**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 08/07/2025 at an unknown time Resident #1 eloped from the facility by reading the door code that was placed by the door and let herself out the front door. Resident # 1 was found by CNA A standing on the front porch when she left work between 6:30PM and 7:00PM. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 08/07/2025 at 6:50 PM and ended on 08/08/2025 2:20 PM .The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began. This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death.During an observation on 08/13/2025 at 11:00 AM all exit doors were checked and locked and equipped with functioning alarms. Additionally, the outside of the entrance door had a sign stating , Please do not let Resident or person not in your party out of front door. The front door code was only posted from outside the door and written in words instead of numbers. Record review of Resident # 1's face sheet (unknown date) reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of dementia with severe other behavior disturbance (memory decline with acting out). Record Review of Resident #1's MDS quarterly assessment, dated 05/17/2025, reflected Resident #1 BIMS score of 10 which indicates a moderate cognitive impairment. Section C Cognitive - pattern reflected short -term memory loss.Record review of Resident #1's care plan dated 05/07/2025, reflected The resident is at risk for wandering; INTERVENTION: Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures and memory boxes. The resident is risk for falls r/t hx of falling and INTERVENTIONS: The resident needs activities that minimize the potential for falls while providing diversion and distraction, Resident resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. INTERVENTIONS: Admit to Secure Care unit per MD orders, allow resident to perform ADLs to their highest ability, offer assistance as needed, Assist and monitor resident for off unit activities if able and Engage resident in group activities and provide them with individualized meaningful activities.Review of Resident #1's incident report dated 08/07/2025 at 6:30PM reflected Resident walked out front door was seen by a CNA when they were leaving the building after their shift, CNA attempted to redirect resident back to the building, redirection unsuccessful, CNA came to get this nurse, and we assisted resident back inside. Immediate action: Resident to reside on secure unit due to history of elopement with active exit seeking behaviors. Vital sign as follows: BP 158/80 Temp 97.7 HR 68 RR 17 O2 98%. Physician, DON, Administrator and RP notified. Record review of a written interview given by ADM on 08/07/2025 to Resident # 1 and signed by Resident #1 and witnesses by CNA A , in a question-and-answer format reflected, [ADM question]: were you trying to go somewhere earlier when you went out the front door. [Resident #1 answer] I went outside. [ADM question] yes, you went outside and was found right outside the front door. Were you needing anything that causes you to go outside? [Resident #1 answer] Well, no, not that I can think of. [ADM question] Are you doing ok right now do you need anything? [Resident #1 answer] I'm fine, thank you for asking. During an observation and interview with Resident #1 on 08/13/2025 at 12:15 PM revealed her walking around in the secure unit with an ink pen in her hand and asked for some paper to write on. Resident #1 was asked her name by Surveyor, and she stated her name and began to repeat yes are you here for me. Therefore, an interview with Resident # 1 was not completed. During an interview with CNA A on 08/13/25 at 1:00 pm, she stated she was leaving for work approximately at 6:30 PM and she observed Resident # 1 standing on the front porch of the facility. She stated Resident #1 was not walking and standing in one spot. She stated she asked Resident # 1 to come back in and she refused. Therefore, she opened the front entrance door to ask for help to MA B, but he could not hear her, so she ran back into the building and told the charge nurse (LVN A) Resident # 1 was outside and she would not come in. She stated LVN A came outside with her to assist, and Resident #1 had walked to unit 200 covered patio area . She stated she could not remember if Resident # 1 was sitting or standing on the patio; however, LVN A was able to get her to come back into the building. She stated Resident # 1 was assessed by LVN A. She stated Resident #1 knew how to read numbers, and it was possible she let herself out or she went out the door when a visitor left. She stated Resident #1 use to leave on the secure unit, but she was moved out because she was not showing exit seeking behaviors. An interview on 08/13/2025 at 1:30 PM with LVN A was attempted by phone; however, she did not answer, and a voicemail was left for her to return my call. During an interview with RP on 08/13/2025 at 2:00PM, she said she was okay with Resident #1 moving to the unsecure unit, but she knew the elopement was going to happen eventually. She stated she wanted to give Resident #1 a chance to prove her wrong ; however, she believed Resident #1 read the pin code instructions and let herself out the front door. She said the facility did call her the day of the incident (08/07/2025) and made her aware that Resident # 1 eloped . During an interview with ADON on 08/13/25 at 3:00pm she stated the day of Resident #1's elopement she was present and was meeting with a visiting family. She stated she last saw Resident # 1 standing by the nursing station between 5:30PM- 6:00 PM. She stated their facility team and family members had discussed moving Resident #1 to a non- secure area for some time , so they decided to move her on 07/17/2025. She stated she was moved to hall 500 and was able to recognize her name on her door and there was no exit seeking behaviors. She stated her RP wanted Resident # 1 to have free access to the vending machine at her leisure, which gave the team another reason to move her to a non-secure area. She said she completed an elopement assessment and secure care unit assessment before and after the incident on 08/07/2025 and Resident #1 moved from the secure unit on 07/21/2025. She stated on 08/07/2025, Resident #1 was assessed for injuries and was moved back to the secure unit, and her RP gave consent to move her back. An interview on 08/13/2025 at 3:15 PM with MA A was attempted by phone; however, he did not answer after two attempts. MA A voicemail was not set-up; therefore, a voice mail was not left. During an interview on 08/13/2025 at 6:20 PM with Social Worker, she stated she had observed Resident # 1 never exit seeking and she remembered they talked about her moving out of the secure unit because since her admission she has never showed any exit seeking behavior. The Social Worker looked at Resident EHR to find documents of an official IDT meeting, and stated she could not find any documents, but she knew her RP agreed with the move. She stated she could not explain why any pre-move meetings was not documented and was not sure if Resident #1's Physician agreed with her move for the secure unit. During an interview on 08/14/2025 with LVN A at 6:34 PM she stated on 08/07/2025 , CNA A was leaving work and saw Resident # 1 standing outside on the front porch . She stated Resident # 1 would not come in for CNA A; therefore, she went outside to assist. She stated Resident # 1 was not overheated and was found walking on the sidewalk to hall 200's outside covered patio sitting . She stated she was dressed in clothes appropriate for the warm weather. She stated once Resident # 1 came into the facility she completed her vitals and there were no concerns. She stated she called the ADM and informed her Resident #1 was found outside and she contacted her RP and Physician. She stated earlier on 08/07/2025 she observed Resident #1 demonstrating exit seeking behaviors by walking around the facility with some bags and a box. She stated she observed her with her belongings while walking around the nurse's station and Resident # 1 was redirected to put her things up, and she did. She stated prior to 08/07/2025, Resident # 1 did not demonstrate any exit seeking behaviors once she was moved from the secure unit. She stated the alarm to the front doors work and was never broken, and if Resident #1 had pushed the door the alarm would have sounded . She stated it was very likely for Resident # 1 read the code and let herself out the front door because she could read. She stated she did not know if the IDT had met prior to Resident # 1's move but the facility did provide in-services on self- report / missing resident or elopement protocol elopement drills and ANE. Record Review of Elopement nurse's note-12hr dated 08/07/2025 at 6:54 PM by LVN A reflected, 3. Follow-Up: Resident walked out front door was seen by a CNA when they were leaving the building after their shift, CNA attempted to redirect resident back to the building, redirection unsuccessful, this nurse followed CNA to resident and assisted back inside. New order from Physician: Resident to reside on secure unit due to history of elopement with active exit seeking behaviors. Review of Secure care Environment Screening Tool dated 05/8/2025 for Resident # 1 reflected, diagnosis of Alzheimer's disease or related dementia disorders, resident continue to exhibit exit seeking behavior. Record review of elopement risk assessment dated [DATE] reflected Resident #1 had no history of attempts to leave facility. Her current behaviors: restlessness. [Resident #] 1 can state her name and recognizes stop lights and signs; however, she did not know her current residence, or recognize her physical needs. Record Review of Elopement Assessments dated 08/8/2025, reflected all current residents who were located in the secure unit and non-secure unit were re-assessed for elopement risk. No new residents were identified to be at high risk who resided in non- secure unit. During an interview on 08/14/2025 at 2:00 PM with ADM she stated she, the DON and ADON were in-serviced by their [NAME] President of clinical services on Pre and Post tools because they did not follow the facility protocol to ensure Resident #1's move was documented, and she was monitored after her move. She stated all staff was in-serviced on ANE, missing resident / elopement monitoring which included checking locking mechanism or alarm function properly on all exit doors, and elopement drills which would be conducted monthly on different shifts at random time. She stated other in-services was a Post elopement drill all staff and QAPI evaluation checklist for administrative staff . She stated without proper pre and post move transfer meeting and monitoring from a secure unit to non-secure being done a negative outcome could be Resident elopement , injury or even death of they are lost and have health issues. Record review of facility's policy on elopement/wandering unknown date, reflected , Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.1. The Elopement Risk Assessment will be completed upon admission. The assessment should becompleted by reviewing the resident's medical history and social history. Informationmay be obtained by reviewing current medical records, if available, interview withresident/family, or conference with the interdisciplinary team member. The assessmenttool should be completed, and interventions implemented as indicated. The ElopementRisk Assessment is to be completed at least quarterly and upon change of condition.2. All residents who are at risk for harm because of wandering (elopement) will be assessed by theinterdisciplinary care planning team.Interventions into elopement episodes will be entered onto the resident's care plan and medical.6. Should an elopement episode occur, the contributing factors, as well as the interventions tried,will be documented on the nurses' notes. Director of Risk Management and\or Director ofNursing Services should be notified of elopement.7. If a resident is discovered to be missing, a search shall begin immediately. On 08/13/2025 at 6:50 PM, the ADM was informed of an IJ. The non-compliance was identified as past non-compliance. The IJ began on 08/07/2025 and ended on 08/08/2025 at 2:20PM The facility had corrected the noncompliance before the investigation began. The interventions and plan of correction included: Review of Resident #1 EMR revealed Resident #1 was moved to the secure unit for her safety immediately.Review of Resident # 1 EMR revealed she was seen by her MD on 08/08/2025. It was recommended by MD for Resident #1 to remain in secure unit. No other concerns noted.Review of facility in-services dated 08/07/2025-08/8/2025 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Review of Elopement drills dated 08/08/2025 revealed a drill was completed on all shifts. Review of Elopement Assessments dated 08/07/2025 revealed current residents were assessed for elopement/wandering risk. No new residents were identified to be at high risk.Review of Ad Hoc QAPI meeting held on 08/08/2025 revealed an QAPI meeting was held to discuss the elopement of Resident #1. Record review of elopement follow- up interviews conducted by DON to all staff on 08/08/2025.Observations at facility on 08/13/2025 - 08/14/2025 and did not reveal observations of exit seeking or wandering residents. Interviews with facility staff on 8/13/2025-8/14/205 revealed they were educated on elopements, securing doors and alarms, supervision of residents, abuse and neglect, monitoring and documenting procedures during pre and post move from secure unit to a non- secure unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's physician when there was an unwitnessed fall in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's Physician was notified on 05/03/2024 when resident was found on the floor by CMA A. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. This failure placed residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nurse was to give directions of what to do after she completed all her assessments. 3. Report any falls or accidents immediately to the nurse. If nurse super[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each residents written plan of care for one (Resident #1) of four residents reviewed for qualified persons. The facility failed to ensure Resident #1 received assessment after an unwitnessed fall by a qualified staff member on 05/03/2024 when CMA A stated she conducted range of motion assessment, transferred the resident from the floor to the wheelchair and did not inform administrative staff. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures placed residents at risk for not receiving appropriate care and treatment by qualified staff. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1, who was found on the floor by CMA A was properly assessed or monitored on 05/3/2024 until Resident #1 was transferred to the hospital on [DATE] at approximately 10:30 AM. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nu[TRUNCATED]