**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of ten residents reviewed for care plans. The facility failed to ensure staff followed Resident #1's care plan on 03/26/25 when CNA A was giving her a bed bath alone and she slid from the bed onto the floor sustaining a severe laceration to her right hip and fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. While the IJ was removed on 04/09/25, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for negligence, injury, and hospitalization. Findings included: Review of Resident #1's face sheet, dated 04/09/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] and 07/07/23 with diagnoses including Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the body, particularly in the lungs and extremities), varicose veins (swollen, twisted, and enlarged veins, usually seen on the legs), and body mass index BMI 45.0 - 49.9 (indicates Class III obesity, also known as morbid obesity). Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS of 15, indicating resident had intact cognition. Review of Resident #1's quarterly care plan, revised on 11/24/21, reflected ADL performance deficit related to immobility, pain, and poor vision with interventions of: Toilet use - Resident #1 required (X2) staff participation to use toilet revised on 11/24/21 Transfer - Resident #1 required (X2) staff participation with transfers revised on 11/24/21 Bed Mobility - Resident #1 required (X2) staff participation to reposition and turn in bed revised on 11/24/21 Bathing - Resident #1 required (X2) participation with bathing revised on 11/24/21 Review of Resident #1's hospital HPI dated 03/26/25 reflected Resident #1 presented to the ER after a fall. Resident lived at a nursing home and reportedly when they were changing the sheets she fell out of bed. In the ER she was found to have a left comminuted intertrochanteric fracture (a break in the femur (thigh bone) that occurs in the intertrochanteric region, specifically between the greater and lesser trochanters. This fracture type is often seen in older adults and can result from a fall or impact. The comminuted aspect means the fracture has multiple bone fragments making it a more unstable fracture) and a large V-shaped skin tear that was stabled in the ER. A review of the Texas Unified Licensure Information Portal for the facility revealed that on 03/26/25 the facility reported that on 03/26/25 CNA A administered ADL care to Resident #1 and rolled her to her right side. Resident #1 slid out of bed onto the floor. Resident #1 received a laceration to her right lower extremity and was sent to the Emergency Room. The facility later received notification that Resident #1 had a left hip fracture. Review of unsigned facility statement from CNA A dated 03/26/25 reflected, I [CNA A] was giving [Resident #1] a bed bath, when I turned her over to clean the other side of her she slid out of her bed on to the Floor. I ran fast to tell nurse. we came back with help to get her off the floor. her legs were bleeding bad, so the nurse called 911, the nurses wrapped her legs to slow some of the bleeding. By then the paramedics/EMT Came and took her to the hospital. A review of Resident #1's Progress Note by LVN B reflected he was called to Resident #1's room by staff and found resident on floor at bedside closest to window. Resident #1 was nude from ADL care and her lower extremities lay across the legs of the bedside table, while her head was partially resting against wheels of bed. Resident #1 was alert and oriented and able to converse about her condition. After returning resident to bed with assistance of staff and mechanical devise it was determined that the laceration on the upper part of right thigh required a physician's intervention. While additional staff nurses remained with resident to help control bleeding RN B returned to desk and called EMS and reported to hospital ER of impending transfer. Resident was transferred to [hospital] by EMS, MD was made aware, and DON was informed. Resident #1 was her own responsible party and concurred with the treatment plan. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she spoke with CNA A regarding the incident with Resident #1 and asked if she know how to read the [NAME] (a concise nursing documentation system that summarizes key patient information, including medications, treatments, and daily care plans) and CNA said she did. Administrator asked her if she read it the morning of the incident with Resident #1 and CNA A said she did not. The Administrator asked CNA A how many people it took to assist Resident #1 and with peri care (cleaning the genital and anal areas to maintain hygiene and prevent infections) as well as other ADL's and CNA A said 2 (two). The Administrator asked CNA A if she used another person to assist Resident #1 and CNA A replied no, that the other aides were assisting other residents. The Administrator revealed she educated CNA A on the importance of reading the [NAME] as well as following the [NAME] and that it was to prevent any injuries to the resident. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she asked CNA A to go to Resident #1's room and show her how the incident occurred. The Administrator said CNA A raised the bed to the position it was at the time of the incident and CNA A stated that when she got ready to turn [Resident #1] she pulled the sheet up and turned [Resident #1] on her right side. This is when [Resident #1's] left leg swung over the side of the bed causing [Resident #1] to slide off the bed landing on her stomach. [Resident #1's] head was by the front wheels of the bed and her legs were by the back wheels of the bed. [CNA A] stated that [Resident #1's] lower right leg was laying on the top of the bottom of the over the bed table. This table has a metal frame that holds the table with the bottom of the bedside table where [Resident #1's] right lower extremity landed. CNA A told the Administrator that there was blood at the bottom of the bedside table where [Resident #1's] right lower extremity landed. The Administrator said she asked if Resident #1 complained of pain to either of her hips and CNA A stated that [Resident #1] did not. Review of signed statement dated 03/26/25 of CNA C who stated I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came to help get [Resident #1] off the floor. Review of signed statement dated 03/26/25 of CNA D who stated, I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came and grabbed the [assistive device] to help assist until no longer needed. Attempted interview on 04/09/25 with Resident #1 at 11:42 am, who discharged to another facility after she discharged from the hospital, reflected, when phoning Resident #1, received a voice mail that the number requested could not be dialed and unable to interview Resident #1. Interview on 04/09/25 with a Family Member of Resident #1 at 11:25 am revealed Resident #1 no longer had a telephone. Family Member reported the facility staff, rolled [Resident #1] right off the bed. The Family member said there was a policy in place for Resident #1 to have 2 (two) people always go in and assist Resident #1 when she needed to be changed. The Family member reported Resident #1 had, 30 staples and 7 stitches and a broken hip. An interview on 04/09/25 with CNA A at 12:36 pm reflected she felt like the facility was short staffed and she did not want to bother the other staff and ask for help. She said she had helped Resident #1 alone previously and Resident #1 had been sitting in urine and needed to be changed. CNA A said she did not purposely hurt Resident #1, but she did not ask for help to assist Resident #1. She said she had not been asked to return to work at the facility. CNA A said when Resident #1 fell, she ran to get a nurse and he assessed with getting Resident #1, using an assistive devise, off the floor. CNA A she was not trained on how to use the [NAME] but did know that Resident #1 was a 2 (two) person assist when changing or moving Resident #1. A phone call interview on 04/10/25 with LVN B at 02:12 pm revealed he was the nurse on shift at time of Resident #1's fall on 03/26/25 and, to his knowledge the resident was a 2 (two) person assist. He said the [NAME] contained information about Resident #1's ADLs and transfer status. LVN B stated the CNAs referred to the [NAME] to determine the care needs of a resident and the [NAME] was available to all CNAs. LVN B stated, he was not aware, at the time of the incident, that CNA A was providing care alone. LVN B stated he was informed by staff (staff name unknown) that Resident #1 had a large bowl movement and CNA A wanted to bath her after but stated that CNA A should have gotten help and that there was plenty of staff that night to assist and no reason for her to not ask for help. CNA B revealed, Why she chose not to do that I don't know, I was at the nurses station charting when she came to get me for help after. He stated if CNA A had told him that she was going to bathe Resident #1 he would have gotten up to help CNA A, but she did not inform him that she needed a second staff member to help her with Resident #1. He stated he was the charge nurse that night. He stated the caregiver was ultimately responsible for asked for assistance with residents because they knew the rules when they were given their assignments. LVN B stated anyone would be crazy to take a resident her size on by themselves and he did not know why to this day CNA A did not ask for help. LVN B recalled the resident's weight to be in the area of 260 plus pounds. Resident #1 was in a bariatric bed, and it was hard for LVN B to imagine that someone would attempt changing and cleaning her alone. When LVN B walked into the room to help after CNA A called him, he said it looked like she [CNA A] was getting ready to change the oil on the bed- that was never safe at any time for any patient especially someone with Resident #1's weight to have a bed that high. The aide should have gotten help, the call light was available there was always a way to get help. An interview on 04/10/25 with CNA C at 2:33 pm revealed she was at the nurses' station on the rehabilitation side of the facility when LVN B came to get her stating they needed help getting a resident off the floor. CNA C stated she saw the resident on the floor in between the wall and the bed and Resident #1's bed was pretty high up. CNA C stated prior to this event, she never worked with Resident #1 but upon seeing Resident #1, because of Resident #1 was a big woman, she would have known that Resident #1 was a 2 (two) person assist. CNA C stated that the number of staff assistance a resident required for safe resident care was in the [NAME] located in EMR. A CNA could click on the [NAME] to see if the resident was a one or two person assist. The CNA C said if there was not another person to assist a resident who was a 2 (two) person assist, she would ask a nurse to help or wait for a coworker to get help before assisting the resident. She said she did not recall how many staff members were working that night but said there were plenty of people listing herself, two aides, a nurse, and a nurse trainee. CNA C stated that CNA A could have also asked the people in the rehabilitation side of the facility for help. CNA C stated it was never appropriate to proceed with just one person if the resident was listed in the [NAME] as a 2 (two) person assist. If the [NAME] says the Resident require a 2 (two) person assist, you wait until you have 2 (two) people to assist. CNA C stated, you never know the condition or if they just had hip surgery, you always wait to have the amount of people you need. CNA C stated she has no idea why the CNA A did not ask for help that night. A phone interview on 04/10/25 with CNA D at 2:50 pm revealed LVN B asked for help with a resident. CNA D she walked into Resident #1's room and saw Resident #1 on the floor and she went to grab the mechanical devise to lift help get Resident #1 off the floor. CNA D stated they needed a mechanical device due to Resident#1's size and also because of Resident #1's ADL abilities. CNA D stated she had worked with Resident #1 in the past and stated it was very obvious for anyone, even working with Resident #1 for the first time, to see that Resident #1 was a 2 (two) person assist based on her size and appearance. CNA D stated she would look at the [NAME] to determine the level of assistance needed for residents. CNA D stated if she did not have the 2nd person needed to assist a resident, she would go find help and stated, you just have to ask for help. CNA D Stated it was never appropriate to proceed to assist without the help of others if they require 2 (two) or more even assist if it appeared manageable. CNA D stated it was everyone's responsibility to ensure the residents received the level of care they need. She stated she referred to the [NAME] daily because something could change. She stated she would report any [NAME] issues to her nurse or the Administrator as needed. In an interview on 04/10/25 with ADON at 6:02 pm she stated CNAs were ultimately responsible for ensuring the correct level of care for residents because they were trained and knew the procedures. She stated that agency and PRN staff also have access to the [NAME]. She stated she was responsible for the PRN and new hire staff be aware of where to locate the [NAME] which displays the care needs of the residents. She stated it was her expectation that they provided the highest level of care, that all residents needs were met in a safe, respectful, and dignified manner. The ADON stated that level of resident care and resident transfer status understanding was the knowledge that kept patients safe. She said that if staff knew the level of resident care needs it helped to makes sure residents remained safe. She stated that if the person was aware of the transfer status of a resident and did not follow the resident transfer status when providing resident care she would consider it negligence because they did not provide the safest level of care. An interview on 04/10/25 with the DON at 6:20 pm revealed she had been the DON at the facility for a week and a half and it was her expectation that the CNAs follow the [NAME] that they have been trained to follow. She stated she would consider it negligence if a CNA knew the transfer status of a resident and failed to follow it and stated that CNA would require retraining. She stated that training for [NAME] occurred frequently. An interview on 04/10/25 with the Administrator at 2:33 pm revealed staff needed to ensure the physical abilities and the level of the ADL care needed for residents when providing assistance. The CNAs can find out if residents require a 1 (one) or 2 (two) person level of assistance by referring to the [NAME]. If there is not a 2nd staff member available, they need to wait until a 2nd staff member is available to provide resident care. An interview on 04/10/25 with the Administrator at 6:45 pm revealed it was the CNAs responsibility to ensure they were providing the care the resident required. She stated all PRN staff had access to the [NAME] and knew how to locate it. She stated it was important to follow the transfer status due to resident safety as well as staff safety. She stated that when she asked CNA A why she didn't ask for help CNA A said that other CNAs were busy, and Resident #1 was impatient. Review of facility Falls and Fall Risk, Managing Policy dated April 2007 reflected based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Review of the facility Falls - Clinical Protocol dated April 2007 based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Review of the facility Abuse and Neglect - Clinical Protocol Assessment and Recognition policy dated April 2007 reflected neglect means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Treatment/Management -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The ADM was notified on 04/09/25 at 5:36 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/10/25 at 2:27 pm: The POR included: PLAN OF REMOVAL Date: April 9, 2025 The Texas Department of Health and Human Services entered facility on April 9, 2025 for a Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited regarding F656 Develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to follow Resident # 1's care plan when care was provided by one staff member only. Immediate action: What corrective actions have been implemented for the identified residents? Resident #1 discharged from the facility on 3-26-25 to the hospital and did not return to the facility. On 4-9-25, the Clinical Service Director in-serviced the nurse managers to include the DON to refer to the [NAME] for the level of assistance: including 2 person assistance required by residents with ADL care. On 4-9-25, DON/designees in-serviced all direct care (full-time, part-time, and PRN) nursing staff to utilize [NAME] to determine the level of assistance required to provide care. On 3-27-25, the Administrator educated CNA A to refer to the [NAME] for the level of assistance: including 2 person assistance required by residents with ADL care. CNA A last day worked was 3-31-25. All direct care nursing staff (full-time, part-time, and PRN) will demonstrate and acknowledge that they are aware of how to identify and utilize the [NAME] to review resident's care plan to identify the level of assistance: including 2 person assistance) required to provide ADL care. The [NAME] was in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the [NAME] button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan including 2 person assistance. On 4-10-25, DON/designees audited residents' [NAME] to ensure the level of required assistance was stated as directed by resident's care plan. 13 residents were identified as needing 2-person assistance for bed mobility. On 4-10-25, DON/designees audited employee roster to ensure 100% of direct care nursing staff (full-time, part-time, and PRN) are in-serviced to refer to the [NAME] for the level of assistance: including 2 person assistance required by residents with ADL care. The training regarding to refer the [NAME] for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance. No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' [NAME] to determine the level of assistance that is required to provide care. DON/designees will conduct random direct care observation audit for compliance with the utilization of the [NAME] for the level of assistance: including 2 person assistance required by residents with ADL care daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately. On 4/9/25, the facility Administrator notified the Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on 4/9/25 as evidenced by facility's failure to: F656 - Develop and implement a comprehensive person-centered care plan The facility failed to follow Resident # 1's care plan when care was provided by one staff member only. All direct care nursing staff is to identify and utilize the [NAME] to review resident's care plan to determine the level of assistance required to provide care. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the [NAME] to review resident's care plan to identify the level of assistance required to provide care. The [NAME] is in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the [NAME] button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan. DON/designees audited residents' [NAME] to ensure the level of required assistance is stated as directed by resident's care plan. DON/designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the [NAME]. The training regarding to refer the [NAME] for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' [NAME] to determine the level of assistance that is required to provide care. Random direct care observation audit will be conducted by DON/designees for compliance with the utilization of the [NAME] to determine the level of assistance that is required to provide care to the residents daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately. This will be reviewed monthly in QAPI until sustained compliance is achieved. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/09/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems. Monitoring: Record review completed on 04/10/25 of inservice dated 04/09/25 by clinical services director - refer to [NAME] on level of assistance required by residents with ADL care including residents that require a 2 person assist, signed by the DON. Record review completed on 04/10/25 of log dated 04/09/25 used to complete training for staff, indicated who was trained over the phone or in person. Of 77 direct care staff, 75 were inserviced which is 97 percent. 2 which have not are PRN staff not scheduled to work, but per the clinical services director, they will be inserviced when they are scheduled prior to their shift. During interviews on 04/10/25 from 12:40 pm - 3:20 pm, two LVNs, one MA, and 9 CNAs from different shifts all stated they were in-serviced before working their shift on utilization of the residents' [NAME] to determine the level of assistance that is required to provide care and observed the CNA's ability to locate the [NAME] and care requirements for ADLS and transfers. Record review completed on 04/10/25 of in-service dated 03/27/25 at 9:00 am presented by Administrator to CNA A you must refer to the [NAME] prior to providing assistance to residents so that you can ensure you are providing the appropriate level of care. Observed signature by CNA A. Record review completed on 04/10/25 of audit done on all residents dated 04/10/25 for bed mobility and level of assist and [NAME] accuracy. Audit was completed of all residents, of 15 that had a x2 status- 2 were corrected which no longer required x2 assistance and changed to x1 assist, condition improved. Record review completed on 04/10/25 of audit of employee rooster to ensure 100% of direct care (full-time, part-time, and PRN) were in-serviced to refer to the [NAME] for the level of assistance: including 2 person assistance required by residents with ADL care. Record review completed on 04/10/25 of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops, DON, ADON E, ADON F, Clinical Services Director, and facility MD. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to protect Resident #1, who required a two person assist for toilet, transfers, bed mobility and bathing, when CNA A, acting alone on 03/26/2025, assisted Resident #1 with ADL care. Resident #1 slid off her bed, sustained a severe laceration (a tear or cut in the skin or other tissues caused by trauma) to her right hip and a fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. While the IJ was removed on 04/09/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for negligence, injury, and hospitalization. Findings included: Review of Resident #1's face sheet, dated 04/09/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] and 07/07/23 with diagnoses including Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the body, particularly in the lungs and extremities), varicose veins (swollen, twisted, and enlarged veins, usually seen on the legs), and body mass index BMI 45.0 - 49.9 (indicates Class III obesity, also known as morbid obesity). Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS of 15, indicating resident had intact cognition. Review of Resident #1's quarterly care plan, revised on 11/24/21, reflected ADL performance deficit related to immobility, pain, and poor vision with interventions of Toilet use - Resident #1 required (X2) staff participation to use toilet revised on 11/24/21. Transfer - Resident #1 required (X2) staff participation with transfers revised on 11/24/21. Bed Mobility - Resident #1 required (X2) staff participation to reposition and turn in bed revised on 11/24/21. Bathing - Resident #1 required (X2) participation with bathing revised on 11/24/21. Review of Resident #1's hospital HPI dated 03/26/25 reflected Resident #1 presented to the ER after a fall. Resident lived at a nursing home and reportedly, when they were changing the sheets she fell out of bed . In the ER she was found to have a left comminuted intertrochanteric fracture (a break in the femur (thigh bone) that occurs in the intertrochanteric region, specifically between the greater and lesser trochanters. This fracture type was often seen in older adults and can result from a fall or impact. The comminuted aspect means the fracture has multiple bone fragments making it a more unstable fracture) and a large V-shaped skin tear that was stabled in the ER. A review of the Texas Unified Licensure Information Portal for the facility revealed that on 03/26/25 the facility reported that on 03/26/25 CNA A was administering ADL care to Resident #1 and rolled her to her right side. Resident #1 slid out of bed onto the floor. Resident #1 received a laceration to her right lower extremity and was sent to the Emergency Room. The facility later received notification that Resident #1 had a left hip fracture. Review of unsigned facility statement from CNA A dated 03/26/25 reflected, I [CNA A] was giving [Resident #1] a bed bath, when I turned her over to clean the other side of her, she slid out of her bed on to the Floor. I ran fast to tell nurse. we came back with help to get her off the floor. her legs were bleeding bad, so the nurse called 911, the nurses wrapped her legs to slow some of the bleeding. By then the paramedics/EMT Came and took her to the hospital. A review of Resident #1's Progress Note dated 03/26/25 by LVN B reflected he was called to Resident #1's room by staff and found resident on floor at bedside closest to window. Resident #1 was nude from ADL care and her lower extremities lay across the legs of the bedside table, while her head was partially resting against wheels of bed. Resident #1 was alert and oriented and able to converse about her condition. After returning resident to bed with assistance of staff and mechanical lift it was determined that the laceration on the upper part of right thigh required a physician's intervention. While additional staff nurses remained with resident to help control bleeding RN B returned to desk and called EMS and reported to hospital ER of impending transfer. Resident was transferred to [hospital] by EMS, MD was made aware, and DON was informed. Resident #1 was her own responsible party and concurred with the treatment plan. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she spoke with CNA A regarding the incident with Resident #1 and asked if she knew how to read the [NAME] (a concise nursing documentation system that summarizes key patient information, including medications, treatments, and daily care plans) and CNA said she did. Administrator asked her if she read it the morning of the incident with Resident #1 and CNA A said she did not. The Administrator asked CNA A how many people it took to assist Resident #1 and with peri care (cleaning the genital and anal areas to maintain hygiene and prevent infections) as well as other ADL's and CNA A said 2 (two). The Administrator asked CNA A if she used another person to assist Resident #1 and CNA A replied no, that the other aides were assisting other residents. The Administrator revealed she educated CNA A on the importance of reading the [NAME] as well as following the [NAME] and that it was to prevent any injuries to the resident. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she asked CNA A to go to Resident #1's room and show her how the incident occurred. The Administrator said CNA A raised the bed to the position it was at the time of the incident and CNA A stated that when she got ready to turn [Resident #1] she pulled the sheet up and turned [Resident #1] on her right side. This was when [Resident #1's] left leg swung over the side of the bed causing [Resident #1] to slide off the bed landing on her stomach. [Resident #1's] head was by the front wheels of the bed and her legs were by the back wheels of the bed. [CNA A] stated that [Resident #1's] lower right leg was laying, on the top of the bottom of the over the bed table. This table has a metal frame that holds the table with the bottom of the bedside table where [Resident #1's] right lower extremity landed. CNA A told the Administrator that there was blood at the bottom of the bedside table where [Resident #1's] right lower extremity landed. The Administrator said she asked if Resident #1 complained of pain to either of her hips and CNA A stated that [Resident #1] did not. Review of signed statement dated 03/26/25 of CNA C who stated I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came to help get [Resident #1] off the floor. Review of signed statement dated 03/26/25 of CNA D who stated, I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came and grabbed the [mechanical lift] to help assist until no longer needed. Attempted interview on 04/09/25 with Resident #1, who discharged to another facility from the hospital after the incident, at 11:42 am reflected, when phoning Resident #1, received a voice mail that the number requested could not be dialed and unable to interview Resident #1. Interview on 04/09/25 with a Family Member of Resident #1 at 11:25 am who stated Resident #1 no longer had a telephone. Family Member reported the facility staff, rolled [Resident #1] right off the bed. The Family member said there was a policy in place for Resident #1 to have 2 (two) people always go in and assist Resident #1 when she needed to be changed. The Family member reported Resident #1 had, 30 staples and 7 stitches and a broken hip. An interview on 04/09/25 with CNA A at 12:36 pm she stated she felt like the facility was short staffed and she did not want to bother the other staff and ask for help. She said she had helped Resident #1 alone previously and Resident #1 had been sitting in urine and needed to be changed . CNA A said she did not purposely hurt Resident #1, but she did not ask for help to assist Resident #1 with ADL care. She said she had not been asked to return to work at the facility since the incident. CNA A said when Resident #1 fell, she ran to get a nurse and he assisted with getting Resident #1 off the floor, using a mechanical assistive devise. CNA A stated she was not trained on how to use the [NAME] but did know that Resident #1 was a 2 (two) person assist when changing or moving Resident #1. A phone call interview on 04/10/25 with LVN B at 2:12 pm revealed he was the nurse on shift at time of Resident #1's fall on 03/26/25 and, to his knowledge the resident was a 2 (two) person assist. He said the [NAME] contained information about Resident #1's ADLs and transfer status. LVN B stated the CNAs referred to the [NAME] to determine the care needs of a resident and the [NAME] was available to all CNAs. LVN B stated, he was not aware, at the time of the incident, that CNA A was providing care alone. LVN B stated he was informed by staff (staff name unknown) that Resident #1 had a large bowl movement and CNA A wanted to bath her after but stated that CNA A should have gotten help and that there was plenty of staff that night to assist and no reason for her to not ask for help. CNA B revealed, Why she chose not to do that I don't know, I was at the nurses station charting when she came to get me for help. He stated if CNA A had told him that she was going to provide ADL assistance for going to bathe Resident #1 he would have gotten up to help CNA A, but she did not inform him that she needed a second staff member to help her with Resident #1. He stated he was the charge nurse that night. He stated the caregiver was ultimately responsible to ask for assistance with residents because they knew the rules when they were given their assignments. LVN B stated anyone would be crazy to take a resident her size on by themselves and he did not know why to this day CNA A did not ask for help. LVN B recalled the resident's weight to be in the area of 260 plus pounds. Resident #1 was in a bariatric bed, and it was hard for LVN B to imagine that someone would attempt changing and cleaning her alone. When LVN B walked into the room to help after CNA A called him, he said it looked like she [CNA A] was getting ready to change the oil on the bed- that was never safe at any time for any patient especially someone with Resident #1's weight to have a bed that high. The aide should have gotten help, the call light was available and there was always a way to get help. An interview on 04/10/25 with CNA C at 2:33 pm revealed she was at the nurses' station on the rehabilitation side of the facility when LVN B came to get her stating they needed help getting a resident off the floor. CNA C stated she saw the resident on the floor in between the wall and the bed and Resident #1's bed was pretty high up. CNA C stated prior to this event, she never worked with Resident #1 but upon seeing Resident #1, because of Resident #1 was a big woman, she would have known that Resident #1 was a 2 (two) person assist. CNA C stated that the number of staff assistance a resident was required for safe resident care and the information was in the [NAME] located in EMR. A CNA could click on the [NAME] to see if the resident was a one or two person assist. CNA C said if there was not another person to assist a resident who was a 2 (two) person assist, she would ask a nurse to help or wait for a coworker to get help before assisting the resident. She said she did not recall how many staff members were working that night but said there were plenty of people listing herself, two aides, a nurse, and a nurse trainee. CNA C stated that CNA A could have also asked the people in the rehabilitation side of the facility for help. CNA C stated it was never appropriate to proceed with just one person if the resident was listed in the [NAME] as a 2 (two) person assist. If the [NAME] says the Resident require a 2 (two) person assist, you wait until you have 2 (two) people to assist. CNA C stated, you never know the condition or if they just had hip surgery, you always wait to have the amount of people you need. CNA C stated she has no idea why the CNA A did not ask for help that night. A phone interview on 04/10/25 with CNA D at 2:50 pm revealed LVN B asked for help with a resident. CNA D stated she walked into Resident #1's room and saw Resident #1 on the floor and she went to grab the mechanical lift to lift help get Resident #1 off the floor. CNA D stated they needed a mechanical lift due to Resident#1's size and also because of Resident #1's ADL abilities. CNA D stated she had worked with Resident #1 in the past and stated it was very obvious for anyone, even working with Resident #1 for the first time, to see that Resident #1 was a 2 (two) person assist based on her size and appearance. CNA D stated she would look at the [NAME] to determine the level of assistance needed for residents. CNA D stated if she did not have the 2nd person needed to assist a resident, she would go find help and stated, you just have to ask for help. CNA D stated it was never appropriate to proceed to assist without the help of others if they require 2 (two) or more even assist if it appeared manageable. CNA D stated it was everyone's responsibility to ensure the residents received the level of care they need. She stated she referred to the [NAME] daily because something could change. She stated she would report any [NAME] issues to her nurse or the Administrator as needed. An interview on 04/10/25 with ADON at 6:02 pm stated stated CNAs were ultimately responsible for ensuring the correct level of care for residents because they were trained and knew the procedures. She stated that agency and PRN staff also have access to the [NAME]. She stated she was responsible for the PRN and new hire staff be aware of where to locate the [NAME] which displays the care needs of the residents. She stated it was her expectation that they provided the highest level of care, that all residents needs were met in a safe, respectful, and dignified manner. The ADON stated that level of resident care and resident transfer status understanding was the knowledge that kept patients safe. She said that if staff knew the level of resident care needs it helped to makes sure residents remained safe. She stated that if the person was aware of the ADL transfer status of a resident and did not follow the resident ADL transfer status when providing resident care she would consider it negligence because they did not provide the safest level of care. An interview on 04/10/25 with the DON at 6:20 pm revealed she had been the DON at the facility for a week and a half and it was her expectation that the CNAs follow the [NAME] that they have been trained to follow. She stated she would consider it negligence if a CNA knew the ADL transfer status of a resident and failed to follow it and stated that CNA would require retraining. DON stated that training for [NAME] occurred frequently. An interview on 04/10/25 with the Administrator at 2:33 pm revealed staff needed to ensure the physical abilities and the level of the ADL care needed for residents when providing assistance. The CNAs can find out if residents require a 1 (one) or 2 (two) person level of assistance by referring to the [NAME]. If there was not a 2nd staff member available, they need to wait until a 2nd staff member was available to provide resident care. An interview on 04/10/25 with the Administrator at 6:45 pm revealed it was the CNAs responsibility to ensure they were providing the care the resident required. She stated all PRN staff had access to the [NAME] and knew how to locate it. She stated it was important to follow the ADL transfer status due to resident safety as well as staff safety. She stated that when she asked CNA A why she didn't ask for help CNA A said that other CNAs were busy, and Resident #1 was impatient. Review of facility Falls and Fall Risk, Managing Policy dated April 2007 reflected based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Review of the facility Falls - Clinical Protocol dated April 2007 based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Review of the facility Abuse and Neglect - Clinical Protocol Assessment and Recognition policy dated April 2007 reflected neglect means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Treatment/Management -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The ADM was notified on 04/09/25 at 5:36 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/10/25 at 2:27 pm: The POR included the following: F- 600 IJ Template provided to entity: 04/09/25 5:36pm F-600 Plan of Removal Date: April 9, 2025 The Texas Department of Health and Human Services entered the facility on April 9, 2025, for a Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited regarding F600 -The resident has the right to be free from neglect . The facility failed to ensure Resident #1 had two staff members assisting her during care as outlined in Resident #1's care plan. What corrective actions have been implemented for the identified residents? A. On 3/26/2025 Resident #1 involved in alleged deficient practice was discharged to the hospital resident did not return to the facility. B. On 3/26/2025 CNA A was in-serviced on Referring to the [NAME] for the level of assistance required by residents with ADL care and the Abuse and Neglect Policy by the administrator. C. On 3/26/025 CNA A was suspended on 3/26/2025 pending investigation findings. D. On 4/09/2025 at 7:20 pm the Administrator notified the Medical Director of the alleged deficient practice. Record review completed on 04/10/25 of screenshot showing call made to the MD 04/09/25 at 7:20 pm. E. CNA A last day employed was on 3/31/2025. F. On 4/09/2025 the Corporate Clinical Service Director re-educated the nurse management team on referring to the [NAME] for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. The completion date was 4/09/2025. G. On 4/09/2025 the Administrator and Nurse Managers re-educated the nursing staff on referring to the [NAME] for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. The completion date was 4/10/2025. H. On 4/10/2025 an audit was conducted by the Corporate Clinical Service Director and the nurse management team to ensure the level of ADL care required, including residents needing 2-person assistance was noted in the [NAME]. There were 13 residents identified that require 2-person assistance with bed mobility. Discrepancies found were immediately corrected on 04/10/2025. I. The Corporate Clinical Service Director reviewed facility policy on 04/09/2025 regarding change in condition and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. On 4/10/2025 the Regional Nurse completed Resident Life Satisfactory Surveys for residents that require 2-person assistance, no concerns were noted. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. On 4/09/2025 the nurse management team re-educated the nursing staff (Full-time, Part-time, and PRN) on referring to the [NAME] for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. Nursing staff will not be allowed to return to work until they receive this in-service. The completion date was 4/10/2025. B. Newly hired nursing staff will be in-serviced upon hire during staff orientation by nurse management/designee on referring to the [NAME] for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. C. DNS /designee will conduct random observations of ADL care including residents needing 2-person assistance is being provided daily for one week, then weekly for one month, and monthly thereafter until compliance is sustained for three consecutive months. Noncompliance identified will be addressed immediately. How will the system be monitored to ensure compliance? A. The ADONs will review the change in condition daily x 3 months for any changes in residents' ADL level of assistance requirements and ensure the [NAME] is updated as applicable. Discrepancies noted during reviews will be immediately corrected. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form. B. The Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for three months. The review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/09/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Record review completed of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops , DON, both ADONs, Clinical Services Director, and facility MD. Monitoring: Monitoring: Record review completed on 04/10/25 of in-service dated 03/27/25 at 9:00 am presented by Administrator to CNA A you must refer to the [NAME] prior to providing assistance to residents so that you can ensure you are providing the appropriate level of care. Observed signature by CNA A. Record review completed on 04/10/25 of disciplinary action for CNA C dated 03/31/25 with violation date of 03/26/25 reflecting termination for not following proper protocol in regard to providing care to resident, the resident sustained a laceration and fractured hip. Record review completed on 04/10/25 of screenshot showing call made to the MD 04/09/25 at 7:20 pm notifying the Medical Director of the alleged deficient practice Record review completed on 04/10/25 of disciplinary action for CNA C dated 03/31/25 with violation date of 03/26/25 reflecting termination for not following proper protocol in regard to providing care to resident as 2x staff, the resident sustained a laceration and fractured hip. Record review completed on 04/10/25 of in-service dated 04/09/25 by clinical services director to nurse management - refer to [NAME] on level of assistance required by residents with ADL care including residents that require a 2 person assist, and ANE signed by DON, two ADONs, LVN MDS, and treatment nurse. Record review completed on 04/10/25 of log used to complete training for staff, dated 04/09/25, that indicated who was trained over the phone or in person. Of 77 direct care staff, 75 were in-serviced which was 97 percent. 2 which are PRN staff not scheduled to work, but per the clinical services director, they will be in-serviced when they are scheduled prior to their shift. During interviews on 04/10/25 from 12:40 pm - 3:20 pm, two LVNs, one MA, and 9 CNAs from different shifts all stated they were in-serviced before working their shift on utilization of the residents' [NAME] to determine the level of assistance that is required to provide care and observed the CNA's ability to locate the [NAME] and care requirements for ADLS and transfers. Record review completed on 04/10/25 of audit done on all residents dated 04/10/25 for bed mobility and level of assist for [NAME] accuracy. Audit was completed of all residents, of 15 that had a x2 status- 2 were corrected which no longer required x2 assistance and changed to x1 assist, condition improved. Record review completed on 04/10/25 of the in-serviced dated 04/09/25 on re-education of the nursing staff on referring to the [NAME] for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. Record review completed on 04/10/25 of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops , DON, both ADONs, Clinical Services Director, and facility MD. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluid were administered consistent with professional standards of practice in accordance with physician orders, the comprehensive-centered care plan, and the resident's goals and preferences for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure Resident #1's PICC line dressing was changed every 7 days or as needed as Resident #1 went 27 days without a dressing change. Resident #1's dressing was dated 2/20/2025 and was not changed on 02/27/2025, 03/06/2025, and 03/13/2025. 2. The facility failed to ensure Resident #1, and Resident #2 were on enhanced barrier precautions for PICC lines. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 03/18/2025 at 2:25 PM and an IJ template was provided. While the IJ was removed on 03/19/2025 at 6:30 PM, the facility remained out of compliance at no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with central lines at risk for serious infection, impaired nutrition, and hospitalization. Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old man re-admitted on [DATE] with diagnoses of other acute osteomyelitis, left femur, sepsis due to Escherichia coli, type 2 diabetes mellitus, unspecified dementia, malignant neoplasm of prostate, and abscess of bursa. Review of Resident #1 quarterly MDS reflected a BIMS score of 06. Further review reflected Resident #1 had septicemia and received intravenous, antibiotics. Review of Resident #1's physician orders dated 02/20/2025 reflected Resident #1 had a PICC inserted for IV access until 03/19/2025. Review of Resident #1's physician orders dated 02/11/2025 reflected to change IV dressing every seven days and as needed. Resident #1's dressing should have been changed on 02/27/2025, 03/06/2025, and 03/13/2025 and/or as needed. Review of Resident #1's physician orders dated 02/11/2025 reflected to administer cefazolin sodium intravenous solution every 8 hours for sepsis until 03/19/2025 through PICC line. Further review reflected orders dated 02/12/2025 to flush IV line before and after administration of IV medication. Observation on 03/18/2025 at 9:53 AM, revealed there were no EBP signage or PPE available for Resident #1. Further observation revealed Resident #1's PICC line dressing was dated 02/20/2025. There was no signs of redness or odor observed at site. During an observation and interview on 03/18/2025 at 11:26 AM, LVN A stated that Resident #1's dressing was dated 02/20/2025. LVN A stated dressings were supposed to be changed at least once a week and if it was not changed the resident could get an infection. LVN A stated she was not sure what residents were supposed to be on EBP. LVN A was observed flushing Resident #1's PICC line with gloves on and no gown. LVN A stated the nurse who was assigned to the resident should change the dressing. LVN A stated she thought she should use a gown and gloves if you were flushing or doing anything with a PICC line. During an observation and interview on 03/18/2025 at 11:43 AM, ADON B stated EBP should have been used on residents who have direct line in or out of the body and any major wound. ADON B stated you should use EBP when you changed dressings or provided personal care. ADON B stated residents who had a PICC line should have been on EBP. ADON B stated he needed to double check whether staff needed to wear a gown to flush the line. ADON B observed Resident #1's dressing and stated, I can tell you right now, that isn't good. ADON B stated that Resident #1's dressing was dated 02/20/2025. During a subsequent interview on 03/18/2025 at 12:23 PM, ADON B stated that he was informed that central supply ran out of dressings two weeks ago and their order was backordered for some time. ADON B stated they should get a new delivery today. ADON B stated he was not aware the facility was out of the dressings. Review of Resident #2's face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of other specified sepsis, infection and inflammatory reaction due to internal right hip prosthesis, abscess of [NAME], staphylococcal arthritis, and hearth failure. Review of Resident #2's physician order dated 03/13/2025 reflected to change foley catheter as needed, and provide catheter care every shift or as needed. Further review reflected to change IV dressing every seven days or as needed. Observation on 03/18/2025 at 10:49 AM, revealed no EBP signage or PPE in or outside of Resident #2's door. Observation on 03/18/2025 at 10:50 AM, revealed facility staff posted EBP sign on Resident #2's door. Observation on 03/18/2025 at 10:55 PM, revealed LVN C flushed Resident #2's line with gloves on and did not have a gown on. During an interview on 03/18/2025 at 11:26 AM, LVN C stated that dressings were supposed to be changed every 7days and if there were not an infection could occur. LVN C stated residents who had a PICC line were usually on EBP. LVN C started EBP was used to provide personal care such as showers. LVN C stated that only gloves could be used for flushing, and it was not considered personal care. During an interview on 03/18/2025 at 1:38 PM, DON stated that EBP should have been used on residents with a foley, PICC, IVs and wounds. She stated that this included using gloves, gown and mask when care was provided. DON stated resident with PICC lines should be on EBP. She stated PPE should have been just inside or just outside of the resident's room. She stated that when staff handled the PICC lines they should have implemented EBP. DON stated the purpose of EBP was to possibly prevent infection. DON stated she was not aware that Resident #1's dressing had not been changed since 02/20/2025. DON stated the nurse was responsible for putting in the orders and changing the dressing when it was needed. DON stated ADONs should have monitored that orders were initiated and PICC dressings were changed. DON stated dressings should be changed every seven days. She stated the potential outcome of not changing the dressing or using EBP was possible introducing an infection. DON stated central supply was responsible for ordering supplies and that PICC line dressings were on back order. DON stated they had one dressing in the facility today and she just learned that there was a PICC dressing shortage. During an interview on 03/18/2025 at 1:18 PM, MD stated that dressing was supposed to be every seven days and as needed. MD stated there was a risk for infection if the dressing was not changed but it was not anything outrageous and stated Resident #1's dressing should have been changed. MD stated there are no standing orders for EBP, but she would expect the staff to have EBP PPE on such as gown and gloves. Review of facility policy titled Central Venous Catheter Dressing Changes with revision date of April 2016 reflected the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Further reviewed reflected general guidelines included to change dressings at least every 5-7 days and PRN. Review of facility policy titled Enhanced Barrier Precautions - Policy dated 04/01/2024 reflected the use of gown and gloves during high-contact resident care activities were required. High-contact resident care activities included device care or use such as central line or urinary catheter. Further review reflected indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. The ADM and DON were notified on 03/18/2025 at 2:25 PM, that an IJ had been identified. An IJ template was provided, and a POR was requested. The following POR was approved on 03/19/2025 at 12:19 PM and indicated: Plan of Removal A. On 3/18/25, an abbreviated survey was initiated at the facility. The surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating the facility failed to ensure resident #1's PICC line dressing was changed every 7 days. The facility failed to ensure resident #1 and resident#2 were on enhanced barrier precautions for PICC line. What corrective actions have been implemented for the identified residents? B. On 3/18/2025 at 2:25pm, resident #1's PICC line dressing change was done by Nurse Manager A. C. On 3/18/2025 at 2:25pm, resident #1 was placed on enhanced barrier precautions and signage posted on resident #1's door by Nurse Manager A. D. On 3/18/25 at 2:30pm, resident #2 was placed on enhanced barrier precautions and signage posted on resident #2's door by Nurse Manager A. E. On 03/18/2025 at 2:40pm the Administrator notified the Medical Director of the alleged deficient practice. F. The Corporate Clinical Service Director in-serviced the Nurse Managers on 3/18/25 at 3:30pm on ensuring PICC line dressing change is done every 7 days. G. On 3/18/25 at 4pm Nurse Manager A and B completed an assessment of 2 residents with PICC line to ensure the dressing change date is less than 7 days, and no concerns were identified. H. Nurse Managers completed a 100% audit of residents residing in the facility to assess the need for barrier precautions, no concerns were identified. I. On 3/18/2025 licensed nurses were in-serviced on ensuring PICC line dressing change is done every 7 days by Nurse Manager A and B. The facility audited all residents with PICC line for dressing change dates less than 7 days old, no concerns were identified by Nurse Manager A and B. J. The Corporate Clinical Service Director reviewed facility policy on 3/18/2025 regarding PICC line dressing change and no revisions were deemed necessary. K. The Corporate Clinical Service Director reviewed facility policy on 3/18/2025 regarding enhanced barrier precautions and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was completed on 3/18/2025 by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents PICC line dressing change is done every 7 days. B. An in-service was completed on 3/18/25 by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents requiring enhanced barrier precautions have signage posted on the door. C. The Director of Nursing completed an in-service on 3/18/2025 with the licensed nursing staff on ensuring PICC line dressing change is done every 7 days. D. The Director of Nursing completed an in-service on 3/18/2025 with the licensed nursing staff on ensuring residents requiring enhanced barrier precautions have signage posted on the door. E. Nurses will not be allowed to return to work until they receive this in-service. Nursing staff who are unable to physically attend the in-service training in person will be in-serviced via phone by Nurse Manager A. The completion date is 3/19/2025. F. Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure PICC line dressing change is done every 7 days during facility orientation upon hire. G. Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure residents requiring enhanced barrier precautions have signage placed on the door during facility orientation upon hire. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the removal was completed on 3/18/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Surveyor monitored the POR on 03/19/2025 as followed: Observation on 03/19/2025 at 11:32 AM revealed Resident #1's dressing was changed and dated for 03/18/2025. No odor or redness was observed. Observation revealed EBP signage on door and PPE such as gown and gloves in bind inside of Resident #1's room. Observation on 03/19/2025 at 11:39 AM, revealed EBP signage posted on Resident #2's door and bin of PPE such as gown and gloves outside of Resident #2's door. Review of facility in-service dated 03/18/2025 completed by corporate nurse reflected EBP signage must be posted on door and PICC line dressing change was done every 7 days was completed with DON, ADON B and ADON D. Review of in-services dated 03/18/2025 and 03/19/2025 by ADON D reflected 56 staff were educated on EBP. Review of in-services dated 03/18/2025 and 03/19/2025 by ADON D reflected 8 nurses were in-serviced on PICC line dressing changes. Review QAPI sign-in sheet undated reflected medical director, ADM, DON and ADONs attended. During an interview on 03/19/2025 at 4:47 PM, ADON B stated that facility nursing staff (CNAs and nurses) work 12-hour shifts. ADON B stated that all nursing staff was called yesterday and if they answered they were in-serviced via telephone or left a voicemail requesting a return phone call. ADON B stated that staff would be in-serviced prior starting their shift if they had not already been in-serviced. During interviews conducted on 03/19/2025 between 3:45 PM and 6:12 PM, 2 RNs, 2 ADONS, DON, 3 LVNs and 6 CNAs it was revealed that staff received an in-service either on 03/18/2025 or 03/19/2025 or prior to their shift by ADON D or ADON B. Staff stated that in-service included that EBP were to be used with residents who have an open wound, catheter, PICC line, or feeding tube to prevent infection from staff to the resident. Staff stated that EBP included to use PPE such as gown and gloves when they provided direct care such as flushing the line, changing the dressing, peri care and/or showers. Staff stated they can tell to use EBP with a resident on signage that was posted and PPE bin in or outside the resident's room. Licensed nurses stated that PICC line dressings were to be changed every 7 days or as needed to prevent infection to the resident. Licensed nurses stated that they should wear a gown and gloves when changing the dressings or flushing the line for residents with PICC lines. Licensed nurses stated that upon admission they can post EBP signage and get PPE needed or if they notice a resident was supposed to be on EBP. The ADM and DON were notified on 03/19/2025 at 6:30 PM that the IJ had be lowered. While the IJ was lowered, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a score of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of two residents reviewed for care plans. (Residents #1, and #2) A) The facility failed to ensure Resident #1's fall care plan intervention were followed by not placing a fall mat in his room. Resident #1 had a fall and died. B) The facility failed to implement Resident #2's fall care plan intervention by not placing a fall mat in her room. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. While the IJ was removed on [DATE], the facility remained at a level of actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical well-being, serious injury, serious harm, serious impairment, or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an original admission date of [DATE], initial admission date [DATE] and admission date [DATE] revealed [AGE] year-old-male with diagnoses of Parkinson's disease without dyskinesia (uncontrolled, involuntary movement), fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 day). Resident #1's care plan focus initiated [DATE] and revised on [DATE] revealed: Resident #1 is high risk for fall, Gait/balance problems, unaware of safety needs, history of multiple falls, orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), and confusion. Resident #1's care plan goal initiated [DATE] and target date [DATE] Resident #1 will be free of falls through the review date. Resident #1's care plan interventions were the falling star program initiated [DATE], CNA and CN to anticipate and meet the resident's needs date initiated [DATE], CNA and CN to be sure the resident #1's call light was within reach and encourage the resident to use it for assistance as needed, resident needed prompt response to all requests for assistance date Initiated [DATE], encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility date Initiated [DATE] revised on [DATE], falling mats date initiated [DATE]. Resident #1's MDS dated [DATE] revealed a BIMS score of 8 suggesting mild cognitive impairment. Functional status reflected extensive assistance - resident involved in activity, staff provide weight-bearing support and 1-person physical assist and mobility devise of use of a wheelchair. Resident #1's fall risk assessment dated [DATE] revealed he was a high risk for falls, reason for assessment recent falls, had fallen 1 - 2 times within the last 6 months, he was disoriented, he was unable to independently come to a standing position and used an assistive device, e.g., cane, walker, etc. Resident #1's Visual/Bedside [NAME] Report revealed SAFETY - [DATE] anti-roll back on wheelchair, [DATE] drop wheelchair seat, [DATE] scoop mattress, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance, encourage the resident to use [NAME] to call for assistance, falling mats. Resident #1's hospital records dated [DATE] revealed, chief complaint of fall of [AGE] year-old man with a hx of Parkinson's disease and advanced dementia, previously on hospice and presents after a fall in his nursing home. He was down on the ground for some about of time. The facility reported they are not exactly sure why he fell, but he did fall frequently. It was revealed he most likely fell from his bed. Physical exam revealed soft tissue contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) with 2-centimeter laceration (cut referring to a skin wound) over the left eyebrow. He struck his head on the ground, was alert disoriented at his neurologic baseline. CT impression large acute left cerebral convexity subdural (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull) hematoma (a bad bruise that happens when an injury causes blood to collect and pool under the skin) with 10 millimeter rightward midline shift (most epidural, subdural, or intracerebral hematomas associated with a midline shift of 5 mm or more are surgically evacuated). Resident had a chronic indwelling right parietal ventriculostomy catheter. He was on hospice, but it was discontinued. He had a significant brain bleed and operating room visit may not benefit the patient if he were to decline. Final dx of traumatic subdural hematoma and intraparenchymal hematoma of brain (blood pools in the tissues of the brain) due to trauma, fall from a height of less than 3 feet. Resident #1's hospital records dated [DATE] revealed worsening of intracranial hemorrhage, was transitioned to comfort measures and passed away. Resident #2's face sheet dated [DATE] with admission date [DATE] revealed [AGE] year-old female with diagnoses of fracture of upper end of right humerus (the bone of the upper arm or forelimb), hyperosmolality (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances common electrolyte problem) and hypernatremia (common electrolyte problem). Resident #2's MDS dated [DATE] revealed a BIMS score of 10 suggesting moderately impaired cognition. Functional status reflected limited assistance needed resident highly involved in activity; staff provided guided maneuvering and one-person physical assist. Resident #2's care plan focus revealed she had an actual fall on [DATE] as the result of cognitive impairment and poor safety awareness and an actual fall on [DATE] fall with injury with laceration (a deep cut or tear in skin or flesh). Resident #2's care plan goal initiated on [DATE] reflected inflicted injured areas will resolve without complication by review date and resident will resume usual activities without further incident through [DATE]. Resident #2's care plan interventions included falling star program initiated [DATE], CNA and CN to perform frequent safety checks to assess and assist resident with needs initiated [DATE], therapy to work on safety awareness and use of assistive devices, CALL DO NOT FALL sign in room initiated [DATE], CNA and CN to place fall mats initiated [DATE], psych eval for increase confusion and refusal of care initiated: [DATE]. Resident #2's Visual/Bedside [NAME] Report revealed SAFETY - [DATE] falling star program, [DATE] frequent safety checks to assess and assist with needs, [DATE] therapy to work on safety awareness and use of assistive devices, [DATE] call do not fall sign in room, [DATE] fall mats while patient is in bed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, sling to right arm. Facility progress note dated [DATE] reflected Resident #2 was admitted to the facility after fall that occurred on [DATE]. Facility progress note dated [DATE] reflected Resident #2 had a fall and was sent to the emergency room and sustained a laceration to her forehead that required 4 staples and a contusion to her left hip. DX recurrent falls and continued to attempt to ambulate on her own. Interview on [DATE] at 11:55 am CNA A revealed she initially discovered Resident #1 laying in the floor. She revealed she went to his room because his call light was on. She revealed there was no fall mat in Resident #1's room but a wheelchair was beside his bed. When asked a second time if a fall mat was present, she said there was no fall mat anywhere and said she could say for sure there was no fall mat. She revealed she did see Resident #1's bed was lowered. Interview on [DATE] at 11:19 am with RN/CN revealed she was the nurse who assessed Resident #1 after he was found by the CNA, and he appeared to have tried to get out of the bed and fell. She said he had fall interventions of a lowered bed, but he did not have a fall matt because it was a trip hazard when he attempted to get out of bed. RN/CN revealed there was no fall mat when she assessed him after his fall on [DATE]. Interview on [DATE] at 1:20 pm with Resident #1's family member said he visited Resident #1 the Friday before Resident #1's fall on [DATE] and there was no mat in the room and there had been no mat in the resident's room for a least two months. The family member said initially, when Resident #1 first had a fall, there was a mat then it was folded up in the corner of the room, but he had not seen it anywhere for about 2 months. Interview on [DATE] at 1:20 pm with who said she visited Resident #1 the Thursday before resident's fall [DATE]. She said resident was sleeping/dozing when she entered his room, and there was no floor mat. She said when the resident first fell, there was a mat for a while, then it was folded and put in a corner of the room, and she had not seen it for about 1 or 2 months. Interview on [DATE] at 3:20 pm with the facility MD revealed that if Resident #1's care plan listed fall mats as an intervention, ideally the fall mat should have been in place. The MD said he can't recall if there was a fall mat in place when he last visited with Resident #1. Interview and observation on [DATE] at 6:47 am with LVN A revealed Resident #2 did not have a fall mat in her room. Surveyor observed the falling star placard on the outside of Resident #1's room and entered room with LVN A. LVN A expressed that all fall interventions were in place and pointed out the saddle seat in the wheelchair for Resident #1's roommate and lowered bed for Resident #1. No fall mat was observed in any area of the room. LVN A told surveyor that all interventions for the falls were in place. Interview on [DATE] at 1:46 pm surveyor told LVN A that when she went to Resident #2's room on [DATE] with LVN A there was no fall mat, and the surveyor went into Resident #2's room later the same day and looked all over the room and on both sides of the room there was no fall mat. Surveyor asked how the staff caring for the resident were informed of resident fall interventions. LVN A said that there was a [NAME] Report that listed all fall interventions. Surveyor showed LVN A Resident #2's [NAME] Report where the report revealed, under SAFETY on [DATE] fall mats. LVN A revealed she did not know that Resident #2 had an intervention for a fall mat. She said she missed the fall mat because she did not see it on the doctor's orders for Resident #2 but agreed, after looking at the [NAME] Report, that Resident #2 should have had a fall mat. LVN A revealed that if a fall intervention was not in place, it was horrible to contemplate what could happen. The resident could break their hip, they could get bruised, and get a hematoma. When the surveyor went into Resident #2's room with her on [DATE] she said she did not mention the fall mats as an intervention for Resident #2 because she did not see the mats in the room to point them out to the surveyor as an intervention in place. Interview on [DATE] at 11:06 pm with the LVN MDS Coordinator revealed care plans tell a story about the resident care needs from medications to dietary needs and resident requests and it was in place to keep resident's safe. The care plan was an integral part to all resident care. If a staff member does not carry out something in a care plan, it could be detrimental to the resident and the resident could receive a physical injury. If the care plan says there should be a fall mat in place for the resident, then, there should be a fall mat for the resident. The MDS Coordinator said that every staff member who goes into the resident's room should know that the resident was care planned for a fall mat and should make sure that a fall mat was there . She revealed that every resident who comes into the facility should have received a fall assessment and the fall assessment would be used to decide any necessary care planned fall interventions. Residents who were at high risk for falls were in the falling star program. Interview a t 12:06 pm with RN A revealed that to learn about resident interventions, staff could look at both or either the residents' care plan located in the EHR or the visual/bedside [NAME] Report, also located in the EHR. The [NAME] Report listed all resident care plan needs, including fall interventions, and both the nurses and CNAs can access the care plans and the [NAME] Report. She revealed she checked that all the interventions were in place at the start of her shifts. She revealed that if there was not a fall mat in a resident's room and the resident was care planned for a fall mat there could be injury to the resident. It was extremely important to make sure fall mats were in place because it can minimize the risk of injury. RN A revealed staff should follow the intervention that was in place. Interview on [DATE] at 4:35 with the DON revealed the entire nursing staff, including the DON, were responsible for the care plans, including fall interventions, and it was the responsibility of the DON to make sure accurate interventions were in place and were being carried out. Interview on [DATE] at 2:46 pm with the DON revealed the facility absolutely has the responsibility to follow the interventions that were in the residents' care plans. A care plan guides the care of a patient and was in place to prevent falls or injuries due to falls. At this time the Surveyor informed him that she had observed on three different occasions that Resident #2, who was care planned for a fall mat, did not have a fall mat in her room and he responded that if it was in her care plan, it should have been in there. He revealed that every nurse should know the plan of care for their patients, that was why they do the plan of care. He revealed that if care planned interventions were not in place, residents could fall and become injured. Interview on [DATE] at 1:26 pm with the ADM revealed facilities have care plans to develop an appropriate plan of care when a resident was receiving services at the facility. She revealed it was necessary to the safety of the residents to do anything possible to prevent them from falling or having injuries and it would jeopardize the safely of the resident if fall interventions were not in place. She revealed that it was the responsibility of the DON and the ADM to ensure interventions were in place. Review of facility Fall Risk assessment dated 02/2012 reflected Facility Nursing will document the following in the nursing note, full assessment and/or approaches in the care plan. Rationale for the fall precautions, falling star program placement, all steps taken to aid in the safety of the resident, education of the resident and responsible party, consult request. Fall status will be documented in the resident care guide and communicated between shifts and disciplines. Review of facility Care Planning - Interdisciplinary Team Policy Statement dated 12/2008 reflected Policy Statement our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation 1. A comprehensive crew plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary team which includes but is not necessarily limited to the following personnel: a. the resident's attending physician b. the registered nurse who has responsibility for resident c. the dietary manager d. the social services worker responsible for the resident e. the activity director f. therapists g. consultants h. the director of nursing i. the charge nurse responsible for resident care j. nursing assistants responsible for the resident's care plan and k. others as appropriate or necessary to meet the needs of the resident. Review of facility Care Plans - Comprehensive dated 12/2009 reflected: Policy Statement - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's care planning/interdisciplinary team in coordination with the resident, his/her family or representative develops and maintains a person-centered comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain through establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and other factors related to effectiveness of the plan of care. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS, Assessments of residents are ongoing and cre plans are revised as information about the resident and the resident's condition change. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the resident's strengths. d. Reflect treatment goals, timetables, and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in prevention or reducing declines in the resident's functional status and/or functional levels. g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program and h. Reflect currently recognized standards of practice for problems areas and conditions. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:00 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on [DATE] at 5:00 pm. [name of facility]PLAN OF REMOVAL F656 Name of Facility: Date: [DATE] Residents residing in the facility have the potential to be affected by not developing and implementing a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. What corrective actions have been implemented for the identified resident? Resident #1 No longer resides in the building. Resident #2 careplan was reviewed by the DON to ensure careplan was updated to meet the resident fall risk. DON ensure resident had fall matt placed in proper location. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE]. a. On [DATE] an audit was completed by DON and/or designee to identify residents care planned for fall mats, all residents currently requiring fall mats careplaned was reviewed and careplans updated by the DON/designee to address patients fall needs. Those care planned for fall mats a check of the residents' room was completed by Don/Designee during the clinical morning meeting. DON/Designee will review 5 days a week and will round to ensure fall mats are in place. The weekend manager/Nurse on duty on the weekend will round to ensure fall mats that are care planned are in place. b. On [DATE], the Director of Nursing (DON) initiated an in-service session for the licensed nursing staff (Nurses,CNA,CMA). The focus of the in-service was to review patient fall interventions and ensure their proper implementation. All untrained Nursing staff (Nurses,CNA,CMA) staff will not be allowed to work on the floor without receiving the in-service c. On [DATE] an in-service was initiated for the facility Nursing Management by the DON on the importance of updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. The MDS/PPS coordinator, unit manager, ADON and DON will update resident care plans with new/changed orders, changes in condition, falls, etc. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR on [DATE] as followed: During interviews on [DATE] from 12:06 pm through 1:46 pm with two CNAs and two LVNs, they all stated they were in-serviced before their shifts on reporting abuse, neglect, and exploitation, patient fall interventions and to ensure their proper implementation and updating and reviewing care plan of resident at risk for fall to ensure proper interventions were placed to meet the residents' needs. Reviewed in-service for the licensed nursing staff (Nurses,CNA,CMA) subject patient fall interventions and ensure their proper implementation. Reviewed in-service for the facility Nursing Management by the DON on the importance of updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. Surveyor observed that Resident #2 had a fall mat placed by her bed. The ADM and DON were informed the Immediate Jeopardy was removed on [DATE] at 4:06 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, inteviews, and record reviews the facility failed to ensure it provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 2 (Resident #1 and Resident #2) out of 15 residents reviewed for accidents and hazards. The facility failed to provide the necessary fall care planned service to Resident #1 by falling to provide the intervention of a fall mat. Resident #1 had a fall, was taken to the hospital, and died. The facility failed to implement interventions for Resident #2 by not placing a fall mat in her room after she had two previous falls, one that resulted in an injury requiring medical intervention. An IJ was identified on 11/08/23. The IJ template was provided to the facility on [DATE] at 5:00 pm. While the IJ was removed on 11/10/23, the facility remained at a level of actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of injury, a decline in physical well-being, serious injury, serious harm, serious impairment, or death. Findings Include: Resident #1's face sheet dated 11/08/23 with original admission date 05/01/22, initial admission date 08/03/22 and admission date 01/18/23 revealed [AGE] year-old-male with diagnoses of Parkinson's disease without dyskinesia (uncontrolled, involuntary movement), fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 day). Resident #1's care plan focus initiated 08/03/22 and revised on 08/04/22: Resident #1 is high risk for fall, Gait/balance problems, unaware of safety needs, history of multiple falls, orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), and confusion. Resident #1's care plan goal initiated 05/02/23 and target date 08/15/23 Resident #1 will be free of falls through the review date. Resident #1's care plan interventions were the falling star program initiated 08/03/22, CNA and CN to anticipate and meet the resident's needs date initiated 05/02/2022, CNA and CN to be sure the resident #1's call light was within reach and encourage the resident to use it for assistance as needed, resident needed prompt response to all requests for assistance date Initiated 05/02/22, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility date Initiated 05/02/22 revised on 08/04/22, falling mats date initiated 05/02/2022. Resident #1's MDS dated [DATE] revealed a BIMS score of 8 suggesting mild cognitive impairment. Functional status reflected extensive assistance - resident involved in activity, staff provide weight-bearing support and 1-person physical assist and mobility devise of use of a wheelchair. Resident #1's fall risk assessment dated [DATE] revealed he was a high risk for falls, reason for assessment recent falls, had fallen 1 - 2 times within the last 6 months, he was disoriented, he was unable to independently come to a standing position and used an assistive device, e.g., cane, walker, etc. Resident #1's Visual/Bedside [NAME] Report revealed SAFETY - 01/04/23 anti-roll back on wheelchair, 11/27/23 drop wheelchair seat, 12/05/22 scoop mattress, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance, encourage the resident to use [NAME] to call for assistance, falling mats. Resident #1's hospital records dated 11/05/23 revealed chief complaint of fall of [AGE] year-old man with a hx of Parkinson's disease and advanced dementia, previously on hospice and presents after a fall in his nursing home. He was down on the ground for some about of time. The facility reported they are not exactly sure why he fell, but he did fall frequently. It was revealed he most likely fell from his bed. Physical exam revealed soft tissue contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) with 2-centimeter laceration (cut referring to a skin wound) over the left eyebrow. He struck his head on the ground, was alert disoriented at his neurologic baseline. CT impression large acute left cerebral convexity subdural (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull) hematoma (a bad bruise that happens when an injury causes blood to collect and pool under the skin) with 10 millimeter rightward midline shift (most epidural, subdural, or intracerebral hematomas associated with a midline shift of 5 mm or more are surgically evacuated). Resident had a chronic indwelling right parietal ventriculostomy catheter. He was on hospice, but it was discontinued. He had a significant brain bleed and operating room visit may not benefit the patient if he were to decline. Final dx of traumatic subdural hematoma and intraparenchymal hematoma of brain (blood pools in the tissues of the brain) due to trauma, fall from a height of less than 3 feet. Resident #1's hospital records dated 11/06/23 revealed worsening of intracranial hemorrhage, was transitioned to comfort measures and passed away. Resident #2's face sheet dated 11/08/23 with admission date 07/29/23 revealed [AGE] year-old female with diagnoses of fracture of upper end of right humerus (the bone of the upper arm or forelimb), hyperosmolality (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances common electrolyte problem) and hypernatremia (common electrolyte problem). Resident #2's MDS dated [DATE] revealed a BIMS score of 10 suggesting moderately impaired cognition. Functional status reflected limited assistance needed resident highly involved in activity; staff provided guided maneuvering and one-person physical assist. Resident #2's care plan focus revealed she had an actual fall on 08/12/23 as the result of cognitive impairment and poor safety awareness and an actual fall on 09/01/23 fall with injury with laceration (a deep cut or tear in skin or flesh). Resident #2's care plan goal initiated on 08/12/23 reflected inflicted injured areas will resolve without complication by review date and resident will resume usual activities without further incident through 10/28/2023. Resident #2's care plan interventions included falling star program initiated 08/12/22, CNA and CN to perform frequent safety checks to assess and assist resident with needs initiated 08/12/2023, therapy to work on safety awareness and use of assistive devices, CALL DO NOT FALL sign in room initiated 09/01/2023, CNA and CN to place fall mats initiated 09/01/23, psych eval for increase confusion and refusal of care initiated: 09/01/2023. Resident #2's Visual/Bedside [NAME] Report revealed SAFETY - 08/12/23 falling star program, 08/12/23 frequent safety checks to assess and assist with needs, 08/12/23 therapy to work on safety awareness and use of assistive devices, 09/01/23 call do not fall sign in room, 09/01/23 fall mats while patient is in bed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, sling to right arm. Facility progress note dated 08/15/23 reflected Resident #2 was admitted to the facility after fall that occurred on 08/12/23. Facility progress note dated 09/01/23 reflected Resident #2 had a fall and was sent to the emergency room and sustained a laceration to her forehead that required 4 staples and a contusion to her left hip. DX recurrent falls and continued to attempt to ambulate on her own. Resident #2 osteopathic progres notes dated 09/01/23 reflected she had a fall on 08/12/23 and was transported to the emergency departrment. X-ray revealed a right humeral (upper arm) fracture, laceration to head that required four staples, and burising to her left hip. Diagnoses recurrent falls, continues to attempt to ambulate on her own, last fall required a trip to the emergency department. Interview at 11:55 am CNA A on 11/07/23 revealed she initially discovered Resident #1 laying in the floor. She revealed she went to his room because his call light was on. She revealed there was no fall mat in Resident #1's room but a wheelchair was beside his bed. When asked a second time if a fall mat was present, she said there was no fall mat anywhere and said she could say for sure there was no fall mat. She revealed she did see Resident #1's bed was lowered. Interview at 11:19 am with RN/CN on 11/07/23 revealed she was the nurse who assessed Resident #1 after he was found by the CAN, and he appeared to have tried to get out of the bed and fell. She said he had fall interventions of a lowered bed, but he did not have a fall matt because it was a trip hazard when he attempted to get out of bed. RN/CN revealed there was no fall mat when she assessed him after his fall on 11/05/23. Interview at 1:20 pm with Resident #1's son on 11/08/23 who said he visited his father the Friday before Resident #1's fall on 11/5/23 and there was no mat in the room and there had been no mat in his father's room for a least two months. Resident #1's son said initially, when his father first had a fall, there was a mat then it was folded up in the corner of the room, but he had not seen it anywhere for about 2 months. Interview at 1:20 pm with resident's former wife on 11/08/23 who said she visited Resident #1 the Thursday before resident's fall 11/05/23. She said resident was sleeping/dozing when she entered his room and there was no floor mat. She said when the resident first fell, there was a mat for a while, then it was folded and put in a corner of the room, and she had not seen it for about 1 or 2 months. Interview at 3:20 pm with the facility MD on 11/07/23 revealed that if Resident #1's care plan listed fall matts as an intervention, ideally the fall mat should have been in place. MD said he can't recall if there was a fall mat in place when he last visited with Resident #1. Interview and observation on 11/08/23 at 6:47 am with LVN A revealed Resident #2 did not have a fall mat in her room. Surveyor observed the falling star placard on the outside of Resident #1's room and entered room with LVN A. LVN A expressed that all fall interventions were in place and pointed out the saddle seat in the wheelchair for Resident #1's roommate and lowered bed for Resident #1. No fall mat was observed in any area of the room. LVN A told surveyor that all interventions for the falls were in place. Observations on 11/08/23 at 2:00 pm and 3:30 pm of Resident #2's room revealed no floor mats. Interview on 11/09/23 at 1:46 pm surveyor told LVN A that when she went to Resident #2's room on 11/08/23 with LVN A there was no fall mat, and the surveyor went into Resident #2's room later the same day and looked all over the room and on both sides of the room there was no fall mat. Surveyor asked how the staff caring for the resident were informed of resident fall interventions. LVN A said that there was a [NAME] Report that listed all fall interventions. Surveyor showed LVN A Resident #2's [NAME] Report where the report revealed, under SAFETY on 09/01/23 fall mats. LVN A revealed she did not know that Resident #2 had an intervention for a fall mat. She said she missed the fall mat because she did not see it on the doctor's orders for Resident #2 but agreed, after looking at the [NAME] Report, that Resident #2 should have had a fall mat. LVN A revealed that if a fall intervention was not in place, it was horrible to contemplate what could happen. The resident could break their hip, they could get bruised, and get a hematoma. When the surveyor went into Resident #2's room with her on 11/08/23 she said she did not mention the fall mats as an intervention for Resident #2 because she did not see the mats in the room to point them out to the surveyor as an intervention in place. Interview at 11:06 pm with LVN MDS Coordinator on 11/08/23 revealed care plans tell a story about the resident care needs from medications to dietary needs and resident requests and it is in place to keep resident's safe. The care plan is an integral part to all resident care. If a staff member does not carry out something in a care plan, it could be detrimental to the resident and the resident could receive a physical injury. If the care plan says there should be a fall mat in place for the resident, then, there should be a fall mat for the resident. The MDS Coordinator said that every staff member who goes into the resident's room should know that the resident was care planned for a fall mat and should make sure that a fall mat is there. She revealed that every resident who comes into the facility should have received a fall assessment and the fall assessment would be used to decide any necessary care planned fall interventions. Residents who were at high risk for falls were in the falling star program. Interview at 12:06 pm with RN A revealed that to learn about resident interventions staff could look at both or either the residents' care plan located in the EHR or the visual/bedside [NAME] Report, also located in the EHR. The [NAME] Report listed all resident care plan needs, including fall interventions, and both the nurses and CNAs can access the care plans and the [NAME] Report. She revealed she checked that all the interventions were in place at the start of her shifts. She revealed that if there is not a fall mat in a resident's room and the resident is care planned for a fall mat there could be injury to the resident. It is extremely important to make sure fall mats are in place because it can minimize the risk of injury. RN A revealed staff should follow the intervention that is in place. Interview at 4:35 with the DON on 11/08/23 revealed the entire nursing staff, including the DON, were responsible for the care plans, including fall interventions, and it is the responsibility of the DON to make sure accurate interventions were in place and were being carried out. 2:46 pm with the DON on 11/8/23 revealed the facility absolutely has the responsibility to follow the interventions that are in the residents' care plans. A care plan guides the care of a patient and are in place to prevent falls or injuries due to falls. He revealed that every nurse should know the plan of care for their patients that is why they do the plan of care. He revealed that if care planned interventions are not in place, residents could fall and become injured. Interview at 1:26 pm with the ADM on 11/10/23 revealed facilities have care plans to develop an appropriate plan of care when a resident is receiving services at the facility. She revealed it is necessary to the safety of the residents to do anything possible to prevent them from falling or having injuries and it would jeopardize the safely of the resident if fall interventions were not in place. She revealed that it is the responsibility of the DON and the ADM to ensure interventions were in place. Review of facility Fall Risk assessment dated 02/2012 reflected Facility Nursing will document the following in the nursing note, full assessment and/or approaches in the care plan. Rationale for the fall precautions, falling star program placement, all steps taken to aid in the safety of the resident, education of the resident and responsible party, consult request. Fall status will be documented in the resident care guide and communicated between shifts and disciplines. Review of facility fall and fall risk managing policy dated December 2007 revealed based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff, with the input of the attending physician, identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of the residence fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions as applicable to try to minimize serious consequences of falling. The staff will monitor and document each resident's responses to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the interventions has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to prevent a risk for falling or injury due to falls. Review of facility falling star program protocol dated February 2012 policy statement based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Purpose and implementation to identify residents at high risk for falls and to attempt to prevent these falls through an interdisciplinary approach in cooperation with nursing, the resident, the family or significant others and facility staff period to assist in preventing resident falls by frequent monitoring of residents need for assistance while in the facility period to implement preventative measures in order to minimize the degree of injury sustained by a resident resulting from a fall. Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are samples of intrinsic risk factors Parkinson's disease and conductive impairments. Extrinsic risk factors for falls are part of their resident environment and are most likely to be seen in areas such as the resident room, bathroom, dining room, and hallways. Policy all residents admitted to the facility will be assessed for risk of falling on admission and at least quarterly or whenever is necessary secondary to a change in resident status. All residents will be assessed for risk of falls on admission, after a fall, after a change of condition, quarterly. Resident identified at a high risk for falling will be placed on the protocol falling star program which includes - consider therapy consult, educate resident and responsible party regarding the risk of falls, provide tips to avoid falls. Ensure adequate lighting and remove clutter from room, provide non slip footwear, observe sleep and elimination and offer assistance, please call light, phone, and personal items within reach, bed in low position, wheels locked, consider a pharmacy consult, consider timing of diuretic and laxative administration, place resident on the falling star program, anticipate toileting needs, consider bed/chair alarm, consider low bed, move resident close to nursing station, if possible, restroom light on in the evening and night, place internal pumps, Avi poles, Foley and other equipment on the side of the bed the resident exits, consider disease processes during room selection, admit process. Overview - interdisciplinary fall teams are a key success factors in fall prevention programs. This section will cover the following information choosing the right people, responsibilities of the team members, options for facilities of various sizes, functions of the interdisciplinary team. Choosing the right people - the interdisciplinary fall team should have people with administrative and direct care functions. We recommend the following people to be involved in the interdisciplinary fall team: Clinical staff - fall clinical nurse specialist (or similar position) if available or applicable, nurse manager, nursing assistant, pharmacy, rehab team, physician or nurse practitioner. Nonclinical staff patient safety manager/quality manager coordinator, facility management manager, central supply manager, environmental manager, transportation, and activities. They should be clearly defined in the policy charter. Clinical staff - fall clinical nurse specialist- not all facilities have a fall clinical nurse specialist. Some facilities have a particular nurse manager, generally in the long term or extended care wards that have an interest in falls and fall related injuries prevention. This person will generally facilitate team meetings, ensure fall prevention measures are being used (this is a responsibility of the entire team), elicit comments from staff regarding the program and other fall related activities. Nurse manager - due to their management responsibilities, they can enforce the interventions taken by the interdisciplinary team. Due to their management responsibilities, they can enforce the interventions taken by the interdisciplinary teams and ensure that interventions become the standard of care for high fall risk residents. Nursing assistant - nursing assistants are generally the most affected by the interventions implemented by the fall team. They can help educate their peers on the interventions. They can also act as fall prevention advocates and collect data for the aggregate reviews submitted. Pharmacy - pharmacy review medications of all high fall risk residents when they are identified and following a fall. Pharmacy help to identify issues with the medications and notify physicians that medication need to be adjusted. This is very important because many falls are the result of medication side effects. Rehabilitation staff - occupational therapy and physical therapies provide balance and strength assessments for high fall risk residents. They can also assess the ability of a resident to use specific interventions taking into account grip strength and other factors. Physician slash nurse practitioner - the physician looks at the medical history and stability of the high fall- risk residents when admitted and following a fall. He or she should identify aspects of the medical history that could contribute to falls. Nonclinical staff - residents safety manager/quality management coordinator - the resident safety manager can facilitate the team if there is no falls clinical specialist. He or she can also act as a liaison between the team and the management of the facility. He or she can provide data to the team to help determine the impact of the intervention taken. Facility management member - the facility management member can help to ensure that the environment of care is set up to reduce falls. they can train the janitorial staff to perform environmental assessments to remove cutter from rooms, ensure that spills are cleaned up promptly and other things. The facility management person can also identify fall hazards related to cleaning supplies, such as a particular cleaning agent causing floor to be sticky. They may assess the environment in common rooms to ensure that furniture is safe for people who are at risk for falls. Central supply manager - the central supply manager can help facilities purchase items to reduce the risk of falls- related injuries. They can also ensure that the supply is adequate and ensure that the correct products are purchased. Environmental manager - the environmental manager can ensure that all devices used are in working order to prevent residents from falling. They can also look into devices that were involved in falls, such as wheelchairs or walkers. Options for facilities of various sizes. Smaller facilities can integrate the falls team into their interdisciplinary treatment teams. The treatment teams for high fall risk residents should include: physician or nurse practitioner, physical or occupational therapist, pharmacy, nurse manager for residents unit, the other suggested members can serve as resources for the treatment team. Responsibilities of the fall team - develop/review facility fall prevention protocols, implement fall prevention strategies across the facility, act as a resource for interdisciplinary treatment teams treating a high fall-risk residents, review fall on a case by case basis and make recommendations to treatment teams, collect and analyze data on falls to see if there are any common factors and determine if the interventions are working to reduce falls and fall-related injuries. Logistics of the fall team - fall teams operate differently depending on the facility: however, once the team is established, they need to decide the following things: when and how often they are going to meet (i.e., monthly, biweekly), where are they going to meet, what their relationship is to the treatment team (i.e., hi fall-risk residents are referred to the falls team or the interdisciplinary treatment team ask for help with specific residence. Tips to avoid falls - for residents and responsible parties - medications such as tranquilizers, sleeping aids, pain relievers, blood pressure pills or diuretics may make you dizzy and disoriented, your illness, and the most common laxatives, long periods without food may leave you weak and unsteady, the nursing facility is born and unfamiliar to you, especially when you wake up at night, some falls, as those associated with illness or therapy, cannot be avoided, however, by following the safety guidelines you and your family can help reduce the risk of falling. Residents attempting to climb out of bed over side rails. Safety guidelines for preventing falls - when you need assistance, use your call light by the bed and/or restroom and wait for assistance. It is recommended that you wear rubber sold or [NAME] sold slippers or shoes whenever you walk in the facility. Ask the nurse or assistant for help if you feel dizzy or weak getting out of bed. Remember you are most likely to feel dizzy after sitting or lying for a long time period before you get up, sit in bed for a while before standing then rise carefully and slowly. Walk carefully and slowly. Do not attempt yourself on rolling objects, always follow your physician's orders and caregivers instructions whether you must stay in bed or require assistance to get up or go to use the restroom. Do not bring excessive amounts of furnishings from home ask administration prior to bringing in outside furniture observe what signs in the hallway or other areas. This was determined to be an Immediate Jeopardy (IJ) on 11/08/2023 at 5:00 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on 118/0/2023 at 5:00 pm. [name of facility]PLAN OF REMOVAL QOC-600 Name of Facility: [name of facility] Date: 11/8/2023 Residents residing in the facility have the potential to be affected and should free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building. Observations on 11/08/23 at 2:00 pm and 3:30 pm of Resident #2's room revealed o What corrective actions were taken? 2. The following actions were initiated immediately on 11/8/23. d. On 11/8/23 an audit was completed by DON and/or designee to identify residents care plan for fall mats. Those care planned for fall mats, a check of the resident's room was completed by DON/Designee to ensure the fall mat was in place. Going forward the Don/Designee will review careplans during the clinical morning meeting 5 days a week and will round to ensure fall mats are in place. The weekend manager/Nurse on duty on the weekend will round to ensure fall mats that are care planned are in place. e. Don was in serviced on 11/7 by the regional nurse consultant on importance of reviewing and updating residents fall careplans to ensure proper interventions are put into place to prevent falls. f. On November 8, 2023, the Director of Nursing (DON) initiated an in-service session for the licensed nursing staff (Nurses,CNA,CMA). The focus of the in-service was to review patient fall interventions and ensure their proper implementation. All untrained Nursing staff, PRN Nursing Staff and Agency nursing staff (Nurses,CNA,CMA) will not be allowed to work on the floor without receiving the in-service to be completed 11/9/2023. g. On 11/8/23 an in-service was initiated for the facility Nursing Management by the DON on the importance of updating and reviewing the care plan of residents with falls to ensure care planned interventions such as fall mats are in place. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 11/8/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR on 11/08/23 as followed: Reviewed in service of by the regional nurse consultant on importance of reviewing and updating residents fall careplans to ensure proper interventions are put into place to prevent falls. Reviewed in-services for the licensed nursing staff (Nurses,CNA,CMA) for patient fall interventions and ensure their proper implementation. Reviwed in-service for the facility Nursing Management by the DON on the importance of updating and reviewing the care plan of residents with falls to ensure care planned interventions such as fall mats are in place. During interviews on 11/08/23 from12:06 pm through 1:46 pm two CNAs and two LVNs they all stated they were in-serviced before their shifts on reporting abuse, neglect, and exploitation, patient fall interventions and to ensure their proper implementation and updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. Observed floor mat in Resident #2's room. The ADM and DON were informed the Immediate Jeopardy was removed on 11/09/23 at 4:06 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for one (Resident #1) of three residents reviewed for discharges, in that: The facility failed to provide or document sufficient preparation for an orderly discharge when they did not allow Resident #1 to return to the facility after being sent to a behavioral health hospital on [DATE]. He was discharged to his FM's home where he had two falls, was not bathed, his wounds worsened, and he subsequently required hospitalization. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/23/23 at 3:15 PM. While the IJ was removed on 08/25/23 at 4:00 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, injury, and hospitalization. Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, stage IV pressure ulcer of right heel, history of heart attack, and repeated falls. Review of Resident #1's quarterly MDS assessment, dated 05/30/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behaviors) reflected he had verbal behavioral symptoms directed toward others. Functional Status (G) reflected he utilized a wheelchair. Section GG (Functional Abilities and Goals) reflected he required partial/maximal assistance with most ADLs. Section H (Bladder and Bowel) reflected he was occasionally incontinent of bladder and bowel. Section M (Skin Conditions) reflected he had one or more unhealed pressure ulcers/injuries. Review of Resident #1's quarterly care plan, r evised 03/09/23, reflected he had potential/actual impairment to skin integrity related to surgical wound to the right foot 3rd digit amputation and stage IV pressure ulcer to his right heel with an intervention of administering treatment as ordered. Review of Resident #1's nursing note in his EMR, dated 06/30/23, reflected the following: [Resident #1] discharged to (behavioral hospital) in stable condition . [Resident #1] was accepted for physical and verbal aggression . There were no further nursing notes documented. Review of Resident #1's medical documentation from the behavioral health hospital, from 06/30-23 - 07/20/23, reflected there was no documentation or orders from the facility on discharge planning or orders for alternate placement upon discharge. Review of Resident #1's medical documentation from the ER, dated 07/24/23, reflected he presented to the ER with complaints of running out of his diabetes medication, an elevated blood sugar (232), four recent falls, and pain to the wound on his right heel. During an interview on 07/26/23 at 10:05 AM, the facility's Ombudsman stated she received a call the previous Monday, 07/17/23, from the MRC requesting recommendations for other nursing facilities for Resident #1. She stated she explained to the MRC that it was the facility's responsibility to accept the resident back after his hospitalization and if they felt they could not meet his needs, she could be of assistance in the discharge process. She stated she explained 30-day discharge letter would also need to be given to Resident #1. She stated she received a call the previous Thursday, 07/20/23, from Resident #1's FM stating that Resident #1 had been discharged to her home and she was not able to care for him and did not have his medications. During an interview on 07/26/23 at 10:55 AM, the MRC stated they had been without a SW for a long time so for three weeks she had been assisting with resident discharges. She stated Resident #1 was admitted to the behavioral hospital due to his verbal abuse towards staff. She stated he would cuss and call the staff derogatory names and had hit a resident. She stated after she spoke with the Ombudsman on the phone, she related the message to their old ADM (he was no longer working for the facility). She stated if he had been discharged home that would have been inappropriate as he was unable to care for himself and was in a wheelchair. She stated she knew it was the facility's due diligence to accept all residents back after hospitalization. She stated she was not informed of the situation and thought he was still at the behavioral hospital. During a telephone interview on 07/26/23 at 11:03 AM, Resident #1's FM stated the behavioral hospital called her last Thursday, 07/20/23, and informed her the nursing facility was not allowing Resident #1 back. She stated she told them it would not be a good idea but agreed because she did not want him to be homeless. She stated attempting to care for him had made her physically sick and she now had a pinched nerve in her back. She stated she was not able to bathe him and had a hard time changing his brief. She stated he came with some medications and a walker. She stated he was not able to walk well due to the wounds on his feet and his amputated toes. She stated he had two falls during the week he was at her home. She stated the wounds to his heels and amputated toes started to cause him a lot of pain and have a foul odor, so she had her family member take him to the ER and he was admitted to the hospital where he remained. During an interview on 07/26/23 at 11:32 AM, the AC stated Resident #1 had been having a lot of problems at the facility, such has hitting a resident and calling staff names, so he was sent to the behavioral hospital. She stated she received a call from the behavioral hospital on [DATE] informing her he was ready to be discharged . She stated she notified the old ADM, and he told her they could not accept him back without giving her a reason. She stated she knew it was unacceptable to not accept a resident back after a hospitalization, but since he was the ADM, she had not known did not know what else to do. She stated she was not aware he was discharged to his FM's home. She stated she was aware that they were having a hard time getting him Medicaid because he was refusing to provide his SS benefits, and was reminded that even in that instance, a 30-day discharge letter was necessary. During an interview on 07/26/23 at 1:18 PM, the DON stated she had been working at the facility for about a week and was not aware of the situation with Resident #1. She stated if they were to discharge a resident to the hospital, they were expected to accept them back. She stated there could be some instances, such as a resident needing a secured unit, in which they may not accept them back. During an interview on 07/26/23 at 2:34 PM, the ADM stated she had started working at the facility that Monday, 07/24/23, and was not aware of the situation with Resident #1. She stated not accepting a resident back to the facility after hospitalization could be considered hospital dumping. She stated yes, generally a resident would be accepted back, but she did not know the whole story with Resident #1. She stated a possible negative outcome of not accepting a resident back after hospitalization could be deterioration in their health. During an interview on 08/23/23 at 3:00 PM, the CSD stated she was involved with all admissions and discharges. She stated she spoke with Resident #1 before he was discharged to the behavioral health hospital and he told her he wanted to be discharged from the hospital to where his FM was residing at another facility. She stated she did not know the name of the facility, nor did she notify the hospital of his wishes, because he was his own RP and could make those decisions as it was his right. She stated once a resident was discharged to a hospital/behavioral health hospital, the facility was no longer responsible for their care. She stated the former ADM did not deny him of being readmitted to their facility and she had text messages to prove it. She stated if the behavioral health hospital was not able to find him placement, they could have brought him back to their facility. Review of the text messages between the former ADM and the CSD, dated 07/18/23, reflected the following: ADM: They're trying to send [Resident #1] back to us from (behavioral health hospital). Do y'all want us to tell them that we don't have a bed for him? Or should we take him back and seek other placement? CSD: Will they not help to send him somewhere else? He is Medicare and easy to find placement at this time. ADM: I'm sure they will if we tell them we can't or won't take him. CSD: Yes tell them and if they can't then we will accept but you will appreciate if they can help us. Review of the facility's Discharge a Resident Policy, revised December of 2016, reflected the following: Purpose: The purpose of this procedure is to provide guidelines for the discharge process. Preparation: 1. The resident should be consulted about the discharge. . 3. If discharging the resident to another long-term care facility tell the resident where the new facility is located. 4. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions. 5. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility. The ADM and CSD were notified on 08/23/23 at 3:15 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 08/25/23 at 12:00 PM: Impact Statement: On 8/23/23 a health survey was initiated at (facility). On 8/23/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all discharges to behavioral hospital completed in the last 30 days for safe discharge plans. All residents sent to behavioral hospital have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to behavioral hospital on [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on 8/23/23 a. On 8/23/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents who had a discharge to behavior hospital in the last 30 days. No residents were identified to be discharged to behavioral hospital in the last 30 days. b. Social worker/discharge planner was educated on 8/23/23 by Clinical Services Director on discharge process of residents to behavioral hospital and readmission process of these residents to facility. c. Admissions Coordinator in-serviced by Clinical Services Director/Designee on readmission of residents sent to behavioral hospital on 8/23/23. 2. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review discharges to behavioral hospital in the morning meeting beginning on 8/24/23 and ongoing to ensure safe discharge process. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The Director of Nurses/Administrator will include the residents discharged to behavioral hospital on daily census list which will be reviewed during weekdays in the morning meeting for re-admission to facility. Any discharges that did not re-admit will be followed up by Social Worker/admission Coordinator/Designee to ensure safe discharge was set up for resident(s). This was started on 8/24/23 and will be monitored 5 days a week for 4 weeks and then ongoing. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/23/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the Plan of Removal from 08/24/23 - 08/25/23 as followed: During interviews on 08/24/23 from 9:15 AM - 9:50 AM, the SW, two medication aides, three LVN's and one CNA all stated they had been in-serviced on resident discharges and readmissions. They all stated nurses were to handle all discharge planning, with assistance from the SW. They stated that discharges to the hospital or a behavioral health hospital were no different than a discharge home or to another facility. During interviews on 08/25/23 from 1:52 PM - 2:20 PM, three RN's and one CNA all stated they had been in-serviced on resident discharges and readmissions. They all stated nurses were to handle all discharge planning, with assistance from the SW. They stated that discharges to the hospital or a behavioral health hospital were no different than a discharge home or to another facility. Review of the facility's Admission/Discharges in-service, dated 08/23/23, reflected staff were being in-serviced before the start of their shifts. The ADM and CSD were notified 08/25/23 at 4:00 PM that the IJ had been lowered. While the IJ was lowered, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of three residents reviewed for behavioral health services., in that: The facility failed to ensure alternate interventions were attempted such as psychiatric care or medication for Resident #1 until admission to a behavioral health hospital for treatment was necessary. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/23/23 at 3:15 PM. While the IJ was removed on 08/25/23 at 4:00 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving needed services and treatments and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the hospital on [DATE] with diagnoses including type II diabetes, stage IV pressure ulcer of right heel, history of heart attack, and repeated falls. Review of Resident #1's quarterly MDS assessment, dated 05/30/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behaviors) reflected he had verbal behavioral symptoms directed toward others. Review of Resident #1's quarterly care plan, revised 04/17/23, reflected he had potential to demonstrate verbally abusive behaviors related to saying racist remarks to the staff with an intervention of assessing his coping skills and support system. Review of Resident #1's EMR, on 07/26/23, reflected no assessments or treatment notes by a psychiatrist or psychologist. Review of Resident #1's physician orders in his EMR, on 07/26/23, reflected he was not prescribed any psychiatric medication. Review of Resident #1's behavior nursing note in his EMR, dated 06/28/23, reflected the following: [Resident #1] was in dining room and was slapping (resident) on the side of his head. Nonpharmacological interventions: N/A PRN medications: N/A Results: sent [Resident #1] out of dining room. Review of Resident #1's behavioral nursing note in his EMR, dated 06/29/23 at 12:46 PM, reflected the following: [Resident #1] verbal aggressive to sitter and this nurse during lunch, stated he did not want to be guarded, he felt like a dog in the pound, stated he is unable to eat while being watched . This behavior continued throughout lunch in the dining room. Resident behavior unchanged PRN medications: N/A Review of Resident #1's incident report, dated 06/28/23, reflected was seen hitting another resident on the head and was put on 1:1 and a referral to behavioral hospital was made to receive appropriate treatment in a controlled environment. Review of Resident #1's nursing note in his EMR, dated 06/30/23 at 2:48 PM, reflected the following: [Resident #1] discharged to (behavioral hospital) in stable condition . [Resident #1] was accepted for physical and verbal aggression . Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/01/23 and signed by their MD, reflected the following: Inpatient Psychiatric Evaluation: History of Present Illness: Per (facility) report, [Resident #1] has been verbally/physically aggressive with peers and staff. [Resident #1] has been hitting peers, difficult to redirect, not always taking meds, decreased sleep. Review of Symptoms: Irritability and Mood Swings Liabilities: Cognitive Impairment, Depression, Psychosis Assessment and Plan: Major depressive disorder recurrent moderate. Major neurocognitive disorder Alzheimer's type mild to moderate with behavioral disturbance. Unspecified psychosis. Complexity of [Resident #1]'s mental condition is severe. Plan: Medication changes on 07/01/2023: Start Aricept 10 mg p.o. every morning Start Zoloft 25 mg p.o. daily Review of Resident #1's medical documentation from the behavioral health hospital, from 06/30/23-23 - 07/20/23, reflected the following additional medications were ordered: 06/30/23 - Hydroxyzine - 50 mg (1 capsule) by mouth every six orders PRN for anxiety 07/02/23 - Sertraline HCL, 25 mg (1 tablet) by mouth for major depressive disorder. 07/02/23 - Donepezil HCL - 5 mg (tablet) by mouth daily for mild to moderate Alzheimer's type dementia. 07/10/23 - Trazodone - 50 mg by mouth at bedside for major depressive disorder. 07/14/23 - Abilify, 10 mg (1 tablet) by mouth daily for major depressive disorder. Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/16/23 and signed by a nurse, reflected the following: Problem from Plan of Care: Alteration in Thought Processes Psychosis related to psychotropic disease process as evidenced by paranoid behavior, sleep disturbance, decreased impulse control, delusional thoughts, withdrawn behaviors, decreased focus and concentration. Disease process that interferes with ability to function appropriately in social situations. Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/016/23 and signed by their MD, reflected the following: Assessment and plan: [Resident #1 is adherent with the treatment recommendations. Gradual dose reduction not recommended due to potential risk of returning psychosis, depression, or manic symptoms. Complexity of [Resident #1]'s mental condition is severe. Current medications are helping. Plan to increased Abilify soon and switch to long-acting injectable before discharge. During an interview on 07/26/23 at 10:55 AM, the MRC stated Resident #1 was admitted to the behavioral hospital due to his verbal abuse towards staff, and the fact that he recently hit a resident. She stated he would cuss and call the staff derogatory names. She stated she was unaware if he was receiving psych services while at the facility. During an interview on 07/26/23 at 1:18 PM, the DON stated she had been working at the facility for about a week and was not aware of the situation with Resident #1. She stated before a resident was sent to a psychiatric hospital, there should be interventions attempted, such as psych services or medication. She stated normally the nurse managers would make the psych referrals. She stated if a resident who needed psychiatric care and/or medication went without, it would lead to the deterioration of their mental health. During an interview on 08/07/23 at 10:12 AM, Resident #1's MD stated he was seeing the resident monthly when he was residing at the facility. He stated the last time he saw Resident #1 back in May, he was notified by staff of his increased verbal aggressive episodes. He stated he ordered a psych consult but had to assume the staff did not get to it in time before Resident #1 needed in-patient psychiatric help. When asked if he thought it was necessary to discharge Resident #1 to a behavioral health hospital before other interventions was appropriate, he stated, That was a facility choice, I will just leave it at that. During an interview on 08/23/23 at 3:00 PM, the CSD stated they attempted psychiatric care with Resident #1, but would tell them, I don't need that, I'm not crazy. She stated there was not any documentation of those attempts. She stated they did provide interventions such as re-direction, and he was placed on 1:1 after he hit another resident on 06/29/23. Review of the facility's Behavior Assessment and Monitoring policy, revised April of 2007, reflected the following: Policy Statement: 1. Problematic behavior will be identified and managed appropriately Management: 1. The staff will identify and discuss with the practitioner situations where nonpharmacologic approaches are indicated and will institute such measures to the extent possible. The ADM and CSD were notified on 08/23/23 at 3:15 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 08/25/23 at 12:00 PM: Impact Statement: On 8/23/23 an abbreviated survey was initiated at (facility). On 8/23/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to ensure immediate actions to ensure residents are receiving mental/behavior health. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all discharges to behavioral hospital completed in the last 30 days to ensure alternate behavioral interventions were implemented. All residents sent to behavioral hospital have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to behavioral hospital on [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on 8/23/23 a. On 8/23/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents who had a discharge to behavior hospital in the last 30 days to ensure alternate behavioral interventions were implemented prior discharge. No residents were identified to be discharged to behavioral hospital in the last 30 days. b. Social worker was educated on 8/23/23 by Clinical Services Director on referral process to in-house mental/behavioral services for all residents with behaviors. c. Initiated in-services on 8/23/23 with licensed nurses by Clinical Services Director/Designee to report behavioral changes to Director of Nurses /Designee and initiate non-pharmacological and pharmacological behavioral interventions. 2. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review behavioral changes in conditions in the morning meeting starting on 8/24/23 and ongoing to ensure behaviors are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The Director of Nurses/Administrator will review during weekdays in the daily stand down meetings all interventions that have been implemented for residents identified in morning meeting experiencing behaviors. Any identified concerns will be addressed to ensure immediate alternative intervention were implemented. This was started on 8/24/23 and will be monitored 5 days a week for 4 weeks and then ongoing. c. The weekend supervisor and/or designee was in-serviced on 8/23/23 by Clinical Services Director/ Designee on identifying all residents experiencing behaviors on Saturdays and Sundays and ensure that any resident with behaviors receive immediate pharmacological and or non-pharmacological behavioral interventions. d. Newly hired staff, agency, and PRN staff will be educated by Clinical Services Director/Designee on implementing immediate pharmacological and or non-pharmacological behavioral interventions. Staff unable to come to receive education will be required to completed training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/23/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the Plan of Removal from 08/24/23 - 08/25/23 as followed: During interviews on 08/24/23 from 9:15 AM - 9:50 AM, the SW, two medication aides, three LVN's and one CNA all stated they had been in-serviced on resident behaviors and dealing with aggressive residents. They stated interventions such as re-directing, offering food, notifying the charge nurse, and ensuring they were receiving their prescribed psych meds as ordered. During interviews on 08/25/23 from 1:52 PM - 2:20 PM, three RN's and one CNA all stated they been in-serviced on resident behaviors and dealing with aggressive residents. They stated interventions such as re-directing, offering food, notifying the charge nurse, and ensuring they were receiving their prescribed psych meds as ordered. Review of the facility's Resident Behaviors in-service, dated 08/23/23, reflected staff were being in-serviced before the start of their shifts. The ADM and CSD were notified 08/25/23 at 4:00 PM that the IJ had been lowered. While the IJ was lowered, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one (Resident #1) of 15 residents reviewed for change in condition. The facility failed to notify the physician of a change in condition in Resident #1 when she became increasingly lethargic, unarousable, unresponsive, experienced high blood sugar and required emergency transfer to the hospital. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure put residents a risk of decline, serious injury and death. Findings included: Review of Resident #1 face sheet dated [DATE] revealed Resident #1 was an [AGE] year old female admitted to the facility on [DATE] with a diagnoses of heart disease, hypertension, UTI and a history of falling. Review of Resident #1 Baseline Care Plan dated [DATE] revealed Resident #1 had a diabetic alert with the goal to manage symptoms and no interventions listed or medications. Resident #1 was noted to be at risk for dehydration with the goal to provide adequate fluids and interventions included determine likes/dislikes and monitor signs/symptoms. Review of Resident #1 eInteract Change in Condition Evaluation dated [DATE] revealed Resident #1 had sign and symptoms of abnormal vital signs, other change in condition and talk/communicates less. An additional change noted was high blood sugar and the change started on [DATE] in the afternoon. It was noted that since the change in condition occurred have the symptoms or signs gotten: worse and the symptoms had not occurred before. Resident #1 had an altered level of consciousness and it was noted to be a sudden change. Resident #1's functional status was noted to be have general weakness. Resident #1 had a blood pressure of 111/53 and the blood sugar noted was from [DATE] at 117.0. The physician was notified at 5:06 PM on [DATE] and Resident #1 was sent to the ER. Respiratory status was noted to be labored or rapid breathing which was recent intermittent change from usual pattern. Resident #1 was not noted to have pain. In an interview on [DATE] at 9:36 AM, JP #1 stated he pronounced the death at [HOSPITAL] for Resident #1 who was sent from [FACILITY] when she was found unresponsive after having high blood sugar. He stated Resident #1 was diabetic and had high blood sugar way above her normal routine blood sugars at the facility. He stated the cause of death he wrote on the death certificate was acute cardiac failure caused by atherosclerotic heart disease related to blood sugar levels were allowed to rise to 334 without medication being given. He stated the responsible party for Resident #1 told him Resident #1's Hemoglobin A1C was a five (to indicate good control of diabetes mellitus with insulin). He stated the RP #1 said Resident #1 had good control on insulin of her diabetes mellitus and rarely had blood sugars higher than 150. He stated he reviewed records from Resident #1 and was concerned Resident #1 had a high blood sugar when she died and was not given any interventions to prevent her blood sugar from continuing to rise. He stated Resident #1's RP reported having to ask the facility staff to send Resident #1 to the ER after she declined and became unresponsive. In an interview on [DATE] at 9:50 AM, RP #1 stated he was the responsible party for Resident #1 who died after being admitted to the facility for 48 hours. He stated Resident #1 lived independently prior to being hospitalized due to a UTI and dehydration. He stated Resident #1 was going to an assisted living facility after the hospital but they decided to have her complete a couple of weeks at the SNF to strengthen her because she was weak after the hospitalization. He stated Resident #1 was not on hospice and no one thought she was close to dying. He stated he was with Resident #1 when she was admitted on [DATE] and though Resident #1 was weak and in a wheelchair (when Resident #1 previously ambulated using a walker at home), Resident #1 was alert and oriented times three. He stated on [DATE] he spoke with Resident #1 and Resident #1 had a good day, went to physical therapy at the facility and was feeling well. He stated Resident #1 spoke easily to him on the phone around 4:00 PM on [DATE]. He stated on [DATE] he tried to call Resident #1 multiple times in the morning and received no answer. He stated he assumed Resident #1 was at therapy. He stated in the afternoon on [DATE] he was unable to reach Resident #1 on her phone so he called the nurse's station and could not reach anyone multiple times. He stated around 4:00 PM on [DATE] he was able to speak with Resident #1's nurse and asked that LVN A check on Resident #1. He stated LVN A said Resident #1 was tired today and refused physical therapy today. He said LVN A told him Resident #1 did not want to do nothing today. He stated LVN A tried to wake Resident #1 during that phone call and Resident #1 was sleeping and would not wake up. He stated he told LVN A he would check back in an hour. He stated he called back around 5:00 PM and LVN A said Resident #1 is laying here making rattling noises and told him to listen. He stated he could hear through the phone Resident #1 making unusual loud breathing noises. He stated LVN A told him Resident #1 would not wake up and he told LVN A to check Resident #1's blood sugar. He stated LVN A checked her blood sugar and blood pressure. LVN A said Resident #1's blood pressure was 111/53, which was low for her. LVNA said Resident #1's blood sugar was 334 which was very high for Resident #1. He stated he told LVN A to call an ambulance since Resident #1 was unresponsive with high blood sugar and low blood pressure. He stated LVN A told him she thought about calling an ambulance but the facility did not have anyone to sit with Resident #1 at the hospital so she did not call an ambulance. He stated he told LVN A to call an ambulance at that time and LVN A hung up. He stated approximately 30 minutes later he received a phone call from the ER physician who said Resident #1 passed away. He stated the ER physician told him Resident #1 was expired upon arrival at the ER. Resident #1's RP stated he was told Resident #1 died of cardiac arrest because she was in a diabetic coma. He stated he does not believe they were monitoring Resident #1's blood sugar closely and did not understand why he had to direct the nurse to check her blood sugar and call 911. He said LVN A did tell her that Resident #1's blood sugar was high that morning at 262 prior to insulin administration. He said LVN A told him she did not re-check Resident #1's blood sugar after administering the insulin to see if Resident #1's blood sugar went down. He stated he did not understand how Resident #1 died within 48 hours of admission to the facility when she was only admitted for a short term stay for weakness. In an interview on [DATE] at 1:00 PM, LVN A stated she worked with Resident #1 on [DATE] - [DATE]. She stated on [DATE] Resident #1 was alert and oriented times three and went to therapy without a problem. She stated on [DATE] Resident #1 was tired and did not want to go to therapy. She stated she checked Resident #1's blood sugar prior to administering her insulin but did not document the result. She stated Resident #1's blood sugar was 262 that morning so she administered the ordered insulin. She said she did not re-check Resident #1's blood sugar later in the day to ensure the blood sugar returned to normal range. She stated Resident #1 did not have a physician order for routine blood sugar checks. She stated Resident #1 did not have routine blood sugar checks because the nurse who admitted Resident #1 did not obtain the order from her physician. She stated normally the admitting nurse would obtain routine blood sugar checks from the resident's physician upon admission. She stated it was an oversight that routine blood sugar checks were not ordered for Resident #1. She stated when Resident #1's RP called later in the day on [DATE], he wanted LVN A to check Resident #1's blood sugar and it was 343. She stated she did not document the high blood sugar or notify the physician as Resident #1's RP wanted Resident #1 sent to the ER. She stated she did not know how long Resident #1 had been experiencing high blood sugar as it had not been monitored since Resident #1 was admitted . She stated if a resident had high blood sugar above their routine readings she would notify their physician for further orders. LVN A was unsure of what blood sugar level she should have notified Resident #1's physician. She stated Resident #1 had no additional symptoms of high blood sugar besides being sleepy, lethargic and arouseable. She stated CNA B came and got her after Resident #1's RP called the first time on [DATE] and said Resident #1 was breathing funny. She stated Resident #1 was breathing faster, shallower and had a rattle. She said she did not notify the doctor at that time or start life saving measures. She stated Resident #1's RP called back and she had him listen to Resident #1's breathing and told Resident #1's RP that Resident #1 would not wake up. She stated she did not notify Resident #1's physician at that time that Resident #1 would not wake up. She stated she called 911 upon direction from Resident #1's RP. She stated she did not start CPR or other life saving measures because Resident #1 was a DNR even though the facility did not have the paperwork at the facility to confirm Resident #1 was an OOH-DNR. In an interview on [DATE] at 1:20 PM, the interim DON stated she was new to the facility and had only been at the facility since [DATE]. She stated she was not very familiar with Resident #1 but knew that she was a new admit that passed away at the hospital on [DATE]. She stated she was called to her room on [DATE] because Resident #1 was unresponsive and she assisted with Resident #1's care while they waited for EMS response. She stated she checked Resident #1's blood sugar approximately 10 minutes after LVN A checked it and Resident #1's blood sugar had increased to 376. She said EMS arrived after that and took over Resident #1's care. She stated the facility had a hypoglycemic protocol for residents that experience low blood sugar but the facility did not have a hyperglycemic protocol (for high blood sugar). She stated for residents with high blood sugar, the physician would need to be notified per physician order at parameters set by the physician for high blood sugar. For instance, the physician would be notified for any blood sugar over 400. She stated she did not know why Resident #1 did not have an order for routine blood sugar checks since she was on insulin. She stated it was likely an oversight by the nurse that admitted Resident #1. She stated Resident #1 should have had her blood sugar checked at least once daily since she was on insulin. She stated she could not say that the reason Resident #1 was unarouseable on [DATE] was because of high blood sugar and/or a diabetic coma. She stated when Resident #1 was admitted routine blood sugar checks should have been ordered. She stated LVN A should have re-checked Resident #1's blood sugar after administering the insulin on [DATE] to ensure Resident #1's blood sugar returned to normal range. She stated the nurse should have recognized the change in condition in Resident #1 on [DATE] and notified her physician. She stated interventions could have put into place sooner to address Resident #1's symptoms. In an interview on [DATE] at 1:30 PM, Resident #1's NP stated he had not examined or seen Resident #1 since she was admitted . He stated based on Resident #1's blood sugar readings and history of well controlled diabetes, he could not rule out that she was in diabetic coma when she was sent to the ER on [DATE] and passed away. He stated he should have been notified and routine blood sugar checks should have been ordered upon admission for Resident #1 with parameters to notify him or the attending physician when results were abnormal. In an interview on [DATE] at 1:12 PM, the ER PHYSICIAN stated she treated Resident #1 upon arrival at the ER. She stated Resident #1 was in full cardiac arrest upon arrival and when they confirmed with Resident #1's RP that Resident #1 had a DNR order, they stopped all life saving measures. She stated Resident #1 was deceased upon arrival and the EMS life saving measures was what kept her showing signs of life. She stated it is unclear what exactly caused Resident #1's death but Resident #1 experienced a rapid decline that day [DATE] that should have been detectable to healthcare staff at the facility. In an interview on [DATE] at 3:00 PM, CNA B stated on [DATE] she notified LVN A that Resident #1 was complaining of pain in the morning and could not even hold a cup to her mouth. She stated she told LVN A Resident #1 had increased weakness and wanted additional pain medication. She stated she told LVN A twice and was not sure if LVN A did anything for Resident #1. She was going to give Resident #1 a bed bath and Resident #1 was too sleepy and lethargic and declined a bed bath. She stated Resident #1 was not voiding normally and did not require routine incontinent care as her brief was dry. She stated later in the day around 1:00 PM she notified LVN A Resident #1 was breathing differently in that Resident #1 was breathing faster and shallower. She stated she did not see LVN A do an assessment on Resident #1. She stated Resident #1 became increasingly less responsive through out the day and she did not see any interventions put into place to address her change in condition. She stated she did as required and notified Resident #1's nurse and did not know what else to do for Resident #1. In an interview on [DATE] at 3:20 PM, PT E stated she went to check on Resident #1 on [DATE] and Resident #1 was weak and reported being in a lot of pain. PT E said she told Resident #1's nurse LVN A. She stated on [DATE] she worked with Resident #1 as her PT and Resident #1 was alert and oriented times three and was able to complete all exercises. She stated Resident #1 did report being tired after her exercises but was otherwise okay. She said on the morning of [DATE] Resident #1 reported to PT A Resident #1's abdomen was sore and Resident #1 was noted to be grimacing in pain. She said Resident #1 could not sit up on the side of the bed as Resident #1 could the day before easily. She said she reported this to LVN A without any interventions noted before she exited the room. In a follow-up interview on [DATE] at 1:23 PM, the interim DON stated the change in condition should have been detected by LVN A sooner in Resident #1 and the physician should have been notified immediately the morning of [DATE] instead of after 911 was called on the evening of [DATE]. She stated any significant change in condition would require physician notification and notification of the resident's RP. She stated she was not aware that Resident #1 had complained of pain to CNA B and PT E. She stated moving forward if staff do not see an appropriate intervention when they notify a charge nurse of a resident change in condition, they should contact her or one of her designees to intervene. Review of Resident #1's progress notes dated [DATE] did not reveal any notes regarding the nurse being notified of Resident #1's change in condition, complaints of pain or change in breathing. There were no notes regarding Resident #1 being increasingly sleepy and refusing therapy. Review of Change in a Resident's Condition or Status Policy dated [DATE] revealed our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been: . d. significant change in the resident's physical/emotional/mental condition . The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 9:45 AM and included the following: Impact Statement: On [DATE] an abbreviated survey was initiated at [FACILITY]. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide needed care and services after a change in condition to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address potential change of conditions on all residents using the 24/72-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on [DATE]. What corrective actions were taken? 3. The following actions were initiated immediately on [DATE] d. On [DATE] an audit was completed by traveling DON and/or designee to identify all residents who were at risk for having a change of condition related to their disease process including those receiving insulin. No residents were identified to be affected including those who receive insulin. Interim DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. e. On [DATE] an in-service was initiated for all staff to include housekeeping, therapy, dietary, and agency/contract staff by the traveling DON on change of condition, notification of the nurse on duty, notifying the physician of changes, verifying orders, and s/s of hypo/hyper glycemia. In-service was completed on [DATE] and all staff who was unable to attend will be required to complete training before their next scheduled shift. f. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. In-service was completed on [DATE] and all staff including agency who was unable to attend will be required to complete training before their next scheduled shift. 4. How will the system be monitored to ensure compliance? f. The ADON, Interim DON and/or designee will review the facilities 24/72 hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. g. The acting DON or designee will review new daily telephone orders, and new/readmit orders after being entered by licensed nursing staff into PCC to ensure anyone with an insulin order has accuchecks in place and parameters of when to call the physician. This was started on [DATE] and will be monitored 5 days a week for 4 weeks and then ongoing. h. The Interim DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. i. The weekend supervisor and/or designee was in-serviced on [DATE] by acting DON on how to review the 24/72-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. j. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician and s/s of hyper hypoglycemia during orientation by the acting DON or designee. Staff unable to come to receive training will be required to complete training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring was completed on [DATE] and [DATE]: In an observation on [DATE] at 1:00 PM, Resident #2 and Resident #3, both diagnosed with insulin dependent diabetes mellitus, were observed with no issues or complications related to diabetes mellitus. Review of inservices completed [DATE] - [DATE] revealed all current staff inserviced on change in condition reporting and interventions. In an interview on [DATE] at 12:15 PM, CNA G stated she received education regarding a resident change in condition, who should notify and what to do if an appropriate intervention was not put into place for the resident. She stated she would notify the charge nurse and if the charge did not put an acceptable intervention into place she would notify the ADON, DON or administrator. In an interview on [DATE] at 12:22 PM, CAN H stated she received education to notify the charge immediately if a resident had a change in condition and if an appropriate intervention was not put into place she would follow the chain of command. She stated a change in condition could a mental change like a cognitive decline or a physical change. In an interview on [DATE] at 12:30 PM, MA J stated she received education about what to do if a resident had a change in condition and she would notify their charge nurse. She stated if the charge nurse did not evaluate the resident and ensure an appropriate intervention was put into place, she would notify the ADON or DON. In an interview on [DATE] at 12:43 PM, RN D stated she received education on resident change in condition and appropriate interventions to put into place and who to notify immediately. She stated if an intervention was not effective she would notify the physician for additional interventions. In an interview [DATE] at 1:23 PM, the interim DON stated all staff were educated regarding what to do if a resident experienced a change in condition, who to notify and what to do if interventions implemented were not effective. She stated new staff or agency staff would be educated prior to working with residents. Review of 24 hour summary report dated [DATE] and no residents were identified as at risk for related to not having blood sugar checks routinely. Review of Stop and Watch form dated [DATE] revealed the form would identify residents at risk for blood sugar issues and change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #1) of 15 residents reviewed for quality of care. The facility failed to obtain orders to check/monitor Resident #1's blood sugar levels/parameters related to her diabetes upon admission. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk of not receiving the care and treatment needed Findings included: Review of Resident #1 face sheet dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of heart disease, hypertension, UTI and a history of falling. Review of Resident #1 Baseline Care Plan dated [DATE] revealed Resident #1 had a diabetic alert with the goal to manage symptoms and no interventions listed or medications. Resident #1 was noted to be at risk for dehydration with the goal to provide adequate fluids and interventions included determine likes/dislikes and monitor signs/symptoms. Review of Resident #1 Blood Sugar vital sign documentation dated [DATE] - [DATE] revealed one blood sugar documented on [DATE] at 6:50 PM and the ready reading was documented as 117.0 mg/dL. There were not additional blood sugars documented during this time period. Review of Resident #1's physician orders dated [DATE] - [DATE] revealed no physician orders for blood sugar checks for Resident #1. Review of Resident #1's physician orders dated [DATE] revealed Resident #1 was ordered Insulin Detemir Subcutaneous Solution Pen-injector 100 unit/mL with orders to inject 12 unit subcutaneously one time a day for Hyperglycemia. In an interview on [DATE] at 9:36 AM, JP #1 (Justice of the Peace) stated he pronounced the death at [HOSPITAL] for Resident #1 who was sent from [FACILITY] when she was found unresponsive after having high blood sugar. He stated Resident #1 was diabetic and had high blood sugar way above her normal routine blood sugars at the facility. He stated the cause of death he wrote on the death certificate was acute cardiac failure caused by atherosclerotic heart disease related to blood sugar levels were allowed to rise to 334 without medication being given. He stated the responsible party (RP) for Resident #1 told him Resident #1's Hemoglobin A1C was a five (to indicate good control of diabetes mellitus with insulin). He stated the RP #1 said Resident #1 had good control on insulin of her diabetes mellitus and rarely had blood sugars higher than 150. He stated he reviewed records from Resident #1 and was concerned Resident #1 had a high blood sugar when she died and was not given any interventions to prevent her blood sugar from continuing to rise. In an interview on [DATE] at 9:50 AM, RP #1 stated he was the responsible party for Resident #1 who died after being admitted to the facility for 48 hours. He stated Resident #1 lived independently prior to being hospitalized due to a UTI and dehydration. He stated Resident #1 was going to an assisted living facility after the hospital but they decided to have her complete a couple of weeks at the SNF to strengthen her because she was weak after the hospitalization. He stated Resident #1 was not on hospice and no one thought she was close to dying. He stated he was with Resident #1 when she was admitted on [DATE] and though Resident #1 was weak and in a wheelchair (when Resident #1 previously ambulated using a walker at home), Resident #1 was alert and oriented times three. He stated on [DATE] he spoke with Resident #1 and Resident #1 had a good day, went to physical therapy at the facility and was feeling well. He stated Resident #1 spoke easily to him on the phone around 4:00 PM on [DATE]. He stated on [DATE] he tried to call Resident #1 multiple times in the morning and received no answer. He stated he assumed Resident #1 was at therapy. He stated in the afternoon on [DATE] he was unable to reach Resident #1 on her phone so he called the nurse's station and could not reach anyone multiple times. He stated around 4:00 PM on [DATE] he was able to speak with Resident #1's nurse and asked that LVN A check on Resident #1. He stated LVN A said Resident #1 was tired today and refused physical therapy today. He said LVN A told him Resident #1 did not want to do nothing today. He stated LVN A tried to wake Resident #1 during that phone call and Resident #1 was sleeping and would not wake up. He stated he told LVN A he would check back in an hour. He stated he called back around 5:00 PM and LVN A said Resident #1 is laying here making rattling noises and told him to listen. He stated he could hear through the phone Resident #1 making unusual loud breathing noises. He stated LVN A told him Resident #1 would not wake up and he told LVN A to check Resident #1's blood sugar. He stated LVN A checked her blood sugar and blood pressure. LVN A said Resident #1's blood pressure was 111/53, which was low for her. LVN A said Resident #1's blood sugar was 334 which was very high for Resident #1. He stated he told LVN A to call an ambulance since Resident #1 was unresponsive with high blood sugar and low blood pressure. He stated LVN A told him she thought about calling an ambulance but the facility did not have anyone to sit with Resident #1 at the hospital so she did not call an ambulance. He stated he told LVN A to call an ambulance at that time and LVN A hung up. He stated approximately 30 minutes later he received a phone call from the ER physician who said Resident #1 passed away. He stated the ER physician told him Resident #1 was expired upon arrival at the ER. Resident #1's RP stated he was told Resident #1 died of cardiac arrest because she was in a diabetic coma. He stated he does not believe they were monitoring Resident #1's blood sugar closely and did not understand why he had to direct the nurse to check her blood sugar and call 911. He said LVN A did tell her that Resident #1's blood sugar was high that morning at 262 prior to insulin administration. He said LVN A told him she did not re-check Resident #1's blood sugar after administering the insulin to see if Resident #1's blood sugar went down. He stated he did not understand how Resident #1 died within 48 hours of admission to the facility when she was only admitted for a short term stay for weakness. In an interview on [DATE] at 1:00 PM, LVN A stated she worked with Resident #1 on [DATE] - [DATE]. She stated on [DATE] Resident #1 was alert and oriented times three and went to therapy without a problem. She stated on [DATE] Resident #1 was tired and did not want to go to therapy. She stated she checked Resident #1's blood sugar prior to administering her insulin but did not document the result. She stated Resident #1's blood sugar was 262 that morning so she administered the ordered insulin. She said she did not re-check Resident #1's blood sugar later in the day to ensure the blood sugar returned to normal range. She stated Resident #1 did not have a physician order for routine blood sugar checks. She stated Resident #1 did not have routine blood sugar checks because the nurse who admitted Resident #1 did not obtain the order from her physician. She stated normally the admitting nurse would obtain routine blood sugar checks from the resident's physician upon admission. She stated it was an oversight that routine blood sugar checks were not ordered for Resident #1. She stated when Resident #1's RP called later in the day on [DATE], he wanted LVN A to check Resident #1's blood sugar and it was 343. She stated she did not document the high blood sugar or notify the physician as Resident #1's RP wanted Resident #1 sent to the ER. She stated she did not know how long Resident #1 had been experiencing high blood sugar as it had not been monitored since Resident #1 was admitted . She stated if a resident had high blood sugar above their routine readings she would notify their physician for further orders. LVN A was unsure of what blood sugar level she should have notified Resident #1's physician. She stated Resident #1 had no additional symptoms of high blood sugar besides being sleepy, lethargic and arousable. In an interview on [DATE] at 1:20 PM, the interim DON stated she was new to the facility and had only been at the facility since [DATE]. She stated she was not very familiar with Resident #1 but knew that she was a new admit that passed away at the hospital on [DATE]. She stated she was called to her room on [DATE] because Resident #1 was unresponsive and she assisted with Resident #1's care while they waited for EMS response. She stated she checked Resident #1's blood sugar approximately 10 minutes after LVN A checked it and Resident #1's blood sugar had increased to 376. She said EMS arrived after that and took over Resident #1's care. She stated the facility had a hypoglycemic protocol for residents that experience low blood sugar but the facility did not have a hyperglycemic protocol (for high blood sugar). She stated for residents with high blood sugar, the physician would need to be notified per physician order at parameters set by the physician for high blood sugar. For instance, the physician would be notified for any blood sugar over 400. She stated she did not know why Resident #1 did not have an order for routine blood sugar checks since she was on insulin. She stated it was likely an oversight by the nurse that admitted Resident #1. She stated Resident #1 should have had her blood sugar checked at least once daily since she was on insulin. She stated she could not say that the reason Resident #1 was unarouseable on [DATE] was because of high blood sugar and/or a diabetic coma. She stated when Resident #1 was admitted routine blood sugar checks should have been ordered. She stated LVN A should have re-checked Resident #1's blood sugar after administering the insulin on [DATE] to ensure Resident #1's blood sugar returned to normal range. In an interview on [DATE] at 1:30 PM, Resident #1's NP stated he had not examined or seen Resident #1 since she was admitted . He stated based on Resident #1's blood sugar readings and history of well controlled diabetes, he could not rule out that she was in diabetic coma when she was sent to the ER on [DATE] and passed away. He stated he should have been notified and routine blood sugar checks should have been ordered upon admission for Resident #1 with parameters to notify him or the attending physician when results were abnormal. In an interview on [DATE] at 3:00 PM, CNA B stated she worked with Resident #1 on [DATE] and reported to LVN A Resident #1 had a change in condition. She stated she saw LVN A check her blood sugar prior to insulin administration but did not see her check Resident #1's blood sugar again until Resident #1's RP requested it via phone later that afternoon around 4:00 PM. In an interview on [DATE] at 11:05 AM, LVN C stated any new admit with a diagnosis of diabetes mellitus would require an order for routine blood sugar checks. She stated new residents on insulin would typically have morning and bedtime blood sugar checks unless the resident was unstable and then it would be more frequently. She stated if a resident experienced a high blood sugar greater than 160 she would notify their physician for further orders. She stated the admitting nurse would be responsible for obtaining the orders and ensuring it was in the EMR. In an interview on [DATE] at 11:20 AM, RN D stated she would ask the admitting physician for an order for routine blood sugar checks and it would be dependent on whether the resident received insulin or oral medication for diabetes mellitus. RN D stated for a resident on insulin the order would typically be for twice daily in the morning and at bedtime. She stated it was likely an oversight by the admitting nurse that Resident #1 did not have a routine order for blood sugar checks. She stated the charge nurses should have checked Resident #1's blood sugar at least daily prior to insulin administration to make sure her blood sugar was not low prior to insulin administration. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 9:45 AM and included the following: Impact Statement: On [DATE] an abbreviated survey was initiated at [FACILITY]. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address potential change of conditions on all residents using the 24/72-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE] a. On [DATE] an audit was completed by traveling DON and/or designee to identify all residents who were at risk for having a change in condition related to their disease process including those receiving insulin. No residents were identified to be affected including those who receive insulin. Interim DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. b. On [DATE] an in-service was initiated for all staff to include housekeeping, therapy, dietary, and agency/contract staff by the traveling DON on change of condition, notification of the nurse on duty, notifying the physician of changes, verifying orders, s/s of altered mental status, and s/s of hypo/hyper glycemia. In-service was completed on [DATE] and all staff who was unable to attend will be required to complete training before their next scheduled shift. c. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. In-service was completed on [DATE] and all staff including agency who was unable to attend will be required to complete training before their next scheduled shift. 2. How will the system be monitored to ensure compliance? a. The ADON, Interim DON and/or designee will review the facilities 24/72 hour summary report in EMR 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The acting DON or designee will review new daily telephone orders and new/readmits orders after being entered by licensed nursing staff into EMR to ensure anyone with an insulin order has blood sugar checks in place and parameters of when to call the physician. This was started on [DATE] and will be monitored 5 days a week for 4 weeks and then ongoing. c. The Interim DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. d. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the 24/72-hour report from EMR and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. e. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician and s/s of hyper hypoglycemia during orientation by the acting DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring was completed on [DATE] and [DATE]: In an observation on [DATE] at 1:00 PM, Resident #2 and Resident #3, both diagnosed with insulin dependent diabetes mellitus, were observed with no issues or complications related to diabetes mellitus. Review of 24 hour summary report dated [DATE] and no residents were identified as at risk for related to not having blood sugar checks routinely. Review of Stop and Watch form dated [DATE] revealed the form would identify residents at risk for blood sugar issues and change in condition. In an interview on [DATE] at 12:23 PM, RN D stated she received education regarding entering orders for routine blood sugar checks for diabetic residents who require insulin. She stated she would notify the physician if there was not an order specified for routine blood sugar checks. She said most of the time diabetic residents on insulin require a morning and bedtime blood sugar check unless the resident's diabetes was unstable and then the physician may order more frequent blood sugar checks. In an interview on [DATE] at 12:45 PM at LVN F stated she received education regarding routine blood sugar checks that should be ordered by the resident's physician upon admission. She stated most of the time if the resident's diabetes was stable the resident would only require twice daily, in the morning before breakfast and at bed time blood sugar checks. She stated she was educated on parameters to notify a resident's physician if the resident's blood sugar was low or high above the normal range. She stated there was also orders for when a resident experienced low blood sugar called the hypoglycemia protocol. Review of Routine Blood Sugar Orders Inservice dated [DATE] - [DATE] revealed all required staff were educated regarding a new admission and asking resident physician for routine blood sugar orders. In an interview [DATE] at 1:23 PM, the interim DON stated all nurses were educated regarding obtaining order upon admission for residents on insulin for blood sugar checks. She stated the nurses should also obtain parameters for which the physician should be notified for abnormal blood sugar levels. The DON stated agency and PRN staff will not be allowed to work until they have received the education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to properly assess or provide effective pain management to Resident #1 after she fell and injured her hip on [DATE], resulting in uncontrolled pain, decline in health, and ultimately death on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:30 PM. While the IJ was removed on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] for respite care with diagnoses of history of falling, chronic respiratory failure, type II diabetes, hypertensive (high blood pressure) heart disease, seizures, and other specified anxiety disorders. Review of Resident #1's fall risk assessment, dated [DATE], reflected a score of 16, indicating she was a high risk for falls. Review of Resident #1's discharge MDS assessment, dated [DATE], reflected she died in the facility. Review of Resident #1's initial baseline care plan, dated [DATE], reflected she had an actual fall (on [DATE]) with no injury related to cognitive impairment and poor balance with interventions of frequent rounding and checking range of motion. Review of Resident #1's progress notes in her EMR documented by RN K, dated [DATE] at 6:59 PM, reflected the following: [Resident #1] admitted into (facility) on respite care per (hospice agency) . care giver will be at beside daily from 8:00 AM - 6:00 PM . clear adequate speech, adequate vision, adequate hearing . Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 7:45 AM, reflected the following: During monitoring rounds observed [Resident #1] attempting to self-ambulate and fell to floor. Unable to reach [Resident #1] before she fell to the floor. [Resident #1] did not hit her head and landed on her bottom. Assessed [Resident #1] and assisted back into wheelchair and assisted back into bed. [Resident #1] does not display any signs of pain/discomfort, with no injuries observed at this time. Review of text messages sent by CG C to Resident #1's RP B reflected the following: [DATE]: 8:28 AM - Soon as I arrived, I asked if [Resident #1] wanted breakfast and she said no . I noticed her making a face and I asked what was wrong and she said her left leg hurts. 9:39 AM - I got [Resident #1] up in the chair and had to ask for help to change her brief . [Resident #1] was asking to get back in bed because her leg was hurting. When breakfast arrived, [Resident #1] did not want to eat because she was nauseated. 1:01 PM - She ate a little (lunch). She's really out of it. Not sure what to do. I don't wanna put her in bed and she doesn't want to do anything else. I had her in the living room but she kept hollering for help . She's also tilted all the way forward (in her wheelchair). 1:11 PM - The hospice nurse arrived and was just told that [Resident #1] fell at 6am. Now we know the reason for the pain. Review of text messages sent by CG D to Resident #1's RP B reflected the following: [DATE]: 2:29 PM - . [Resident #1] isn't talking much today and when they put her in the wheelchair she just stated hunched over. This is not normal for her at all . They put her on oxygen today. 3:29 PM - . HN G told me she was going to figure out why they did not treat [Resident #1] right away because she was in pain. 7:23 PM - . I requested Morphine so I could change her brief . [LVN H] never brought the Morphine so I changed her the best I could. She cried out yelling it hurts. [DATE]: 8:57 AM - I asked for the morphine and other morning meds but [LVN H] still hasn't brought them so [Resident #1] won't stop getting loud saying please let it work, please let it work. Her leg is hurting her a lot and she can't move it. 10:24 AM - [LVN H] came in at 9:57 AM and asked [Resident #1] if she needed anything and I told her she needs her morphine to help with the pain. So she asked [Resident #1] what was hurting and where and she told her she doesn't have any pain so the nurse said ok if you need it hit the red button. So she didn't give her morphine. As soon as [LVN H] left, [Resident #1] starts saying it hurts please help. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: New complaints, problems or concerns: [Resident #1] fell this morning and her hip hurts. Objective findings: [Resident #1] on respite and in room with paid caregiver. [Resident #1] lethargic but answering some questions. [Resident #1] is now total assist [Resident #1] was in wheelchair in room with head hung forward and most of her body limp when RN arrived. CG C was at beside and stated she is not herself today and does not know what's wrong. RN asked if she was aware that [Resident #1] had fallen this morning and CG C she was not told of any fall. RN asked [Resident #1] to lift her head but she stated she was not able to. [Resident #1] stated she was SOB and oxygen was applied via nasal canula at 3 L however oxygen sat was not obtainable. [Resident #1] was breathing comfortably with nasal canula and RN continued assessment. RN had to use both hands to gently lift [Resident #1]'s head to examine her eyes and face . [Resident #1] complained of slight pain with left leg lifting at hip only . Once laying in bed, [Resident #1] did call out in pain with movement of left leg especially at hip joint . RN educated facility staff on medication management and use of PRN Morphine for [Resident #1]'s pain if Tylenol is not enough. LVN H verbalized understanding. Assessment: [Resident #1] is possibly at start of decline in status. She has been more lethargic, not eating much, and had a recent fall . [Resident #1] may have fracture or deep injury of left hip or coccyx. RN also spoke with HA who confirmed they were not notified of [Resident #1] having a fall that morning when she and another aide came to bathe her. She reports it took both of them to transfer [Resident #1] but they were able to shower her . HA recalls that [Resident #1] would groan from time to time but they thought it had something to do with her being medicated because she was less alert than usual. Review of Resident #1's hospice notes documented by an on-call nurse, dated [DATE] at 4:24 PM, reflected the following: CG D would like to speak with the on-call nurse regarding [Resident #1] falling that morning and is experiencing a lot of pain on her left side. She was provided 1 Tylenol and it's not working. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: Objective findings: [Resident #1] complained of pain on left side when is moved or touched on that side . Her left leg was straight, and foot dropped to the left . [Resident #1] had pain when leg was gently turned to point foot up towards ceiling. Anytime left hip was touched or leg slightly moved or lifted she complained of paint. RN got LVN H and had her administer morphine IR 15 MG at 10:20 AM. Per LVN H she had just been in the room and [Resident #1] did not have any s/s of pain . This RN educated LVN H on [Resident #1]'s confusion and that she has pain anytime she moves or is moved for brief changes, and she may need to have caregiver help with administration of meds since [Resident #1] is familiar with her and she may be able to facilitate [Resident #1] accepting needed meds. She verbalized understanding. RN obtained order to schedule Morphine Q4 hours for pain. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:12 AM, reflected the following: Hospice nurse and [CG C] of [Resident #1] c/o left hip pain and wanted MS administered. During assessment of [Resident #1], asked if in any pain or if she needed any medication, she responded no . Hospice nurse enters room and states to [Resident #1] that the nurse is going to give you medication, the resident states okay. MS administered per Hospice. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:56 AM, reflected the following: Hospice in facility, new orders for Morphine sulfate 15mg q4 hours for pain. Hospice nurse/sitter reported [Resident #1] to have pain to her left leg . Review of Resident #1's progress notes in her EMR documented by RN I, dated [DATE] at 12:05 AM, reflected the following: CNA notified the Nurse that [Resident #1] is unresponsive. On assessment, resident unresponsive to verbal and tactile stimulation. No visible breathing, no pulse, pupils dilated and fixed, [Resident #1] has expired . Review of a documented Interview between a Hospice State Surveyor and the hospice agency's Alternate Administrator regarding the timeline of Resident #1, dated [DATE] at 1:30 PM, reflected the following: On [DATE] at approximately 6:30 AM, [Resident #1] was found on the floor by facility staff. [Resident #1]'s private caregiver arrived at 8:00 AM. From 11:30 AM - 12:30 PM, hospice aides assisted [Resident #1] with her shower and personal care. At 12:57 PM, HN G arrived to conduct a skilled nursing visit. It was at that time a facility nurse reported the fall to her. This was the first notification of a fall. Review of a documented Interview between a Hospice State Surveyor and Resident #1's HN G, dated [DATE] at 2:50 PM, reflected the following: Surveyor asked [HN G] to discuss what she recalled about what occurred when she arrived at the facility on [DATE]. [HN G] stated when arrived at the facility to conduct a visit, the client was sitting in a wheelchair with her head hung down. Surveyor asked if this was unusual. [HN G] stated, That was very unusual. I asked her to lift her head and she said she couldn't. I was concerned she had injured her head or neck when she fell. During a telephone interview on [DATE] at 11:22 AM, CG D stated CG C would sit with Resident #1 from 8:00 AM - 2:00 PM and she would relieve her at 2:00 PM - 6:00 PM. She stated CG C contacted her in the morning of [DATE] and asked if Resident #1 had fallen the day prior ([DATE]). She stated she told her no and asked her why. CG C told her Resident #1 was complaining of left hip/leg pain. She stated when she arrived at 2:00 PM on [DATE], Resident #1 was still in pain, and that was when HN G learned of the fall from the facility staff; CG C was never notified during her entire shift. She stated Resident #1 was able to verbalize pain and would yell, Owe! when she attempted to change her brief or reposition her. She stated she had worked with Resident #1 for over two months, and new her tendencies well. The day before, [DATE], when she was admitted , she ate a big breakfast, was able to self-transfer to the toilet, and even ambulated independently into the nursing facility via walker. She stated on [DATE] she was lethargic, was not eating, required oxygen, and needed full assistance. She stated she told LVN H that Resident #1 needed Morphine as she was in pain and her hip appeared swollen. She stated when LVN H came into the room and asked her if she was in pain, she said no. She stated she tried to explain that when Resident #1 was not familiar/comfortable with a person, she would appear as though everything was fine and would not verbalize her pain. She stated she may have been on hospice, but she drastically changed after the fall, and was not at end-of-life stages when she was admitted to the facility. During a telephone interview on [DATE] at 12:12 PM, Resident #1's RP A stated the Justice of the Peace and police were now involved because the death was suspicious/questionable. He stated Resident #1 was completely fine two days before her death and after being admitted to the facility. During a telephone interview on [DATE] at 1:12 PM, a Judge with the Justice of the Peace stated he had contacted the funeral home Resident #1 was sent to and was able to view her body. He stated there had been an abrasion on her left forehead and her left hip was black and blue. He stated he gave legal authority for an autopsy to be conducted due to the questionable death of Resident #1. During an interview on [DATE] at 10:46 AM, LVN H stated she witnessed Resident #1's fall. She stated she saw Resident #1 attempting to stand up out of her wheelchair when she fell to her bottom. She stated she did not hit her head. She stated CNA E assisted her with getting Resident #1 up and into her wheelchair. She stated Resident #1 was guarding her left hip/thigh and moaned a little, so they laid her down in bed. She stated when she did her full-body assessment, she touched her left thigh, she groaned a little bit, so she did not conduct a ROM assessment for this reason. She stated in the early morning sometime on [DATE], Resident #1's sitter (CG C) notified her that she was in pain. She stated around that time, Resident #1's hospice nurse arrived and administered her Tylenol after she informed her about the fall. She stated she had not notified HN G sooner because she was doing her rounds. She stated she had not notified the sitter, as that was not normal protocol. She stated when the sitter continued to notify her that she was in pain later that day, she called her hospice nurse who changed the order to Tylenol 3x/day instead of PRN. She stated she was aware she had an order for PRN Morphine, but when she asked the resident if she was in pain, she would say no. She stated although there were indications of pain, Resident #1 continued to deny pain when asked, and she was not going to administer Morphine to a resident who said they were not in pain. She stated Resident #1 did appear more lethargic on [DATE] during the day, but believed it was from all the medications. She stated she did not know if there was a decline in her health because she had not been at the facility that long. She stated she was not aware if she was eating or drinking normally because she always had a sitter with her during the day, and no one had reported it to her. LVN H denied Resident #1 utilizing oxygen throughout her time at the facility and denied hearing her hollering out in pain from her room. During an interview on [DATE] at 10:35 AM, the DON stated she had not heard anything abnormal about the death of Resident #1. She stated her expectations were that a full fall assessment be conducted after every fall - including a ROM, even if the resident denies pain. She stated if the fall was unwitnessed, neuros would be conducted; if fall was witnessed and the resident had not hit their head, neuros would not be conducted. She stated Resident #1's HN should have been notified immediately and LVN H should have conducted a full fall assessment to ensure proper care was initiated for pain management. During an interview on [DATE] at 11:03 AM with RN J, she stated after a fall, an assessment on a resident should be conducted. She stated this included a head-to-toe assessment, vitals, ROM, pain level, and neuro checks. She stated a ROM should be conducted even if the resident claims of no pain. She stated she would notify the resident's RP, DON, NP immediately after the fall. She stated if the resident was on hospice services, she would call the hospice nurse immediately after the incident as well. During an interview on [DATE] at 11:32 AM, CNA E stated she did not witness Resident #1's fall. She stated LVN H asked for her assistance to get her up. She stated when she entered the room, Resident #1 was on her bottom. She stated she did not believe she had hit her head. She stated she had not seen any bumps or redness on her head. During a telephone interview on [DATE] at 11:02 AM, RP B stated she was still in shock with the quick decline and death of Resident #1. She stated Resident #1 was herself the day of admission to the facility, [DATE]. She stated she ate breakfast, was able to transfer from her wheelchair to the toilet, and even walked into the facility with her walker. She stated although she was sometimes confused, she was able to make her needs known and have a conversation. She stated being lethargic and refusing to eat was definitely not her baseline. She stated no family member should have to go through something like that - they should feel comfortable and at ease dropping their loved one off at a skilled nursing facility for a few days without fear of not being properly cared for. Review of Resident #1's Medication Administration Audit, on [DATE], reflected she was administered Tylenol Extra Strength, 500 MG (order was for three times a day), once on [DATE] at 7:31 PM. It also reflected Resident #1 was not administered PRN Morphine Sulfate, 15 MG until [DATE] at 10:17 AM by LVN H (when HN G mandated her to administer it). Review of the facility's Assessing Falls Policy, Revised [DATE], reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Identify the resident's current medications and active medical conditions. . General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury. Review of the facility's Pain Assessment and Management Policy, revised [DATE], reflected the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for potential pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions h. Modifying approaches as necessary Steps in the procedure: Recognizing Pain: 1. Observe the reside (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming b. Facial expressions such as grimacing, frowning, flinching of the jaw, etc. c. Changes in gait, skin color and vital signs d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities e. Limitations in his or her level of activity due to the presence of pain f. Guarding, rubbing, or favoring a particular part of the body g. Difficulty eating or loss of appetite The ADM and DON were notified on [DATE] at 3:30 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON [DATE] at 3:30 PM. A Plan of Removal was accepted on [DATE] at 5:40 PM: Impact Statement On [DATE] a health complaint survey was initiated at (facility) at (address). On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to the failure to take immediate action to ensure residents are treated for acute injuries and pain effectively. What corrective actions have been implemented for the identified residents? Resident with the deficient practice expired on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (92) residing in the facility on [DATE] are at risk for the same deficient practice. All residents residing in facility on [DATE] were audited by Director of Nursing (DON) and nurse managers for effectiveness of pain management and if acute injuries present and treated effectively. No residents with acute injuries not treated effectively with pain management identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated to licensed nurses on [DATE], by the Director of Nursing (DON) on assessing residents effectively for pain and acute injuries using Numerical/ Painad Scale and head to toe assessment post injuries. Residents will be assessed by licensed nurses immediately for injuries and will be treated with pain medications based on level of pain assessed. Licensed nurses will assess effectiveness of pain management within 30-45 minutes post pain medication administration to ensure the pain medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed by hospice to the resident is not effective in managing the resident's pain, the nurse is to contact the resident's physician to obtain guidance on how to address the pain and notify DON/Designee. Facility in-serviced licensed nurses by DON on [DATE] on calling the hospice resident's responsible party (RP) to notify for changes in condition. If facility unable to reach RP the facility will leave voicemail indicating the RP needs to call facility back and collaborate with hospice company to use all the efforts to contact RP for further direction in plan of care of resident. Licensed nurses educated to notify [NAME] or Administrator when RP is unable to be reached for further direction. All notification attempts will be documented into resident's chart. Nurses that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. Facility will in-service new license nurse hires during orientation. Start Date: [DATE] End Date: ongoing Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Facility's DON contacted on [DATE] the contracted hospice companies to notify that all changes in conditions of hospice residents will be directly notified to the DON/designee and will be documented on the change in condition log at the nursing station after each hospice nurse visit and will include the facility's identified changes of condition for communication between hospice staff and facility's staff. Hospice residents will have change in condition log implemented to use for all hospice visits to log and communicate changes on [DATE]. Hospice change in condition log will be daily reviewed by DON/Designee to ensure all changes in condition identified by hospice are effectively communicated and addressed. Administrator will review the Hospice Change in Condition Log twice a week for four weeks to ensure intervention implemented is effective. Start Date: [DATE] End Date: ongoing Who is Responsible: DON/Designee Who will Monitor: Administrator/Designee An in-service was initiated to certified nurse aides (CNAs) on [DATE], by the Director of Nursing (DON) on pain management. CNAs were in-serviced on reporting any pain needs reported by resident, noted during ADL care, or pain treated but not effective to change nurses. CNAs in-serviced to report to DON/Designee when residents continue to complain of pain post pain treatment and no interventions implemented by nurse. CNAs that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. CNAs unable to be contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. The new CNA hires will be in-serviced on pain management during orientation process. Start Date: [DATE] End Date: ongoing Who is Responsible: DON or Nurse Managers Who will Monitor: Administrator/Designee How will the system be monitored to ensure compliance? The DON or nurse manager will review daily all pain assessments in the residents' eMAR and assess all residents with injuries to ensure all assessments are completed and document by the licensed nurse appropriately in addressing patients' acute injuries and pain for 2 weeks starting [DATE]. Any discrepancies identified will be addressed immediately and further education by the DON or nurse manager. Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Starting [DATE] the DON or nurse manager will interview 10 residents daily for 2 weeks to ensure the licensed charge nurses are assessing and addressing pain and acute injuries effectively. Post the daily monitoring the DON/nurse manager will review pain assessments of 10 residents and acute injuries twice weekly for 4 weeks to ensure acute injuries are effectively treated for pain. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. Administrator will review the pain assessment auditing and rounding on patients on a weekly basis to ensure nurse managers are following the plan of correction for six weeks or until it is determined the metric is met starting [DATE] Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Survey team monitored the Plan of Removal from [DATE] - [DATE] as followed: During interviews on [DATE] from 5:51 PM - 6:21 PM, three RN's, two LVN's, one MA, and one CNA stated they had been in-serviced on resident falls, assessments, and pain management. They were able to identify different indicators of pain - groaning, wincing, grimacing, clenching fists. All stated if when providing care, the resident voices pain or shows indicators of pain, care should be stopped immediately, and a nurse should be notified. During interview on [DATE] from 1:15 PM - 3:00 PM, two LVN's and on RN stated they had received education regarding assessing for pain and effective pain management, education regarding communication with hospice agencies/staff and addressing acute injuries, and non-verbal indicators of pain. During an interview on [DATE] at 1:45 PM, the DON stated she had finished the in-services for all staff for the completion of the POR. She stated staff that were unable to be reached would be in-serviced before working the floor. She stated there were currently no resident with acute injuries or unmanaged pain. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on ADL Care and Pain: When providing ADL care, if resident complains of pain or shows signs/symptoms of pain, notify nurse immediately. If nurse does not administer medication, notify DON/ADON. If resident is in pain, you must stop ADL care until pain is addressed. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on Acute Injury Incidents and Pain: - Assessing residents effectively for pain and injuries using numerical/painAD sale with head-to-toe assessment pot injuries - Assess immediately after fall and medicate based on pain level - Assess effectiveness of pain management within 30-45 minutes post pain medications The ADM and DON were notified [DATE] at 4:30 PM that the IJ had been lowered. While the IJ was lowered on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated identified due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to properly assess or provide effective pain management to Resident #1 after she fell and injured her hip on [DATE], resulting in uncontrolled pain, decline in health, and ultimately death on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:30 PM. While the IJ was removed on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] for respite care with diagnoses of history of falling, chronic respiratory failure, type II diabetes, hypertensive (high blood pressure) heart disease, seizures, and other specified anxiety disorders. Review of Resident #1's fall risk assessment, dated [DATE], reflected a score of 16, indicating she was a high risk for falls. Review of Resident #1's discharge MDS assessment, dated [DATE], reflected she died in the facility. Review of Resident #1's initial baseline care plan, dated [DATE], reflected she had an actual fall (on [DATE]) with no injury related to cognitive impairment and poor balance with interventions of frequent rounding and checking range of motion. Review of Resident #1's progress notes in her EMR documented by RN K, dated [DATE] at 6:59 PM, reflected the following: [Resident #1] admitted into (facility) on respite care per (hospice agency) . care giver will be at beside daily from 8:00 AM - 6:00 PM . clear adequate speech, adequate vision, adequate hearing . Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 7:45 AM, reflected the following: During monitoring rounds observed [Resident #1] attempting to self-ambulate and fell to floor. Unable to reach [Resident #1] before she fell to the floor. [Resident #1] did not hit her head and landed on her bottom. Assessed [Resident #1] and assisted back into wheelchair and assisted back into bed. [Resident #1] does not display any signs of pain/discomfort, with no injuries observed at this time. Review of text messages sent by CG C to Resident #1's RP B reflected the following: [DATE]: 8:28 AM - Soon as I arrived, I asked if [Resident #1] wanted breakfast and she said no . I noticed her making a face and I asked what was wrong and she said her left leg hurts. 9:39 AM - I got [Resident #1] up in the chair and had to ask for help to change her brief . [Resident #1] was asking to get back in bed because her leg was hurting. When breakfast arrived, [Resident #1] did not want to eat because she was nauseated. 1:01 PM - She ate a little (lunch). She's really out of it. Not sure what to do. I don't wanna put her in bed and she doesn't want to do anything else. I had her in the living room but she kept hollering for help . She's also tilted all the way forward (in her wheelchair). 1:11 PM - The hospice nurse arrived and was just told that [Resident #1] fell at 6am. Now we know the reason for the pain. Review of text messages sent by CG D to Resident #1's RP B reflected the following: [DATE]: 2:29 PM - . [Resident #1] isn't talking much today and when they put her in the wheelchair she just stated hunched over. This is not normal for her at all . They put her on oxygen today. 3:29 PM - . HN G told me she was going to figure out why they did not treat [Resident #1] right away because she was in pain. 7:23 PM - . I requested Morphine so I could change her brief . [LVN H] never brought the Morphine so I changed her the best I could. She cried out yelling it hurts. [DATE]: 8:57 AM - I asked for the morphine and other morning meds but [LVN H] still hasn't brought them so [Resident #1] won't stop getting loud saying please let it work, please let it work. Her leg is hurting her a lot and she can't move it. 10:24 AM - [LVN H] came in at 9:57 AM and asked [Resident #1] if she needed anything and I told her she needs her morphine to help with the pain. So she asked [Resident #1] what was hurting and where and she told her she doesn't have any pain so the nurse said ok if you need it hit the red button. So she didn't give her morphine. As soon as [LVN H] left, [Resident #1] starts saying it hurts please help. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: New complaints, problems or concerns: [Resident #1] fell this morning and her hip hurts. Objective findings: [Resident #1] on respite and in room with paid caregiver. [Resident #1] lethargic but answering some questions. [Resident #1] is now total assist [Resident #1] was in wheelchair in room with head hung forward and most of her body limp when RN arrived. CG C was at beside and stated she is not herself today and does not know what's wrong. RN asked if she was aware that [Resident #1] had fallen this morning and CG C she was not told of any fall. RN asked [Resident #1] to lift her head but she stated she was not able to. [Resident #1] stated she was SOB and oxygen was applied via nasal canula at 3 L however oxygen sat was not obtainable. [Resident #1] was breathing comfortably with nasal canula and RN continued assessment. RN had to use both hands to gently lift [Resident #1]'s head to examine her eyes and face . [Resident #1] complained of slight pain with left leg lifting at hip only . Once laying in bed, [Resident #1] did call out in pain with movement of left leg especially at hip joint . RN educated facility staff on medication management and use of PRN Morphine for [Resident #1]'s pain if Tylenol is not enough. LVN H verbalized understanding. Assessment: [Resident #1] is possibly at start of decline in status. She has been more lethargic, not eating much, and had a recent fall . [Resident #1] may have fracture or deep injury of left hip or coccyx. RN also spoke with HA who confirmed they were not notified of [Resident #1] having a fall that morning when she and another aide came to bathe her. She reports it took both of them to transfer [Resident #1] but they were able to shower her . HA recalls that [Resident #1] would groan from time to time but they thought it had something to do with her being medicated because she was less alert than usual. Review of Resident #1's hospice notes documented by an on-call nurse, dated [DATE] at 4:24 PM, reflected the following: CG D would like to speak with the on-call nurse regarding [Resident #1] falling that morning and is experiencing a lot of pain on her left side. She was provided 1 Tylenol and it's not working. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: Objective findings: [Resident #1] complained of pain on left side when is moved or touched on that side . Her left leg was straight, and foot dropped to the left . [Resident #1] had pain when leg was gently turned to point foot up towards ceiling. Anytime left hip was touched or leg slightly moved or lifted she complained of paint. RN got LVN H and had her administer morphine IR 15 MG at 10:20 AM. Per LVN H she had just been in the room and [Resident #1] did not have any s/s of pain . This RN educated LVN H on [Resident #1]'s confusion and that she has pain anytime she moves or is moved for brief changes, and she may need to have caregiver help with administration of meds since [Resident #1] is familiar with her and she may be able to facilitate [Resident #1] accepting needed meds. She verbalized understanding. RN obtained order to schedule Morphine Q4 hours for pain. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:12 AM, reflected the following: Hospice nurse and [CG C] of [Resident #1] c/o left hip pain and wanted MS administered. During assessment of [Resident #1], asked if in any pain or if she needed any medication, she responded no . Hospice nurse enters room and states to [Resident #1] that the nurse is going to give you medication, the resident states okay. MS administered per Hospice. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:56 AM, reflected the following: Hospice in facility, new orders for Morphine sulfate 15mg q4 hours for pain. Hospice nurse/sitter reported [Resident #1] to have pain to her left leg . Review of Resident #1's progress notes in her EMR documented by RN I, dated [DATE] at 12:05 AM, reflected the following: CNA notified the Nurse that [Resident #1] is unresponsive. On assessment, resident unresponsive to verbal and tactile stimulation. No visible breathing, no pulse, pupils dilated and fixed, [Resident #1] has expired . Review of a documented Interview between a Hospice State Surveyor and the hospice agency's Alternate Administrator regarding the timeline of Resident #1, dated [DATE] at 1:30 PM, reflected the following: On [DATE] at approximately 6:30 AM, [Resident #1] was found on the floor by facility staff. [Resident #1]'s private caregiver arrived at 8:00 AM. From 11:30 AM - 12:30 PM, hospice aides assisted [Resident #1] with her shower and personal care. At 12:57 PM, HN G arrived to conduct a skilled nursing visit. It was at that time a facility nurse reported the fall to her. This was the first notification of a fall. Review of a documented Interview between a Hospice State Surveyor and Resident #1's HN G, dated [DATE] at 2:50 PM, reflected the following: Surveyor asked [HN G] to discuss what she recalled about what occurred when she arrived at the facility on [DATE]. [HN G] stated when arrived at the facility to conduct a visit, the client was sitting in a wheelchair with her head hung down. Surveyor asked if this was unusual. [HN G] stated, That was very unusual. I asked her to lift her head and she said she couldn't. I was concerned she had injured her head or neck when she fell. During a telephone interview on [DATE] at 11:22 AM, CG D stated CG C would sit with Resident #1 from 8:00 AM - 2:00 PM and she would relieve her at 2:00 PM - 6:00 PM. She stated CG C contacted her in the morning of [DATE] and asked if Resident #1 had fallen the day prior ([DATE]). She stated she told her no and asked her why. CG C told her Resident #1 was complaining of left hip/leg pain. She stated when she arrived at 2:00 PM on [DATE], Resident #1 was still in pain, and that was when HN G learned of the fall from the facility staff; CG C was never notified during her entire shift. She stated Resident #1 was able to verbalize pain and would yell, Owe! when she attempted to change her brief or reposition her. She stated she had worked with Resident #1 for over two months, and new her tendencies well. The day before, [DATE], when she was admitted , she ate a big breakfast, was able to self-transfer to the toilet, and even ambulated independently into the nursing facility via walker. She stated on [DATE] she was lethargic, was not eating, required oxygen, and needed full assistance. She stated she told LVN H that Resident #1 needed Morphine as she was in pain and her hip appeared swollen. She stated when LVN H came into the room and asked her if she was in pain, she said no. She stated she tried to explain that when Resident #1 was not familiar/comfortable with a person, she would appear as though everything was fine and would not verbalize her pain. She stated she may have been on hospice, but she drastically changed after the fall, and was not at end-of-life stages when she was admitted to the facility. During a telephone interview on [DATE] at 12:12 PM, Resident #1's RP A stated the Justice of the Peace and police were now involved because the death was suspicious/questionable. He stated Resident #1 was completely fine two days before her death and after being admitted to the facility. During a telephone interview on [DATE] at 1:12 PM, a Judge with the Justice of the Peace stated he had contacted the funeral home Resident #1 was sent to and was able to view her body. He stated there had been an abrasion on her left forehead and her left hip was black and blue. He stated he gave legal authority for an autopsy to be conducted due to the questionable death of Resident #1. During an interview on [DATE] at 10:46 AM, LVN H stated she witnessed Resident #1's fall. She stated she saw Resident #1 attempting to stand up out of her wheelchair when she fell to her bottom. She stated she did not hit her head. She stated CNA E assisted her with getting Resident #1 up and into her wheelchair. She stated Resident #1 was guarding her left hip/thigh and moaned a little, so they laid her down in bed. She stated when she did her full-body assessment, she touched her left thigh, she groaned a little bit, so she did not conduct a ROM assessment for this reason. She stated in the early morning sometime on [DATE], Resident #1's sitter (CG C) notified her that she was in pain. She stated around that time, Resident #1's hospice nurse arrived and administered her Tylenol after she informed her about the fall. She stated she had not notified HN G sooner because she was doing her rounds. She stated she had not notified the sitter, as that was not normal protocol. She stated when the sitter continued to notify her that she was in pain later that day, she called her hospice nurse who changed the order to Tylenol 3x/day instead of PRN. She stated she was aware she had an order for PRN Morphine, but when she asked the resident if she was in pain, she would say no. She stated although there were indications of pain, Resident #1 continued to deny pain when asked, and she was not going to administer Morphine to a resident who said they were not in pain. She stated Resident #1 did appear more lethargic on [DATE] during the day, but believed it was from all the medications. She stated she did not know if there was a decline in her health because she had not been at the facility that long. She stated she was not aware if she was eating or drinking normally because she always had a sitter with her during the day, and no one had reported it to her. LVN H denied Resident #1 utilizing oxygen throughout her time at the facility and denied hearing her hollering out in pain from her room. During an interview on [DATE] at 10:35 AM, the DON stated she had not heard anything abnormal about the death of Resident #1. She stated her expectations were that a full fall assessment be conducted after every fall - including a ROM, even if the resident denies pain. She stated if the fall was unwitnessed, neuros would be conducted; if fall was witnessed and the resident had not hit their head, neuros would not be conducted. She stated Resident #1's HN should have been notified immediately and LVN H should have conducted a full fall assessment to ensure proper care was initiated for pain management. During an interview on [DATE] at 11:03 AM with RN J, she stated after a fall, an assessment on a resident should be conducted. She stated this included a head-to-toe assessment, vitals, ROM, pain level, and neuro checks. She stated a ROM should be conducted even if the resident claims of no pain. She stated she would notify the resident's RP, DON, NP immediately after the fall. She stated if the resident was on hospice services, she would call the hospice nurse immediately after the incident as well. During an interview on [DATE] at 11:32 AM, CNA E stated she did not witness Resident #1's fall. She stated LVN H asked for her assistance to get her up. She stated when she entered the room, Resident #1 was on her bottom. She stated she did not believe she had hit her head. She stated she had not seen any bumps or redness on her head. During a telephone interview on [DATE] at 11:02 AM, RP B stated she was still in shock with the quick decline and death of Resident #1. She stated Resident #1 was herself the day of admission to the facility, [DATE]. She stated she ate breakfast, was able to transfer from her wheelchair to the toilet, and even walked into the facility with her walker. She stated although she was sometimes confused, she was able to make her needs known and have a conversation. She stated being lethargic and refusing to eat was definitely not her baseline. She stated no family member should have to go through something like that - they should feel comfortable and at ease dropping their loved one off at a skilled nursing facility for a few days without fear of not being properly cared for. Review of Resident #1's Medication Administration Audit, on [DATE], reflected she was administered Tylenol Extra Strength, 500 MG (order was for three times a day), once on [DATE] at 7:31 PM. It also reflected Resident #1 was not administered PRN Morphine Sulfate, 15 MG until [DATE] at 10:17 AM by LVN H (when HN G mandated her to administer it). Review of the facility's Assessing Falls Policy, Revised [DATE], reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Identify the resident's current medications and active medical conditions. . General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury. Review of the facility's Pain Assessment and Management Policy, revised [DATE], reflected the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for potential pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions h. Modifying approaches as necessary Steps in the procedure: Recognizing Pain: 1. Observe the reside (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming b. Facial expressions such as grimacing, frowning, flinching of the jaw, etc. c. Changes in gait, skin color and vital signs d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities e. Limitations in his or her level of activity due to the presence of pain f. Guarding, rubbing, or favoring a particular part of the body g. Difficulty eating or loss of appetite The ADM and DON were notified on [DATE] at 3:30 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON [DATE] at 3:30 PM. A Plan of Removal was accepted on [DATE] at 5:40 PM: Impact Statement On [DATE] a health complaint survey was initiated at (facility) at (address). On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to the failure to take immediate action to ensure residents are treated for acute injuries and pain effectively. What corrective actions have been implemented for the identified residents? Resident with the deficient practice expired on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (92) residing in the facility on [DATE] are at risk for the same deficient practice. All residents residing in facility on [DATE] were audited by Director of Nursing (DON) and nurse managers for effectiveness of pain management and if acute injuries present and treated effectively. No residents with acute injuries not treated effectively with pain management identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated to licensed nurses on [DATE], by the Director of Nursing (DON) on assessing residents effectively for pain and acute injuries using Numerical/ Painad Scale and head to toe assessment post injuries. Residents will be assessed by licensed nurses immediately for injuries and will be treated with pain medications based on level of pain assessed. Licensed nurses will assess effectiveness of pain management within 30-45 minutes post pain medication administration to ensure the pain medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed by hospice to the resident is not effective in managing the resident's pain, the nurse is to contact the resident's physician to obtain guidance on how to address the pain and notify DON/Designee. Facility in-serviced licensed nurses by DON on [DATE] on calling the hospice resident's responsible party (RP) to notify for changes in condition. If facility unable to reach RP the facility will leave voicemail indicating the RP needs to call facility back and collaborate with hospice company to use all the efforts to contact RP for further direction in plan of care of resident. Licensed nurses educated to notify [NAME] or Administrator when RP is unable to be reached for further direction. All notification attempts will be documented into resident's chart. Nurses that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. Facility will in-service new license nurse hires during orientation. Start Date: [DATE] End Date: ongoing Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Facility's DON contacted on [DATE] the contracted hospice companies to notify that all changes in conditions of hospice residents will be directly notified to the DON/designee and will be documented on the change in condition log at the nursing station after each hospice nurse visit and will include the facility's identified changes of condition for communication between hospice staff and facility's staff. Hospice residents will have change in condition log implemented to use for all hospice visits to log and communicate changes on [DATE]. Hospice change in condition log will be daily reviewed by DON/Designee to ensure all changes in condition identified by hospice are effectively communicated and addressed. Administrator will review the Hospice Change in Condition Log twice a week for four weeks to ensure intervention implemented is effective. Start Date: [DATE] End Date: ongoing Who is Responsible: DON/Designee Who will Monitor: Administrator/Designee An in-service was initiated to certified nurse aides (CNAs) on [DATE], by the Director of Nursing (DON) on pain management. CNAs were in-serviced on reporting any pain needs reported by resident, noted during ADL care, or pain treated but not effective to change nurses. CNAs in-serviced to report to DON/Designee when residents continue to complain of pain post pain treatment and no interventions implemented by nurse. CNAs that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. CNAs unable to be contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. The new CNA hires will be in-serviced on pain management during orientation process. Start Date: [DATE] End Date: ongoing Who is Responsible: DON or Nurse Managers Who will Monitor: Administrator/Designee How will the system be monitored to ensure compliance? The DON or nurse manager will review daily all pain assessments in the residents' eMAR and assess all residents with injuries to ensure all assessments are completed and document by the licensed nurse appropriately in addressing patients' acute injuries and pain for 2 weeks starting [DATE]. Any discrepancies identified will be addressed immediately and further education by the DON or nurse manager. Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Starting [DATE] the DON or nurse manager will interview 10 residents daily for 2 weeks to ensure the licensed charge nurses are assessing and addressing pain and acute injuries effectively. Post the daily monitoring the DON/nurse manager will review pain assessments of 10 residents and acute injuries twice weekly for 4 weeks to ensure acute injuries are effectively treated for pain. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. Administrator will review the pain assessment auditing and rounding on patients on a weekly basis to ensure nurse managers are following the plan of correction for six weeks or until it is determined the metric is met starting [DATE] Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Survey team monitored the Plan of Removal from [DATE] - [DATE] as followed: During interviews on [DATE] from 5:51 PM - 6:21 PM, three RN's, two LVN's, one MA, and one CNA stated they had been in-serviced on resident falls, assessments, and pain management. They were able to identify different indicators of pain - groaning, wincing, grimacing, clenching fists. All stated if when providing care, the resident voices pain or shows indicators of pain, care should be stopped immediately, and a nurse should be notified. During interview on [DATE] from 1:15 PM - 3:00 PM, two LVN's and on RN stated they had received education regarding assessing for pain and effective pain management, education regarding communication with hospice agencies/staff and addressing acute injuries, and non-verbal indicators of pain. During an interview on [DATE] at 1:45 PM, the DON stated she had finished the in-services for all staff for the completion of the POR. She stated staff that were unable to be reached would be in-serviced before working the floor. She stated there were currently no resident with acute injuries or unmanaged pain. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on ADL Care and Pain: When providing ADL care, if resident complains of pain or shows signs/symptoms of pain, notify nurse immediately. If nurse does not administer medication, notify DON/ADON. If resident is in pain, you must stop ADL care until pain is addressed. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on Acute Injury Incidents and Pain: - Assessing residents effectively for pain and injuries using numerical/painAD sale with head-to-toe assessment pot injuries - Assess immediately after fall and medicate based on pain level - Assess effectiveness of pain management within 30-45 minutes post pain medications The ADM and DON were notified [DATE] at 4:30 PM that the IJ had been lowered. While the IJ was lowered on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated identified due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents admitted without pressure ulcers do not develop pressure ulcers and once developed, provide care to prevent decline for one of eight residents with pressure ulcers (Resident #63). 1. The facility failed to ensure Resident #63's unstageable pressure ulcer to his heel was assessed and treated daily to ensure Resident #63's pressure ulcer did not decline. 2. The facility failed to update the care plan to indicate a change in the status of the pressure ulcer. 3. The facility failed to ensure that once the pressure ulcer declined, that the Physician treatment orders were followed and failed to notify the Physician of x-ray results indicating osteomyelitis. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Findings include: Review of Resident #63's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of ataxia (impaired balance or coordination) following unspecified cerebrovascular disease (group of conditions that affect blood flow and blood vessels in brain), transient cerebral ischemic attack (brief stroke-like attack), idiopathic normal pressure hydrocephalus (potentially reversible neurodegenerative disease characterized by dementia, gait and urinary disturbance), anxiety disorder, primary hypertension (high blood pressure), polyneuropathy (malfunction of many peripheral nerves throughout the body), contracture left hip and knee (condition of shortening and hardening of muscles, tendons or other tissue, leading to deformity and rigidity of joints). Review of Resident #63's Care Plan dated [DATE] reflected he had a pressure injury Stage 2 (some of outer surface of skin, (epidermis) or deeper layer (dermis) is damaged leading to skin loss) to the left heel with potential for further pressure injury development related to deceased mobility. Goal: pressure injury will show signs of healing and remain free from infection through review date. Target date: [DATE]. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Obtain and monitor lab/Diagnostic work as ordered. Report results to MD and follow up as indicated. (The care plan did not reflect the current stage or treatment of Resident #63's left heel pressure ulcer.) Review of Resident #63's Quarterly MDS dated [DATE] reflected he had a BIMS of 7 indicating severe cognitive impairment, Prognosis: no to does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. Reflected no unhealed pressure ulcers or injuries. Review of a Facility Wide Pressure Ulcer Assessment list dated [DATE] and completed by LVN Treatment Nurse reflected Resident #63 first documentation on the list with a stage 3 pressure ulcer ( full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue) to his left heel measuring 6 cm length X 4 cm wide and 0.2 cm deep, and indicated it was facility acquired on [DATE]. Treatment was alginate and chemical debridement. Review of a Facility Wide Pressure Ulcer Aassessment completed by LVN Treatment Nurse on [DATE] reflected Resident #63's wound measurements had not changed, the treatment remained the same and reflected multivitamins and protein supplement had been added to his treatment. Review of a Surgical Progress Note dated [DATE] by the Wound Care Dr. for Resident #63 reflected the reason for the visit was consultation and evaluation of a wound found on the left heel. Patient conversive, alert and oriented X 2 (person, place). Location: left heel pressure injury/ulcer wound stage 3 - pressure injury, Preoperative indications: Breakdown of muscle, breakdown of tissue, necrotic tissue, poor healing, and slough. Signs of infection: none. A muscle tissue debridement was performed using surgical incision of devitalized subcutaneous (fat) muscle, fascia (connective tissue) and tendon tissue. The preop wound area was 4 cm X 4 cm X 0.2 cm with post-op wound area measuring the same. There was no odor noted to the wound and the drainage was moderate and serosanguineous. (yellow with small amounts of blood) The wound progress was noted as decreased in size. Assessment and plan: The patient has a wound at the left heel. The wound debrided today is at the left heel. For this wound, there was confirmation of tissue breakdown which will entail ongoing surveillance and may require future debridement. Reason for continued debridement: the patient continues to need ongoing weekly debridement since he shows signifiers that can hamper wound healing which consist recurring slough, difficulty offloading ulcer, and resistance to prescribed protective devices. This patient has a chronic wound which may or may not heal and may worsen because of chronic comorbidities (more than one disease or condition in body), restricted mobility, and wound edge epiboly (rolled or curled under closed wound edges). Follow up at an interval of one week. Goals: overall goals for the wound are wound stabilization, prevention of wound decline and prevention of further wound decline. Review of a Pressure Ulcer Assessment completed by LVN Treatment Nurse on [DATE] reflected the wound for Resident #63's left heel was 4 cm length X 4 cm wide X 0.2 cm deep. On [DATE] Resident #63's wound had slightly increased in size to 4.0 cm length X 5.0 cm wide X 0.8 cm deep. Review of a Progress Note by the NP service date [DATE] for Resident #63 reflected Patient is seen sitting up in WC in common area, he appears fatigued and reports his left foot has been bothering him. He is noted to have a Stage 3 pressure ulcer on his left heel, foul odor noted. Review of Physician Orders for Resident #63 dated [DATE] and signed by LVN A reflected x-ray left heel. Review of a Radiology Report for Resident #63 dated Saturday [DATE] at 3:52 PM reflected Findings suspicious for calcaneal (heel) osteomyelitis (bone infection), recommend MRI. Review of the [DATE] TAR for Resident #63 reflected that treatment was not documented as completed on the weekend of [DATE]-[DATE]. Review of Progress Notes for Resident #63 on the weekend of [DATE]-[DATE] reflected there were no wound care progress notes documented. Review of Physician Orders for Resident #63 dated [DATE] reflected Location of wound: stage 3 pressure ulcer left heel. Treatment order, every day shift for wound healing Cleanse with dakins 1/4 strength, pat dry gently, wipe skin prep to peri wound, apply thin layer of santyl to wound bed, apply calcium alginate to wound bed , cover with foam dressing. Review of the Hospital Records for Resident #63 reflected he presented to the ER on [DATE] at 8:15 AM with a fever, was hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions) with an O2 sat of 80%, had chronic pressure wounds to his right hip and left heel. He had an open, necrotic wound on his left heel draining black, foul-smelling liquid at the base of his calcaneus (heel). Probable acute osteomyelitis (bone infection) of the plantar aspect (thick tissue at bottom of foot) of the calcaneus with adjacent gas gangrene (bacterial infection releasing toxins that cause tissue death) He was admitted to the hospital for sepsis. (blood infection). Interview on [DATE] at 8:30 AM LVN Treatment Nurse stated Resident #63's left heel wound was getting worse on Friday [DATE], had dark eschar and was starting to smell necrotic. The NP saw Resident #63 on Friday [DATE] and changed the wound care to Dakins solution ( broad-spectrum antibacterial cleanser) and Santyl (removes damaged tissue from the wound) and LVN Treatment Nurse stated he was going to start that treatment on Monday. LVN Treatment Nurse further stated, the wound care Dr. was involved with Resident #63's wound care every Monday, but the Wound Care Dr. was out due to illness for two weeks and last saw the Rresident #63 on [DATE]. LVN Treatment Nurse stated, We used to have a wound care nurse on the weekends but haven't for the past two months. Interview [DATE] at 8:45 AM DON stated there was no proof the wound care for Resident #63 was completed on the weekend of [DATE]-[DATE] as it was not documented on the TAR. DON further stated they used to have an RN weekend supervisor who completed the wound care but now the charge nurses were doing wound care. Interview on [DATE] at 9:00 AM LVN Treatment Nurse stated the potential risk of not doing wound care is it could get infected, but he was unsure if that would lead to osteomyelitis. (Infection of the bone). Interview [DATE] at 10:16 AM LVN A stated she performed the wound care over the weekend of [DATE]-[DATE] for Resident #63 but could not recall the condition of the wound except for a little yellow slough in the middle. LVN A did not remember any odor from the wound. LVN A stated she had repositioned him in his wheelchair several times and fed him in the dining room but denied noticing any change in his condition. Interview on [DATE] at 10:51 AM NP stated the nurses told her Resident #63 didn't look right on Friday ([DATE]) and described him as sluggish. NP stated she ordered labs CBC, BMP, ESR, CRP, an x-ray of the foot and a wound culture. NP stated she assumed they would collect the lab that day and further stated if they had collected the lab, she would have received the lab results on Saturday and would have started a broad-spectrum antibiotic. NP said the wound care nurse said he was going to wait to collect the wound culture on Monday and she was unsure why he would wait. NP received the lab results on Monday and the WBCs were up, (indicating infection) but by the time the facility called, Resdient #63 had been sent to the hospital. Interview on [DATE] at 1:38 PM with LVN A who stated an x-ray technician came and performed the left heel x-ray for Resident #63 (on Saturday, [DATE]). LVN A stated she didn't see the x-ray results and Those (results) go directly to management. LVN A denied noticing any changes in Resident #63's behavior and did not smell any unusual odors. Interview on [DATE] at 11:18 AM ADON stated she had been ADON since July and did not know anything about Resident #63's condition on Friday the 13th, 2023 when the NP came to her unit and gave her a verbal order for labs. (blood work). ADON stated she asked the NP if she wanted them STAT (now) or the next lab draw, and she stated the next lab draw was fine. ADON stated she was not sure the NP was aware the next draw was to be on Monday or not and that the DON oversaw the wound care system. Interview on [DATE] at 9:20 AM with Resident #63 in his hospital room who stated, I've been hurting every minute from his heel wound. Resident #63 was unable to answer any other questions. Interview on [DATE] at 9:25 AM with Resident #63's family member who stated they couldn't do surgery because they were afraid to put him under anesthesia, that he wouldn't make it. The family member stated, Hospice is coming. I never asked what size the wound was on his foot. I thought it was healed. Someone from the facility called and told me they had checked the wound on Friday (13th, 2023), and it was fine and that he had developed a fever over the weekend. She stated He's septic and has pneumonia. I was never informed how bad the wound was getting. Interview on [DATE] at 11:18 AM ADON LVN stated, Wound care is coordinated by the DON and wound care nurse and the charge nurses perform wound care on the weekends. ADON LVN further stated The facility used to have an RN weekend supervisor who completed wound care on the weekends but now the LVN Treatment Nurse leaves the keys to the treatment cart with the charge nurses on Fridays. Interview on [DATE] at 12:30 PM the Wound Care Dr. stated The last time I saw (Resident #63) was on [DATE]nd (2023) when I debrided his left heel. It was 20% slough. We were having luck with Medi-honey. I changed the orders to silver gel and calcium alginate. On [DATE] it measured 6 cm X 4 cm, then on [DATE] it was 4 cm X 4 cm. There's no way the wound could go from necrotic with foul odor on Friday ([DATE]th, 2023) to no odor and slight yellow drainage and yellow slough on the weekend then back again. I think we failed him on the weekend. Interview on [DATE] at 1:22 PM LVN M stated the last time she saw Resident #63 prior to the morning of [DATE]th (2023) was on Thursday [DATE]th (2023). LVN M stated Resident #63 was getting up in his WC, was talking and responding and he was at his normal baseline. LVN M stated Monday morning ([DATE]) the CNA working on Resident #63's hall came to her and told her the resident was not doing well. LVN M stated she went to assess him, and he was clammy to touch, was not responding, had a low-grade temperature of 99.7 and his heart rate was 138. LVN M stated she felt at that time he was full blown septic (the body's extreme reaction to an infection) and knew Resident #63 had a wound on his heel with a very strong necrotic (dead tissue) odor. LVN M stated Resident #63's oxygen saturation rate was 73-83%. LVN M further stated she called the MD to have Resident #63 sent to the hospital and stated the night nurse, LVN N, did not give her any report that Resident #63 was not doing well. Interview attempt was made by Surveyor who placed a phone call to LVN N on [DATE] at 1:25 PM and left a message for a return call. Surveyor placed a call on [DATE] at 1:41 PM to CNA O (who had worked the night shift of [DATE]-[DATE] with LVN N) and she responded she was busy and would call back. As of [DATE] no return calls had been received. Interview on [DATE] at 1:30 PM CNA B stated she had worked the 6-2 shift on [DATE]-[DATE] and cared for Resident #63. CNA B stated when she turned him over, he screamed in pain. CNA B stated she smelled his foot and the odor smelled like death. CNA B stated she told LVN A he was in pain because every time she moved him, he yelled. CNA B stated she got Resident #63 up in his wheelchair and could tell he was not his normal self as he was moving a lot in pain and fidgeting. Interview on [DATE] at 1:50 PM ADMIN stated his expectation for wound care is that it be done and to follow the Dr's orders. Interview on [DATE] at 2:07 PM DON stated her expectations for wound care are that it should be done and documented. The potential risk if not completed is deterioration of the wound and that could cause a change of condition and infection. She further stated she pulled the x-ray report on Monday morning ([DATE]) for Resident #63 indicating osteomyelitis and that LVN A had access to that report over the weekend. DON stated, I don't know why (LVN A) didn't pull the x-ray report. The NP knew the next lab draw wouldn't be until Monday. Interview on [DATE] at 2:18 PM DON stated regarding Resident #63's Care Plan it should have been updated as his wound progressed and the Care Plan stating Resident #63 had a Stage 2 pressure ulcer was not appropriate and could affect his care. DON stated his wound measurements and staging indicating Resident #63's wound had slough and necrotic tissue and staging at Stage 3 was not appropriate since the wound bed was not fully visible, but they were staging it that way because the wound doctor did. DON stated nurse aides can update the management staff on resident conditions in the POC (point of care, wall mounted kiosk) and none of the aides did that regarding Resident #63. Interview on [DATE] at 8:08 AM ER RN at a local hospital stated when Resident #63 arrived at the ER on [DATE] he had altered mental status and was not at his baseline per the NH. He could gesture yes or no. He was non-verbal. He did react to painful stimuli. The first thing I noticed was a putrid odor. I removed his sock and dressing, and he had a nasty heel ulcer that desperately needed attention. His sock was soaked through with sero-sanguineous (yellow body fluid with blood) and purulent (thick, foul smelling) wound drainage. I don't recall a date on the old dressing. He had the beginning of pressure ulcers on his right hip in three spots. He had a nasty cough, sepsis, and pneumonia. That odor ranked in the top three worst in my twelve years of nursing. It was so bad that when the daughter came in, she asked for air freshener. Interview on [DATE] at 2:00 PM ER Dr. stated Resident #63 came into the ER with a foul-smelling wound on his left foot. ER Dr. said the wound was necrotic with osteomyelitis and had black fluid draining from the wound. ER Dr. did not see the date of the dressing that was on the wound, but it did not appear to be a fresh dressing or one that had been changed recently as it was soaked through and dirty. ER Dr. said the wound did not appear to have been cared for or treated recently and it was likely it had not been since Friday. ER Dr. stated he would find it hard to believe that the heel had wound treatment the day before his admission. ER Dr. stated it was tough to say if earlier transfer to the hospital would have changed the outcome to the wound but it would have given Resident #63 a better chance of saving his foot (as an amputation of the foot was recommended) and a better chance for a positive outcome. ER Dr. stated Resident #63 also had diagnoses of pneumonia and a UTI. Review of a Facility Policy titled Change in Residents Condition or Status dated 2001 and revised in [DATE] reflected Our facility shall promptly notify the resident, his or her attending Physician and representative of changes in the residents medical/mental condition and or status. The nurse will notify the resident's Attending Physician or physician on call when there has been a significant change int the residents physical/emotional/mental condition, need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Impacts more than one area of the resident's health status. Requires interdisciplinary review and/or revision to the care plan. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:20 PM and the IJ template was provided. The Administrator stated he understood the meaning of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 5:00 PM and included the following: Impact Statement: On [DATE], a health survey was initiated at Accel at College Station at 1500 Medical Ave., College Station, TX 77845. On [DATE], the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute an Immediate Jeopardy to the resident's health due to the failure to prevent wound, development and worsening of a wound, which caused the resident to be admitted to the hospital with sepsis related to acute osteomyelitis of the wound. What corrective actions have been implemented for the identified residents? The resident with the deficient practice was discharged to the hospital on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (95) residing in the facility on [DATE] are at risk for the same deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? The Clinical Service Director completed an in-service on [DATE] with the DON (Director of Nursing) and Administrator on how to properly complete and review skin treatments, lab orders, and diagnostic test orders are completed and followed as per physician's orders during the daily clinical meeting held Monday - Friday. Start Date: [DATE] End Date: [DATE] Who is Responsible: DON, and Nurse Managers Who will Monitor: Administrator/Designee The DON completed an in-service with Nurse Managers on [DATE] to review and ensure that skin treatments, lab, and diagnostic orders are completed and followed as per the physician's orders during the clinical meeting. Facility Nursing Managers will complete these tasks during the weekends by following the assigned Manager on Duty Schedule. The facility's nurse managers will complete these tasks on weekends until a weekend manager is hired to monitor wound treatment is provided, documentation of wound care, and abnormal diagnostic test and labs are reported to the DON and Physician. Start Date: [DATE] End Date: [DATE] Who is Responsible: Nurse Managers Who will Monitor: DON and Administrator The DON completed a 1 to 1 with the Wound Care nurse on [DATE] covering wound care treatments, assessing skin, receiving and implementing wound care orders, reporting any wound changes to the DON and Physician, reporting abnormal labs and diagnostic test results to the DON and Physician, and documenting wound care. Start Date: [DATE] End Date: [DATE] Who is Responsible: Wound Care Nurse Who will Monitor: DON The DON completed an in-service on [DATE] with nurse managers on; wound treatments, wound prevention, assessing skin, receiving and implementing wound care orders, reporting any wound changes to the DON and Physician, reporting abnormal labs and diagnostic test results to the DON and Physician, and documenting wound care. Start Date: [DATE] End Date: [DATE] Who is Responsible: Nurse Managers Who will Monitor: DON The DON initiated in-service on [DATE] with licensed nursing staff on the wound care treatments, assessing skin, receiving, and implementing wound care orders, reporting any wound changes, following, and reporting abnormal lab and diagnostic test results, and documenting wound care. The facility will continue to be in service until 100% of the nursing staff have received in-servicing. PRN and agency staff will be in service prior to their next scheduled shift and provide care to the residents. Start Date: [DATE] End Date: [DATE] Who is responsible: DON Who will Monitor: Administrator The DON initiated in-services on [DATE] with licensed nurses, CNAs, and MAs, on pressure injury prevention including reporting any skin changes to the licensed nurse. The facility will continue to be in service until 100% of the nursing staff have completed the training. PRN and agency staff will be in-serviced prior to the start of their next scheduled shift and prior to providing care to residents. Start Date: [DATE] End Date: [DATE] Who is Responsible: DON/Nursing Managers Who will Monitor: Administrator Starting on [DATE] all newly hired licensed nurses will be in-serviced by DON/Nurse Managers during the orientation process prior to providing care to residents on wound care, skin assessments, receiving, and implementing wound care orders, reporting any wound changes, following, and reporting labs and diagnostic test results, when to notify the DON and physician of changes and documenting wound care. Start Date: [DATE] End Date: Ongoing Who is Responsible: DON/Nurse Managers Who will Monitor: Administrator Starting on [DATE] all newly hired nursing staff including certified nurse aides, medications aides, and licensed nurses will be in-serviced by DON/Nurse Managers during the orientation process on pressure injury prevention to include but not limited to turning and repositioning, incontinent care, offloading, nutrition, reporting skin discolorations or any skin changes. Start Date: [DATE] End Date: Ongoing Who is Responsible: DON/Nurse Managers Who will Monitor: Administrator How will the system be monitored to ensure compliance? DON or designee will audit the wound system and labs/diagnostics weekly to ensure residents with wounds have necessary treatment and services initiated and followed, and any wound with decline will be evaluated for signs and symptoms of infection. Any decline in wounds will be reported immediately to the physician for evaluation and a treatment plan. The DON and Administrator will make bi-weekly random rounds starting on [DATE] to ensure residents at risk for skin injuries are proactively turned and repositioned, toileted, and nutritional needs addressed to prevent wounds. This will continue for the next two months or until further recommendations by the QAPI process. Weekly skin assessments will be completed on residents residing in the facility. The DON or designee will conduct a weekly skin meeting to review current wounds in the facility to monitor for healing or worsening wounds and the physician will be notified of any concerns for further orders. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director reviewed and agreed with this plan. Monitoring for Plan of Removal was completed from [DATE] - [DATE] as follows: In an interview on [DATE] 09:30 AM DON stated they have initiated a change on the weekend for the week supervisor to do treatments for all wounds. She stated the treatment nurse was on call this weekend for treatments and is doing them today. She stated the charge nurses would no longer be responsible for wound care on the weekends. In an interview on [DATE] at 10:12 AM LVN charge nurse on 500 & 600 hall stated she had been in-serviced on wound management and the new protocol that the weekend supervisor would be doing wound care on the weekend. Observation on [DATE] at 10:15 AM revealed the TREATMENT NURSE was performing a treatment on Resident #66 with no concerns noted during the treatment. Review of IJ in-service training on [DATE] reflected a one on one with CSD RN and the DON which reflected training in wound care and assessment. Wounds were to be reviewed by the DON in clinical meetings to ensure orders were implemented and followed. Any decline in wounds would be further assessed and evaluated and to ensure all preventive measures were implemented and followed. In an in interview on [DATE] at 10:30 AM the DON stated her training reflected she was knowledgeable about the new process and verbalized understanding of the importance of monitoring the wound care nurse assessment but also monitoring the documentation from the wound care physician to ensure the wound care nurse and the physicians assessments were accurate. Orders were to be carried out and changes in condition were to be monitored and reported. Review of IJ in-service training on [DATE] for the TREATMENT NURSE reflected he was in-serviced by the DON regarding completion of wound care and notifying the MD of wound declines and if the wound care MD was not available, the Primary MD must assess the wounds weekly and the assessment of the wounds must be completed weekly. Any changes in wound would be reported to the DON promptly. In an interview with the TREATMENT NURSE on [DATE] at 11:58 AM he verbalized understanding of the above. Review of IJ in-service training dated [DATE] regarding stop and watch related to CNAs reporting all changes in condition including wound odor must be competed and preventative measures must be checked and in place for residents. Interviews on [DATE] with CNA Q, CNA R, CNA S, CNA T, and CNA U stated they received training on the stop and watch program and verbalized understanding of when changes should be reported. Observation [DATE] at 12:07 PM revealed the DON trained CNA V on the stop and watch procedures in the EMR and regarding reporting changes in condition and sending alerts to her. The DON trained CNA V notifying nursing of resident changes she covered preventative measures and ensuring they are in place. CNA V verbalized understanding. Observation and interview on [DATE] at 12:20 PM revealed Resident #42 in bed and he stated he received his wound care treatment to his right heel. His his heel boot was in place. Resident #42 stated he had no pain. Observation and interview on [DATE] at 12:30 PM revealed Resident #89 in room in bed on an air mattress. RP at bedside stated she had received her wound care treatment and was getting ready for lunch with resident and RP had no concerns. Observation and interview on [DATE] at 12:35 PM revealed Resident #79 in room in bed on air mattress. Observation of his coccyx wound revealed dressing D&I dated [DATE]. Review of QA&A Committee Minutes dated [DATE] revealed QA&A committee members held an ad hoc QAPI meeting regarding the IJ for 686 and the plan of removal. The meeting included the ADMIN, MEDICAL DIRECTOR, the DON, the CSD RN, and the regional director of operations. Review of 1 on 1 In-Service Record dated [DATE] revealed the DON, the ADMIN and TREATMENT NURSE were inserviced by the CSD RN regarding weekly skin integrity reviews to be completed by TREATMENT NURSE by a schedule per hallway. Any new skin issues will be immediately reported to the MD/DON for new orders to be placed. If there was another skin integrity review that a nurse had placed that was not accurate the findings should be reported to the DON promptly. Review of On Call Schedule 2023 revealed on call nurses designated each weekend for the remainder of 2023 and will complete wound care on the weekends. In an interview on [DATE] at 2:10 PM , LVN E stated she received training regarding the on call nurse will complete wound care on the weekends. She stated if a resident had a new skin issue or decline in a wound she would contact the doctor immediately and notify the DON. She stated aides were to notify the charge nurses immediately if a resident had a change in a wound or a new skin issue. In an interview on [DATE] at 2:30 PM, LVN G stated she received training on new skin issues or decline of a wound and would notify the MD or the DON. She stated the weekend on call nurse would be completing the wound treatments and charge nurses would no longer be responsible for wound care on the weekends. In an interview on [DATE] at 2:45 PM, the ADMIN stated he received training on the wound care protocol and what nursing staff should do if a resident experienced a change in condition or decline of a wound. He stated the wounds would be monitored by the DON and they would review in clinical meetings weekly. On [DATE] at 11:00 AM, the ADMIN was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.