family member #1, , notified. When informed that family member #2, , would be notified next, family member #1, stated no that she would like to call herself. Resident was sent to an ER via EMS. 11:00 PM - Nurse Note Text: Report called into an [sic] ER. Resident not received. Resident was transferred to THR FW. Report called in & family member #2 & family member #1, notified. In an interview with CNA A, on 6-4-2024 at 2:00 PM, it was revealed CNA A was a CNA in training but had completed the in-house CNA training program. CNA A stated she had not yet taken her exam to be a certified CNA. CNA A worked the 2 PM-10 pm shift and had worked at the facility for approximately 6 weeks. CNA A stated on 5-21-2024, around dinner time, at approximately 4:30pm, she went into Resident #1's room, by herself, to prepare her for a Mechanical lift Transfer. CNA A stated Resident #1 needed her shirt changed and sat Resident #1 up from a lying position to a sitting position, on the side of Resident #1's bed facing CNA A. CNA A stated Resident #1 started to slip off the bed and she was not strong enough to hold Resident #1. As a result, Resident #1 fell off the bed onto the floor. CNA A said Resident #1 made an ouch noise as her left knee was bent underneath her, sitting on her left foot. CNA A stated she ran to the doorway, saw CMA B, and called for her to help her. CNA A and CMA B lifted Resident #1 off the floor back onto Resident #1's bed by hand. Once Resident #1 was back on her bed, CMA B told CNA A that Resident #1's left leg looked swollen while Resident #1 was crying. CNA A stated at that point, CMA B told CMA A to go find a nurse and tell the nurse that Resident #1 needed something for pain. CMA B then left the room of Resident #1 and goes back doing her job duties in the hallway. CNA A said she left the room of Resident #1, found LVN A, on another hall, told LVN A that Resident #1 needed some pain medication. CNA A stated that she did not tell LVN A that Resident #1 had a fall but only about needing a pain pill. CNA A stated that she assumed CMA B was going to tell a nurse about Resident #1 falling. CNA A stated after she told LVN A that Resident #1 needed a pain pill, CNA A went back to doing other duties that she was assigned and left Resident #1 in her bedroom alone. CNA A did not know how long it took for Resident #1 to get a pain pill. CNA A stated that somewhere between 5:30 PM to 6:00 PM, she was working in the dining room, assisting residents with feeding, when she saw the MD. CNA A said she told MD about Resident #1 falling. CNA A stated MD rolled Resident #1 out of the dining room in her wheelchair. CNA A stated that the next day, 5-22-2024, the DON called her into her office and stated that she should not have sat Resident #1 up on the side of her bed but should have kept her in a lying position and changed her shirt. The DON further told CNA A, that she and CMA B should not have put Resident #1 back onto her bed without a nurse being present. The DON told CNA A she should not have assumed CMA B had told a nurse about Resident #1 falling, should have already had the Mechanical lift in the room because Resident #1 is a Mechanical lift, and should have used the Mechanical lift to move Resident #1, before trying to sit Resident #1 up. CNA A stated she has been using Mechanical lifts for a month. In an interview with CMA B, on 6-4-2024, at 3:30 PM, it was revealed that CMA B had worked at the facility for two years, worked the evening shift from 2 PM-10 PM, and worked halls 200-300. CMA B stated she was working on 5-21-2024, and ordering medications around 4:30 PM, when she heard her name being called by CNA A to come help her with Resident #1. CMA B stated she walked into Resident #1's room, saw Resident #1 sitting on the floor, and assisted CNA A in helping Resident #1 back onto her bed. CMA B stated she then retrieved the Mechanical lift, brought it into Resident #1's room, moved Resident #1, with the help of CNA A, from the bed to her wheelchair. CMA B stated Resident #1 was crying and in pain. CMA B stated she assumed Resident #1 was in pain from a past fall she had at the facility -breaking her hip. At that time, CMA B wheeled Resident #1 in her wheelchair to the nurse's station to get pain medication. CMA B stated she left Resident #1 at the nurse's station with LVN A to get pain medicine while CMA B went back to ordering medications. CMA B did not have a time frame to give but said someone wheeled Resident #1 into the dining room to eat supper. CMA B said, at some point in time, CNA A saw the MD, in the dining room, and told MD that Resident #1 had fallen. CMA B said somewhere around 5:30-5:40 PM, she and MDS Coordinator wheeled Resident #1, in her wheelchair, back to her room and put her in her bed so the MD could examine her. CMA B stated that around 6:20 PM, she gave Resident #1 her regular medication pass. CMA B stated after that, she had no more interaction with Resident #1 for the day. In an interview with the DON, on 6-4-2024, at 3:45 PM, she stated that CMA B was assigned to mentor CNA A. The DON said that the problem with the fall incident with Resident #1 was the aides moved Resident #1 without an assessment from a nurse. The DON stated that CMA B and CNA A were both written up for the incident. In an observation/interview with Resident #1, on 6-4-2024, at 4:30 PM, Resident #1 was observed lying in bed wearing an oxygen cannula. Resident #1 was speaking very softly and was very hard to hear when she said, on the day she fell, one person was trying to get her ready, and she slid off her bed. Resident #1 stated she was in a lot of pain but could not put a number rating on the pain. Resident #1 stated it was a long time before she received pain medication for the fall. In an interview, on 6-4-2024, at 5:00 PM, LVN A stated she had been working at the facility full-time since January 2024 and worked the evening shift from 2:00 PM - 10:00 PM. LVN A said she worked various halls according to what the facility needed. LVN A said on 5-21-2024 at approximately 4:45 PM, just before dinner, a trainee CNA (CNA A) came to her to ask for pain medication for Resident #1. LVN A said she told CNA A, it does not work that way, I will come and look at Resident #1. LVN A said she was working on a different hall, than the one Resident #1 was on, when CNA A told her about Resident #1 needing pain medicine. LVN A would not state the time it took her to come to Resident #1's hall to check on her. LVN A said she pushed her nursing cart to where Resident #1 was sitting in her wheelchair. LVN A stated that when she found Resident #1, she was sitting by herself, close to the nurse's station. LVN A said she asked Resident #1 what was wrong. Resident #1 responded she was in pain. LVN A stated she then gave Resident #1 a pain pill. LVN A said sometime before 6:00 PM, she called for someone to take Resident #1 to the dining room to get assistance with eating. LVN A said later (she did not state the time) she witnessed the MD talking to Resident #1 and escorted Resident #1 back to her room. LVN A stated no one told her that Resident #1 had fallen. LVN A stated, during the time of her employment at the facility, she always witnessed a trainee CNA with a fully trained staff in situations where Resident #1 was getting prepped to transfer. LVN A said it was unusual for a trainee CNA to be doing such things by herself. LVN A said at some point, the MD took over doing an assessment on Resident #1 and ordered x-rays. LVN A said dinner started at 5:30 PM. In an interview, on 6-5-2024, at 11:45 AM, CNA C (in training), stated she had worked at the facility since May 13, 2024, and worked on the morning shift from 6:00 AM - 2:00 AM. CNA C stated she finished the classroom training program for CNAs yesterday (06-04-2024). CNA C said she was allowed to watch licensed staff complete a task and then she could complete the task with licensed supervision but not alone. CNA C said if a licensed CNA or nurse instructed her to do something, then she can do it alone. CNA C said Mechanical lift patients cannot be sat up in bed whether one was licensed or not. This was part of what the in-house training program teaches. If they were a fall risk and don't have the strength to hold themselves up, they should either roll them on the bed or use a Mechanical lift to put them in the wheelchair to change their shirt. CNA C stated the fall protocol for the facility was to get a nurse immediately when a resident fell and to not touch or move them. CNA C stated when she started her in-house training, at the facility, there were 7 CNA trainees. In an interview, on 6-5-2024, at 12:20 PM, with the MD, it was disclosed the MD was at the facility on 5-21-2024 during dinner time. The MD refused to give a more specific time frame. The MD said she was seeing patients during dinner time, with the MDS Coordinator, when Resident #1's [Family Member #2] brought Resident #1 to a TV room, then came to the nurse's station, saying Resident #1 was in pain. MD said LVN A told her she had already given Resident #1 something for pain. The MD said she went to the TV room and asked Resident #1 how she was feeling. Resident #1 responded saying she was in pain. The MD said she then brought Resident #1 back to her room, assessed her, and saw that her left knee was swollen. The MD said she then ordered a stat x-ray and gave Resident #1 Norco pain medicine. In an interview, on 6-5-2024, at 1:00 PM, the Training Coordinator said CNA A started her classroom training on 4-15-2024 and completed it on 5-3-2024. The Training Coordinator said once CNA A finished her classroom training, she was on her own. In an interview on 6-5-2024, at 1:15 PM, the DON said trainees were hired at first as hospitality aides. The DON said CNA A had finished her classroom training one day before the incident on 5-20-2024. The DON said the facility did not train CNAs to sit residents up on a bed before a Mechanical lift was used. The DON said the facility did not have a policy against sitting Mechanical lift Residents up in bed. In an interview, on 6-5-2024, at 3:00 PM, [Family Member #1] revealed she received a phone call on 5-21-2024, at 5:00 PM, from one of the facility's physical therapists, and told her that Resident #1, was sitting in a hallway crying and that she should have come to the facility and checked on her. Resident #1's [Family Member #1] then called Resident #1's [Family Member #2] and told her what the PT told her. In an interview, on 6-5-2024, at 3:24 PM, [Family Member #2] revealed she had received a phone call from [Family Member #1] informing her that Resident #1 was at the facility crying sitting in a hallway and that she needed to check on Resident #1. Resident #1's [Family Member #2] said she arrived at the facility around 5:40 PM and found Resident #1 in the dining room sitting at a dining table in her wheelchair. Resident #1's [Family Member #2] said Resident #1 told her she was in pain and her left leg hurt. Resident #1 kept saying this repeatedly to Resident #1's [Family Member #2]. As a result, Resident #1's [Family Member #2] started to wheel Resident #1, out of the dining room, to the nurse's station, when CNA A approached Resident #1's [Family Member #2] and told her that CNA A, earlier in the evening, was attempting to change Resident #1's shirt while she was seated on her bed, and Resident #1 fell. CNA A then told Resident #1's [Family Member #2] that Resident #1 was okay as she was eating her food. Resident #1's [Family Member #2] then wheeled Resident #1 to the nurse's station and asked the nurses about Resident #1 falling earlier in the day. Resident #1's [Family Member #2] said the nurses did not know Resident #1 had fallen earlier in the evening. Resident #1's [Family Member #2] said the MD was also at the nurse's station and overheard this conversation. Resident #1's [Family Member #2] said LVN A informed her that Resident #1 had received a Tramadol pill and she was fine. Resident #1's [Family Member #2] then told LVN A that Resident #1 was not fine and was crying in pain. Resident #1's [Family Member #2] then said the MD took Resident #1 and her family member to the dining room, where CNA A told the MD that Resident #1 had fallen earlier in the evening. The MD, Resident #1's, and her family member then went to the TV room together, where the MD examined Resident #1. Resident #1's [Family Member #2] said then other staff wheeled Resident #1 back into her room where staff put her back in bed, at which time she screamed in pain. Resident #1's [Family Member #2] said she had never heard Resident #1 scream like that in pain in her entire life. Resident #1's [Family Member #2] said that on a pain scale of 0-10, Resident #1 was past a 10 on 5-21-2024. In an interview, on 6-5-2024 at 4:40 PM, the MDS Coordinator disclosed she assisted Resident #1 back into her bed with CMA B for the MD to finish assessing Resident #1. The MDS Coordinator stated Resident #1 was crying in pain, so she administered Norco to Resident #1. MDS Coordinator did not give a time frame as to when this occurred. In an interview on 6-5-2024, at 4:45 PM, CMA B confirmed that she and the MDS Coordinator transferred Resident #1 back into her bed after 6:00 PM and Resident #1 was crying in pain. Record review, on 6-5-2024, at 5:20 PM, of the facility's Fall Prevention Policy, dated 3-12-2022, reflected: Policy:w It is the policy of this facility to ensure that risks and factors contributing to falls are mitigated as able. Policy Explanation and Compliance Guidelines: 1 - Upon admission and with noted risks such as prior a prior fall, resident will be assessed. If a fall was present, an incident report will be completed. 2 - Physician and responsible party will be notified of fall immediately. 3 - If a fall was unwitnessed or the resident was unable to communicate if head injury occurred, neuros will be initiated, and resident will be monitored for two subsequent shifts. Resident may be sent to the hospital based on nursing assessment and MD order. 4 - New fall risk assessment will be completed with contributing factors identified such as new medications, appropriate footwear, lighting and other contributing factors. Record review, on 6-5-2024, at 5:25 PM, of the facility's Fall Risk Assessment Policy, dated 3-12-2022, reflected: Policy: It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents . ( .) 3 - An At Risk for Fall care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. On 6-5-2024, at 5:41 PM, the Administrator was notified that an Immediate Jeopardy had been identified and exited on 5-21-2024, and a copy of the IJ template was provided to the Administrator regarding Accident/Hazards. The following POR was accepted on 6-6-2024 at 3:14 PM: F689 - Failure to provide resident adequate supervision and assistance devices to prevent accidents. F689 - Accidents/Hazards Azle Manor Plan of Removal Azle Manor submits the following Plan of Removal for F689 related to the alleged action of accidents/hazards by not following proper protocol in the capacity of a trainee, which caused a resident to fall and incur a fracture. By submitting this plan of removal Azle Manor does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? On 5/22/24 residents identified as requiring mechanical lift have been assessed for appropriate transfer technique. Mechanical lift Audit was completed, and care plans updated. One-on-one competency training on Post-Fall Protocol and mechanical lift training was completed by the DON with staff members CNA and CMA-A on 5/22/24. o Competency consists of Mechanical Lift Pre-Operations Checks and Mechanical Lift Operations. o Fall Prevention and Post-Fall Protocol Fall Prevention Response to falls-notification of nurse Intrinsic/Extrinsic Factors increasing risk Use of correct transfer type/assistive devices Walkway-room hazards Keeping items within reach Disciplinary action has been completed with staff members CNA and CMA-A for not following the proper protocol on 5/22/24. How were other residents at risk to be affected by this deficient practice identified? All residents identified as requiring mechanical lift have been identified as being at risk to be affected by this alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? CNA Student(s), CNA(s), Medication Aides, and Licensed Nurses have completed Total Mechanical Lift Training was completed on 5/29/2024 by the Director of Rehab/Therapy. Staff completed in-service training were cleared to work with residents requiring mechanical lifts. Using active staff roster, all clinical/direct-care staff attended the in-service training prior to working with residents requiring mechanical lift. How will the system be monitored to ensure compliance? o All new residents will be reviewed upon admission and change of condition to identify those that require total mechanical lift by Therapy (OT/PT) screening services. o DON will verify all CNA Students are properly trained and have completed competencies related to mechanical lift, post-fall policy and procedure. o DON, ADON, or nurse manager will round in facility to ensure appropriate use of mechanical lift for identified residents. o Mechanical lift rounds began 5/22/24 and will be completed three times weekly x 14 days; then weekly for three months and as needed. o Any discrepancies noted throughout monitoring period will immediately be reviewed by Quality Assurance Team. Of Note The CNA in-training term used does not correctly identify the staff, Student CNA. Student CNA has met all the requirements for OBRA nurse aide training regulations per the Nurse Aide Training and Competency Evaluation Program (NATCEP) set forth in the Texas Curriculum for Nurse Aides in Long-Term Care Facilities. The OBRA nurse aide training regulations include: o Placed on the Nurse Aide Registry o The first 16 hours of training must be completed prior to any direct contact with a resident. o After the first 16 hours, nurse aides can perform only those skills for which they have been trained and found to be proficient by the instructor. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/5/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 6-6-2024, at 1:20 PM, Resident #12 was observed being properly transferred from her wheelchair to her bed by way of mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that adequate pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 12 residents reviewed for pain management. The facility failed to ensure Resident #1 was properly assessed, monitored, and received effective pain management after Resident #1 fell on 5-21-2024 at approximately 4:30 PM and sustained a comminuted fracture of the left distal femur just above the femoral condyles and was not sent to the hospital for treatment for 6.5 hours at approximately 11:00 PM. The nurse was not notified for 1 to 1.5 hours of the fall until Resident #1's family member intervened and notified the nurses of Resident #1's pain. An immediate Jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems. These failures placed residents at risk of experiencing significant pain and discomfort. Findings Included: Record review of Resident #1's Face Sheet dated 6-4-2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Alzheimer's Disease with late onset, and secondary diagnosis of Dementia, Cerebral Infarction (Stroke), and Need for Assistance with Personal Care. Record review of Resident #1's Comprehensive MDS Assessment, dated 3-25-2024, revealed Resident #1 had a BIMS Score of 11 indicating moderate cognitive impairment. The Functional abilities and goals section revealed Resident #1 was Dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers were required for the resident to complete the activity) for upper body/lower body dressing, bathing, and Chair-to-bed transfers. Because of Resident #1's medical conditions or safety concerns, Resident #1 was coded for there to be no attempt made by staff to move Resident #1 from Lying to sitting on side of bed. Resident #1 had a diagnosis of stroke, brain and spinal cord dysfunction, amputation, hip and knee replacement, fractures, and other multiple traumas. Record review of Resident #1's doctor orders revealed an order for Norco Oral Tablet 325 MG to being on 5-28-2024 to be given for pain every 6 hours as needed for pain. Record review of Resident#1's Care Plan, dated 4-5-2024, indicated Resident #1 had an ADL self-care performance deficit and required maximum assistance for lying in bed to sitting on the side of the bed by staff. Resident #1 also had a right hip fracture which placed Resident #1 at risk for pain, informing staff to be alert for nonverbal pain cues (changes in vital signs, emotions, and behavior). Listen to reports of family members regarding my pain. The right hip fracture put Resident #1 at risk for falls and impaired physical mobility. The care plan stated for staff to follow facility fall protocol. Resident #1 had a fall on 5-4-2023 causing a right hip fracture. Resident #1's Care Plan reflected Right hip fracture status post reduction percutaneous pinning placing at risk for pain, limited ROM, mobility, peripheral neurovascular dysfunction, impaired gas exchange, impaired physical mobility, impaired skin integrity, infection, Knowledge deficit, further injury, and falls Impaired physical mobility evidenced by: Inability to move purposefully within the physical environment, imposed restrictions. record review of the MAR for Resident #1, on 6-5-2024, at 5:00 PM, revealed Resident #1 received Norco on 5-21-2024 at 6:20 PM. Record review of Resident #1's Nursing Notes dated 5-21-2024 revealed the following: 7:00 PM, Nurse Note Text: N/O received from MD for STAT L knee X-Ray. Dx: Pain & to change PRN Tramadol to Tramadol 50mg TID. MAR updated & XR ordered. 10:23 PM - Nursing Note Text: This writer informed by staff that resident fell in her room on her knee during transfer. Resident crying for pain on left leg. Upon MD assessment, resident given additional pain medication and new order for STAT X-ray. Pain medication administered and MD order obtained. BP 152/72 P 79 SPO2 99% RR 20 Temp. 97.7 DON, MD and POA notified. 10:40 PM - Nurse Note Text: XR results positive for Comminuted fracture of the left distal femur just above the femoral condyles. MD notified. Order given to send resident out for evaluation & treatment. [Family member #1], notified. When informed that [family member #2], would be notified next [family member #2], stated no that she would like to call herself. Resident was sent to emergency room via EMS. 11:00 PM - Nurse Note Text: Report called into the emergency room. Resident not received. Resident was transferred to the emergency room. Report called in & RP, [family member #2] & [family member #1], notified. In an interview with CNA A, on 6-4-2024 at 2:00 PM, it was revealed CNA A was a CNA in training but had completed the in-house CNA training program. CNA A stated she had not yet taken her exam to be a certified CNA . CNA A stated on 5-21-2024, around dinner time, at approximately 4:30pm, she went into Resident #1's room, by herself, to prepare her for a Mechanical lift Transfer. CNA A stated Resident #1 needed her shirt changed and sat Resident #1 up from a lying position to a sitting position, on the side of Resident #1's bed facing CNA A. CNA A stated Resident #1 started to slip off the bed and she was not strong enough to hold Resident #1. As a result, Resident #1 fell off the bed onto the floor. CNA A said Resident #1 made an ouch noise as her left knee was bent underneath her, sitting on her left foot. CNA A stated she ran to the doorway, saw CMA B, and called for her to help her. CNA A and CMA B lifted Resident #1 off the floor back onto Resident #1's bed by hand. Once Resident #1 was back on her bed, CMA B told CNA A that Resident #1's left leg looked swollen while Resident #1 was crying. CNA A stated at that point, CMA B told CMA A to go find a nurse and tell the nurse that Resident #1 needed something for pain. CMA B then left the room of Resident #1 and goes back doing her job duties in the hallway. CNA A said she left the room of Resident #1, found LVN A, on another hall, told LVN A that Resident #1 needed some pain medication. CNA A stated that she did not tell LVN A that Resident #1 had a fall but only about needing a pain pill. CNA A stated that she assumed CMA B was going to tell a nurse about Resident #1 falling. CNA A stated after she told LVN A that Resident #1 needed a pain pill, CNA A went back to doing other duties that she was assigned and left Resident #1 in her bedroom alone. CNA A did not know how long it took for Resident #1 to get a pain pill. CNA A stated that somewhere between 5:30 PM to 6:00 PM, she was working in the dining room, assisting residents with feeding, when she saw the MD. CNA A said she told MD about Resident #1 falling. CNA A stated MD rolled Resident #1 out of the dining room in her wheelchair. CNA A stated that the next day, 5-22-2024, the DON called her into her office and stated she and CMA B should not have put Resident #1 back onto her bed without a nurse being present. In an interview with CMA B, on 6-4-2024, at 3:30 PM, it was revealed that CMA B assisted CNA A in helping Resident #1 back onto her bed after she fell on the floor during care. CMA B stated Resident #1 was crying and in pain. CMA B stated she assumed Resident #1 was in pain from a past fall she had at the facility -breaking her hip. At that time, CMA B wheeled Resident #1 in her wheelchair to the nurse's station to get pain medication. CMA B stated she left Resident #1 at the nurse's station with LVN A to get pain medicine while CMA B went back to ordering medications. CMA B did not have a time frame to give but said someone wheeled Resident #1 into the dining room to eat supper. CMA B said, at some point in time, CNA A saw the MD, in the dining room, and told the MD that Resident #1 had fallen. CMA B said somewhere around 5:30-5:40 PM, she and MDS Coordinator wheeled Resident #1, in her wheelchair, back to her room, and put her in her bed so the MD could examine her. CMA B stated that around 6:20 PM, she gave Resident #1 her regular medication pass. CMA B stated after that, she had no more interaction with Resident #1 for the day. In an interview with the DON, on 6-4-2024, at 3:45 PM, it was stated that CMA B was assigned to mentor CNA A. The DON stated that the problem with the fall incident with Resident #1 was the aides moved Resident #1 without an assessment from a nurse. The DON stated that CMA B and CNA A were both written up for the incident. In an observation/interview with Resident #1, on 6-4-2024, at 4:30 PM, Resident #1 was observed lying in bed with a oxygen cannula. Resident #1 was speaking very softly and was very hard to hear when she said, on the day she fell, one person was trying to get her ready, and she slid off her bed. Resident #1 stated she was in a lot of pain but could not put a number rating on the pain. Resident #1 stated it was a long time before she received pain medication for the fall. In an interview, on 6-4-2024, at 5:00 PM, LVN A stated she had been working at the facility full-time since January 2024 and worked the evening shift from 2:00 PM - 10:00 PM. LVN A said she worked various halls according to what the facility needed. LVN A said on 5-21-2024 at approximately 4:45 PM, just before dinner, a trainee CNA (CNA A) came to her to ask for pain medication for Resident #1. LVN A said she told CNA A, it does not work that way, I will come and look at Resident #1. LVN A said she was working on a different hall, than the one Resident #1 was on, when CNA A told her about Resident #1 needing pain medicine. LVN A would not state the time it took her to come to Resident #1's hall to check on her. LVN A said she pushed her nursing cart to where Resident #1 was sitting in her wheelchair. LVN A stated that when she found Resident #1, she was sitting by herself, close to the nurse's station. LVN A said she asked Resident #1 what was wrong. Resident #1 responded she was in pain. LVN A stated she then gave Resident #1 a pain pill. LVN A said sometime before 6:00 PM, she called for someone to take Resident #1 to the dining room to get assistance with eating. LVN A said later (she did not state the time) she witnessed the MD talking to Resident #1 and escorted Resident #1 back to her room. LVN A stated no one told her that Resident #1 had fallen. LVN A stated, during the time of her employment at the facility, she always witnessed a trainee CNA with a fully trained staff in situations where Resident #1 was getting prepped to transfer. LVN A said it was unusual for a trainee CNA to be doing such things by herself. LVN A said at some point, the MD took over doing an assessment on Resident #1 and ordered x-rays. LVN A said dinner started at 5:30 PM. In an interview, on 6-5-2024, at 11:45 AM, CNA C (in training), revealed CNA C stated the fall protocol for the facility was to get a nurse immediately when a resident fell and to not touch or move them. In an interview, on 6-5-2024, at 12:20 PM, with the MD, it was disclosed the MD was at the facility on 5-21-2024 during dinner time. The MD refused to give a more specific time frame. The MD said she was seeing patients during dinner time, with the MDS Coordinator, when Resident #1's [Family Member #2] brought Resident #1 to a TV room, then came to the nurse's station, saying Resident #1 was in pain. MD said LVN A told her she had already given Resident #1 something for pain. The MD said she went to the TV room and asked Resident #1 how she was feeling. Resident #1 responded saying she was in pain. The MD said she then brought Resident #1 back to her room, assessed her, and saw that her left knee was swollen. The MD said she then ordered a stat x-ray and gave Resident #1 Norco pain medicine. In an interview, on 6-5-2024, at 3:00 PM, [Family Member #1] revealed she received a phone call on 5-21-2024, at 5:00 PM, from one of the facility's physical therapists, and told her that Resident #1, was sitting in a hallway crying and that she should have come to the facility and check on her. Resident #1's [Family Member #1] then called Resident #1's [Family Member #2] and told her what the PT told her. In an interview, on 6-5-2024, at 3:24 PM, [Family Member #2] revealed she had received a phone call from [Family Member #1] informing her that Resident #1 was at the facility crying sitting in a hallway and that she needed to check on Resident #1. Resident #1's [Family Member #2] said she arrived at the facility around 5:40 PM and found Resident #1 in the dining room sitting at a dining table in her wheelchair. Resident #1's [Family Member #2] said Resident #1 told her she was in pain and her left leg hurt. Resident #1 kept saying this repeatedly to Resident #1's [Family Member #2]. As a result, Resident #1's [Family Member #2] started to wheel Resident #1, out of the dining room, to the nurse's station, when CNA A approached Resident #1's [Family Member #2] and told her that CNA A, earlier in the evening, was attempting to change Resident #1's shirt while she was seated on her bed, and Resident #1 fell. CNA A then told Resident #1's [Family Member #2] that Resident #1 was okay as she was eating her food. Resident #1's [Family Member #2] then wheeled Resident #1 to the nurse's station and asked the nurses about Resident #1 falling earlier in the day. Resident #1's [Family Member #2] said the nurses did not know Resident #1 had fallen earlier in the evening. Resident #1's [Family Member #2] said the MD was also at the nurse's station and overheard this conversation. Resident #1's [Family Member #2] said LVN A informed her that Resident #1 had received a Tramadol pill and she was fine. Resident #1's [Family Member #2] then told LVN A that Resident #1 was not fine and was crying in pain. Resident #1's [Family Member #2] then said the MD took Resident #1 and her family member to the dining room, where CNA A told the MD that Resident #1 had fallen earlier in the evening. The MD, Resident #1, and her family member then went to the TV room together, where the MD examined Resident #1. Resident #1's [Family Member #2] said then other staff wheeled Resident #1 back into her room where staff put her back in bed, at which time she screamed in pain. Resident #1's [Family Member #2] said she had never heard Resident #1 scream like that in pain in her entire life. Resident #1's [Family Member #2] said that on a pain scale of 0-10, Resident #1 was past a 10 on 5-21-2024. In an interview, on 6-5-2024 at 4:40 PM, the MDS Coordinator disclosed she assisted Resident #1 back into her bed with CMA B for the MD to finish assessing Resident #1. The MDS Coordinator stated Resident #1 was crying in pain, so she administered Norco to Resident #1. MDS Coordinator did not give a time frame as to when this occurred. In an interview on 6-5-2024, at 4:45 PM, CMA B confirmed that she and the MDS Coordinator transferred Resident #1 back into her bed after 6:00 PM and Resident #1 was crying in pain. Record review on 6-5-2024, at 5:25 PM, of the facility's Pain Management Policy, reflected: All residents will receive the best level of pain control that can safely be provided in order to prevent unrelieved pain. a. Pain is recognized as a vital sign ( .) Definition a. PAIN is whatever the experiencing resident says it is, exiting whenever he/she says it is. Self-reporting is the preferred indicator of pain. Behavioral and physiological indicators are used only when resident is unable to self-report. b. Facility uses a self-rating scale 0-10 to evaluate pain. 0 indicates no pain, 10 worst pain imaginable. Facility also uses the face scale to evaluate pain. Smiling face in dates no pain and crying face indicates worst pain imaginable. d. Pain relief is the alleviation of pain or reduction in pain to a level of comfort that is acceptable to the patient ( .) e. Multi-model approach to pain management. This is defined as using pharmacological (opioid and non-opioid) interventions and non-pharmacological interventions together to provide comfort ( .) Process a. On initial assessment and at regular intervals assess the potential for, the causes of, the onset or presence of and the extent of resident's pain On 6-5-2024, at 5:41 PM, the Administrator was notified that an Immediate Jeopardy had been identified and exited on 5-21-2024, and a copy of the IJ template was provided to the Administrator regarding Pain Management. The following POR was accepted on 6-6-2024 at 3:14 PM: F697 - Failure to adequately assess and treat a resident's pain. F697 - Pain Management [Facility] Plan of Removal [Facility] submits the following Plan of Removal for F697 related to the alleged action of pain by not providing pain medication. By submitting this plan of removal Azle Manor does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? o Residents residing in the facility are assessed for pain every shift and after incidents/accidents. On 6/5/24 the DON/designee completed audits on residents receiving routine and PRN pain medications to determine appropriate timing and resident response to effectiveness of treatment modalities; and On 6/5/24 the DON/designee completed audits on residents with active pain assessments to determine accuracy in level of pain and update the treatment plan How were other residents at risk to be affected by this deficient practice identified? All residents residing in the facility are at risk for pain. Pain assessments are completed every shift, as needed, and following incidents/accidents. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? The DON/designee initiated immediate training on 6/5/24 and completed training on 6/6/24 with CNA Student(s), CNA(s), Medication Aides, and Licensed Nurses to include areas of: o Assessing pain/pain complaints. o Modalities of assessment to include those with communication difficulties and/or cognitive issues. How will the system be monitored to ensure compliance? o All new residents will be reviewed by the DON/designee upon admission, after incident/accident, and as needed (PRN) and to assess for presence of pain and ensure that the facility has available medications and non-pharmacological measures to address pain. o DON, ADON, or nurse manager will monitor pain assessments to determine if resident pain is assessed accurately and effectiveness of treatment modalities. Audits on pain assessments, interventions, and effectiveness of treatment will be completed three times weekly x 14 days; then weekly for three months and as needed. o Any discrepancies noted throughout monitoring period will immediately be reviewed by Quality Assurance Team. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/5/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The facility was monitored for compliance with the POR on 6-6-2024 as follows: In an interview on 6-6-2024, at 12:48 PM, LVN B stated: She had been in serviced on pain on the morning of this interview. She said non-licensed staff should get a nurse in the event of any incident with a resident, and the nurse would assess them, including assessing for pain and range of motion. The proper protocol for pain was to assess the level of pain, and provide medication as ordered, then monitor them. if the pain medication was not effective, she would contact the physician to get an order for stronger medication, maybe X-rays. She described the non-verbal signs of pain she would look for. She said they did not want their residents to be in pain. In an interview on 6-6-2024 at 2:45 PM, CNA F stated she had been taught pain protocols to get the nurse if a resident expressed pain. CNA F said the risk to the residents if proper protocols were not followed could be the resident being in increased pain. In an interview on 6-6-2024 at 3:53 PM, CNA G stated she has been in-serviced on pain management on 6-4-2024 and it included signs of pain on a resident, and how to respond. In an interview on 6-6-2024 at 4:15 PM, LVN C stated she was in-serviced on pain, and how do proper pain assessment, find out why a resident was in pain, where the pain was, different signs of pains, non-verbal expression of pain. LVN C said the risk for not following the correct protocols were residents need not being met, and something worse happening, they could stay in pain, and not knowing the cause of pain in their bodies. In an interview on 6-6-2024 at 5:00 PM the DON said going forward, to ensure this kind of situation did not take place again, the residents would be assessed for pain at each shift, and on MDS on admission quarterly and with significant change. She said she was currently auditing pain assessments for accuracy and to see if pharmaceutical and non-pharmaceutical interventions were effective and updating the plans of care. In an interview on 6-6-2024 at 5:15 PM, the Administrator stated he thought the reason the Immediate Jeopardy occurred was that the student took on more than what they were capable of doing. He said to ensure this type of incident did not occur again, the facility was restructuring the CNA training classes to allow more training and mentorship before being put on the floor. He was not aware that CNAs were being put on the floor as fast as they were. He said they extended the course from a 5-day class to an 8-day class, and the CNA trainer would follow the trainee on the floor for 7 days. After that, they would be paired with a mentor and take their test. He said everyone was an individual and trained at different paces. An immediate jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM. While the IJ was removed on 6-6-2024 at 3:14 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 7 (Residents #3, #7, #9, #11, #13, #16, and #18) of 19 residents reviewed for infection control. The facility failed to cohort residents based upon their COVID-19 status: Residents #9 and #16 contracted COVID-19 after being cohorted with roommates who were COVID-19 positive. Residents #3, #7, #11, #13 and #18 were negative for COVID-19 but their roommates were positive. An Immediate Jeopardy was identified on 11/08/22 at 2:12 PM. While the Immediate Jeopardy was removed on 08/04/22, the facility remained out of compliance at a severity level of no actual harm that was not Immediate Jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents, who resided in the facility, at risk of exposure to COVID-19, which could result in serious illness, hospitalization, and/or death. Findings included: In an interview with the Administrator and DON on 11/08/22 at 9:10 AM, the DON said the facility had a recent outbreak of COVID-19. She said the outbreak began with a positive staff member on 11/02/22. She said the first resident tested positive on 11/04/22. She said the facility had, as of 11/08/22, five positive staff and 22 positive residents. She said most of the residents were asymptomatic or had very mild symptoms. The DON said the facility had two stations, which had three halls each. She said Station One did not have any positive cases but was considered warm due to exposure from positive staff members. She said Station Two had COVID-19 positive residents and residents, who tested negative, but had been exposed, and were considered of unknown status. She said the facility conducted outbreak testing on Tuesdays and Fridays for staff and residents. The Administrator said, based on the Local Health Department's guidance, the facility was cohorting, residents who tested positive with residents who tested negative, if they were roommates, because the roommates had been exposed and were now considered of unknown COVID-19 status. The DON said the cohorted residents were both placed on droplet precautions. He said space was limited in the facility to move residents to other rooms, and the facility did not want to expose other residents to a resident that was considered of unknown COVID-19 status due to exposure from their roommate. He said HHSC was aware of the cohorting and had approved the mitigation plan. The Administrator said the facility had an outbreak in July 2022 and received the same directive from the Local Health Department to cohort residents, who were roommates, and it worked well to stop the spread of COVID-19. Record review of an email dated 07/11/22 at 10:03 AM, the Administrator sent the Local Health Department Epidemiology Investigator an email, which in part, read; Isolating residents in room with positive roommate if unknown status. At 10:08 AM the Local Health Department Epidemiology Investigator responded, Looks good! I'll just add that anyone being discharged from isolation after day 5 should still wear a mask for the next 5 days. At 10:14 AM, indicated the Administrator informed all the staff, he was instructed, by HHSC, to follow closely all the Local Health Department's rules and regulations regarding the COVID-19 outbreak. Record review of the COVID-19 resident tracking, provided by the DON, on 11/08/22 at 9:10 AM, indicated Residents #3, #7, #9, #11, #13, #16, and #18 tested negative for COVID-19 on Friday, 11/04/22, but were cohorted with roommates that tested positive, Residents #4, #6, #8, #10, #12, #15, and #17. Resident #3 Record review of Resident #3's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included dementia. She was roommates with Resident #4. Record review of Resident #3's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #3's Physician Order dated 11/05/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #4 Record review of Resident #4's admission Record dated 11/08/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, dementia and diabetes. Record review of Resident #4's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #4's Nurses' Note dated 11/04/22 at 2:07 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. She was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #4's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #7 Record review of Resident #7's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included dementia and diabetes. She was roommates with Resident #6. Record review of Resident #7's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #7's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #6 Record review of Resident #6's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, dementia. Record review of Resident #6's Immunization Report dated 11/09/22 indicated she refused the COVID-19 vaccination. Record review of Resident #6's Nurses' Note dated 11/04/22 at 2:13 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. She was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #6's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #9 Record review of Resident #9's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included dementia, congestive heart failure and emphysema. She was roommates with Resident #8. Record review of Resident #9's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 02/18/22. Record review of Resident #9's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #8 Record review of Resident #8's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, dementia and diabetes. Record review of Resident #8's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 on 06/23/21. She refused a booster. Record review of Resident #8's Nurses' Note dated 11/04/22 at 2:29 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. She was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #8's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #11 Record review of Resident #11's admission Record dated 11/09/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included dementia and chronic obstructive pulmonary disease. He was roommates with Resident #10. Record review of Resident #11's Immunization Report dated 11/09/22 indicated he was vaccinated for COVID-19 on 02/23/21. Record review of Resident #11's Physician Order dated 11/05/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #10 Record review of Resident #10's admission Record dated 11/09/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included, acute respiratory failure with hypoxia. Record review of Resident #10's Immunization Report dated 11/09/22 indicated he was vaccinated for COVID-19 and received a booster on 12/02/21. Record review of Resident #10's Nurses' Note dated 11/04/22 at 2:42 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. He was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #10's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #13 Record review of Resident #13's admission Record dated 11/09/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included dementia. He was roommates with Resident #12. Record review of Resident #13's Immunization Report dated 11/09/22 indicated he was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #13's Physician Order dated 11/05/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #12 Record review of Resident #12's admission Record dated 11/09/22 indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included dementia and chronic obstructive pulmonary disease. Record review of Resident #12's Immunization Report dated 11/09/22 indicated he was vaccinated for COVID-19 on 01/19/21. Record review of Resident #12's Nurses' Note dated 11/04/22 at 1:55 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. He was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #12's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #16 Record review of Resident #16's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included dementia and diabetes. She was roommates with Resident #15. Record review of Resident #16's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #16's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #15 Record review of Resident #15's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, dementia and diabetes. Record review of Resident #15's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 and received a booster on 10/25/21. Record review of Resident #15's Nurses' Note dated 11/04/22 at 2:40 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. She was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #15's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Resident #18 Record review of Resident #18's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease and diabetes. She was roommates with Resident #17. Record review of Resident #18's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 on 10/25/21. Record review of Resident #18's Physician Order dated 11/05/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. The resident did not have a physician's order for contact droplet isolation. Resident #17 Record review of Resident #17's admission Record dated 11/09/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, dementia and diabetes. Record review of Resident #17's Immunization Report dated 11/09/22 indicated she was vaccinated for COVID-19 on 05/19/21. Record review of Resident #17's Nurses' Note dated 11/04/22 at 2:47 PM, indicated the resident tested positive for COVID-19, but was asymptomatic. She was placed on contact droplet precautions. The MD was notified and orders for an anti-viral medication and zinc, a dietary supplement, were received. The staff was to monitor for symptoms. The responsible party was notified. Record review of Resident #17's Physician Order dated 11/04/22 indicated to monitor for COVID symptoms, notify MD and DON immediately for any symptoms observed. Contact droplet isolation precautions. Observations on 11/08/22 from 11:00 AM - 12:00 PM indicated the following residents were roommates and both were on contact droplet isolation precautions, per the signage outside the rooms and full PPE was to be worn in the rooms: Residents #3 and #4 were roommates Residents #6 and #7 were roommates Residents #8 and #9 were roommates Residents #10 and #11 were roommates Residents #12 and #13 were roommates Residents #15 and #16 were roommates Residents #17 and #18 were roommates In an interview on 11/08/22 at 3:01 PM, LVN A said Resident #9 and #16 tested negative for COVID-19 on Friday, 11/04/22 and were cohorted with their positive roommates, but today, 11/08/22, they tested positive. She said Resident #16 did not have any signs or symptoms of COVID-19. She said Resident #9 had chronic symptoms of illness, so it was difficult to tell if her symptoms were related to COVID-19 or her chronic condition. She said she thought it was a good idea to cohort roommates who tested negative and positive because the negative roommate had already been exposed to COVID. She said the facility did not want to put residents, who had been exposed to a positive roommate, in a room with a negative resident because the exposed resident's status could change to positive within a few days and increase the spread of the infection. An observation and interview on 11/08/22 at 3:07 PM, Resident #7 was in her room, she said her roommate, Resident #6, had COVID. She said she was concerned about contracting COVID, from her roommate, because she was a diabetic. The curtain was no drawn in the room, Resident #6 was in bed, asleep, no signs or symptoms of COVID-19 were observed. An observation on 11/08/22 at 3:11 PM, Resident #8 was in her room in her wheelchair. She had no observable signs or symptoms of COVID -19. She was not able to answer question appropriately. Her roommate, Resident #9, was not in the room. In an interview and observation on 11/08/22 at 3:16 PM, Resident #10 was wearing oxygen and coughing. The curtain was not pulled between the residents. Resident #10 said he was doing better and had no issues with his care or treatment. Resident #11 had no concerns. In an interview on 11/08/22 at 3:18 PM, CNA B said she showered Resident #9, in the shower room, and had just brought her back to her room. She said she was not aware Resident #9 had tested positive for COVID-19 today. She said she did not get that information in report at 2:00 PM. In an interview and observation on 11/08/22 at 3:24 PM, Resident #12 was in bed, the privacy curtain was pulled. He had no visible signs of COVID-19. He and Resident #13 reported no issues with their care or treatment. The Administrator were notified of the Immediate Jeopardy (IJ) on 11/08/22 at 3:45 PM, due to the above failures. A Plan of Removal was also requested and the IJ template was provided. In an observation and interview on 11/08/22 at 4:31 PM, Resident #9 was in her room; she said she was not worried about COVID, she reported feeling fine. She did not report any issues with her care or treatment. In an interview and observation on 11/08/22 at 4:34 PM, Residents #17 and #18 were in their room. The privacy curtain was not drawn. They did not report any issues with their care or treatment. In an interview and observation on 11/08/22 at 4:38 PM, Residents #15 and #16 were in their room. No signs or symptoms of COVID-19 were observed. They reported no issues with their care or treatment. In an interview and observation on 11/09/22 at 12:48 PM, Resident #3 and #4 reported no issues with their care or treatment. No signs or symptoms of COVID-19 were observed. In a telephone interview on 11/09/22 at 1:11 PM, Medical Director said the facility sought guidance from the Local Health Department regarding the COVID-19 outbreak and did as they were directed. She said the facility always tried to act in the best interest of the residents. She said she would have thought the Local Health Department would follow the CDC guidelines. She said the facility did not have room for a COVID-19 wing or a lot of additional beds. She said she had no concerns regarding the facility's infection control practices or the residents' care. In an interview on 11/09/22 at 1:32 PM, the Administrator said the facility was almost done moving all residents who tested positive, who had a roommate, that tested negative out of the room. In a telephone interview on 11/09/22 at 1:36 PM, the Local Health Department Official said he was not the facility's contact in July 2022; however, he was contacted on 11/04/22 regarding the facility outbreak. He said the best practice was to have resident of like status cohorted together. He said positive residents with positive residents, exposed residents with exposed residents and negative residents with negative residents. He does not recommend cohorting positive with negative due to the risk of COVID-19 transmission. He said the Administrator informed him it would be impossible to move residents due to the lack of available beds. He said it was his understanding the facility did not have rooms to move the residents, so he agreed with the cohorting plan. Record review of the Daily Census dated 11/07/22 indicated, on Station 2, there were 23 empty beds. 10 empty beds had a COVID-19 positive resident in the room. room [ROOM NUMBER] was empty. In an interview, with the DON and Administrator, on 11/10/22 at 9:25 AM, the DON said now, if a resident tests positive for COVID-19 and their roommate tests negative for COVID-19, the positive resident will be moved out of the room and the roommate will be considered exposed, status unknown. She said they had hospitalizations as a result of the COVID-19 outbreak, no negative outcome and no harm done by cohorting. She said Residents #9 and #16 were already exposed and may have contracted COVID-19 even if they were not cohorted with positive roommates. She said orders for contact droplet precautions for the residents of unknown status should be in the electronic medical record and was just an oversight. She said staff receive report on any new resident COVID-19 cases, but on 11/08/22 there was a little time lapse because she tested all the residents and then updated the staff on any new cases. The Administrator said he believed moving the residents around increased the risk for the spread of COVID-19. He said the only reason the residents were moved was because HHSC directed the facility to do so. He said he felt the moves caused extreme anguish to some of the residents. He said on 07/13/22 HHSC investigated an incident regarding their outbreak and found the cohorting of residents appropriate and agreed with the Local Health Department's recommendations. He said if the facility had been informed in July 2022 the practice of cohorting was not recommended, they would not have replicated the practice during this most recent outbreak. Record review of the facility's COVID-19 policy, CMS policy revised on 09/23/22 regarding COVID-19 Response and Testing Requirements. The policy indicated, residents who have signs or symptoms of COVID-19 regardless of vaccination status must be tested as soon as possible. While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions in accordance with CDC guidance. Once test results are obtained, the facility must take the appropriate actions based on the results. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. Record review of the CDC website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, on 11/08/22 at 1:15 PM, indicated: 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. The facility's POR (Plan of Removal) was accepted on 11/09/22 at 7:24 PM and reflected the following: What corrective actions have been implemented for the identified residents? o Residents with known positive COVID19 testing will be cohorted with other residents testing positive for COVID19. o Residents with unknown status with known exposure to COVID19 roommates remain in rooms and are placed on transmission-based precautions and monitored every shift for developing signs and symptoms of COVID19. o Residents testing COVID19 positive rooming with residents of unknown status are assessed immediately and every shift for developing signs and symptoms of COVID19. How were other residents at risk to be affected by this deficient practice identified? All residents of unknown status rooming with COVID19 positive residents in the facility have the potential to be affected by this proposed deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? o During outbreak testing, all residents testing COVID19 positive will be cohorted with other residents testing COVID19 positive. o Residents of unknown status with close contact, considered exposed, will remain in room. Monitoring for developing signs and symptoms of COVID19 will be completed every shift. o An In-service was initiated on 11/8/22 with staff regarding proper cohorting of positive residents and monitoring of signs and symptoms of COVID19 by the DON. How will the system be monitored to ensure compliance? o All new residents will be reviewed prior to admission by clinical management team to determine proper placement within the facility. o DON will continue to test residents for COVID19, until a full 14 days of no newly identified COVID19 positive cases. o DON, ADON, or nurse manager will round on facility to ensure appropriate PPE use with COVID19 positive residents and those of unknown status. o Any discrepancies noted throughout monitoring period will immediately be reviewed by Quality Assurance Team. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/8/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 11/10/22 the surveyor confirmed the facility implement their Plan of Removal sufficiently to remove the IJ by : In an interview, with the DON and Administrator, on 11/10/22 at 9:25 AM all the residents who tested positive had been moved in with other positive roommates, as of 11/09/22. The residents, who tested negative, but were exposed to COVID-19 positive roommates, were left in the room, placed on monitoring, and contact droplet precautions. She said all staff had been in-serviced on cohorting residents of the same COVID-19 status. She said any new cases would be reported to her and she would contact the residents/responsible parties regarding the test results and required room changes. She said the weekend shift would be educated on the plan prior to working their shifts. Record review of the facility's Daily Census dated 11/09/22 indicated the positive residents were now cohorted with other positive residents. The residents, who tested negative, but were considered exposed and of unknown status were in rooms by themselves. Record review of the in-services with all the staff regarding infection control outbreak, cohorting, PPE, testing schedule, and hand hygiene. In an interview, with the DON and Administrator, on 11/10/22 at 9:25 AM, they disagree with the Immediate Jeopardy; however, they have implemented the Plan of Removal, and will ensure residents of like COVID-19 status are cohorted. In an interview on 11/10/22 at 10:08 AM, the Housekeeping Supervisor said she was aware residents of like COVID-19 status were cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said staff would wear full PPE to complete the move and conduct the appropriate cleaning procedures. In an interview on 11/10/22 at 10:10 AM, LVN D said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:19 AM, LVN E said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:30 AM, Weekend RN F said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:34 AM, Weekend MA G said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:38 AM, LVN H said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:40 AM, CNA I, who was the staffing coordinator for the CNAs, MAs, and Nurses, said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. In an interview on 11/10/22 at 10:49 AM, CNA J said she was aware residents of like COVID-19 status were to be cohorted together and if a resident tested positive and their roommate tested negative, the positive roommate would be moved out of the room. She said both residents would be placed on monitoring and contact droplet precautions. Observations on 11/10/22 from 10:50 AM - 11:06 AM, indicated all residents of like[TRUNCATED]