**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #1) of three residents reviewed for injuries. The facility failed when CNA A did not ensure Resident #1 was medically assessed before picking up Resident #1 off the floor after she fell off the bed and CNA A left her unattended and misaligned in bed on 09/07/2024. Resident #1 sustained a femur fracture and her feeding tube was dislodged as a result of the fall. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. This failure could place residents with any acquired injury at risk for complications. Findings included: Record review of Resident #1's admission record dated 04/12/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses of cerebrovascular disease (stroke), and hemiplegia (paralysis) of right dominant side. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 which meant moderate cognitive impairment and was dependent on staff for ADLs. Record review of Resident #1's care plan initiated 01/04/2021 and revised on: 06/20/2023 revealed Resident #1 has an ADL self-care performance deficit. Goal: Resident #1 will maintain current level of function in (ADLs) through the review date. Bed mobility: Elder requires substantial max assist by staff to turn and reposition in bed (every 2 hours) and as necessary. Elder requires total dependence on staff with dressing. Personal hygiene: Elder requires substantial max assistance with personal hygiene. Elder requires dependent by staff for toileting. Transfer: Elder is dependent with transfers with staff assistance for transfers. Record review of local hospital emergency room records dated 10-Sep-2024 revealed Right distal femur nondisplaced fracture. Nonsurgical management of nondisplaced femoral fracture. Orthopedic surgery evaluated your fracture and recommended non-operative management. You will need to keep your brace on at all times. Frequently check the skin under your brace for skin breakdown. You will need a Hoyer lift to get into your wheelchair, which should have an elevated rest for your right leg. Primary Impression: Right femoral fracture Secondary Impressions: Fall, Malfunction of percutaneous endoscopic gastrostomy (PEG) tube. Disposition. Reason For Visit: Right Femoral Fracture Problems: Malfunction of gastrostomy tube. Onset: 7-Sep-2024. Impression By: Procedures PEG Tube Replacement. Observation of the in-room surveillance video dated 09/07/24 revealed the clock on the wall, located directly in front of Resident #1, showed a time of approximately 8:22, when CNA A was observed to be providing Resident #1 perineal/incontinent care while on her left side. Resident #1 was awake, was seen to move her arms and independently held the grab bars of the bed. Resident #1 had a sleeveless shirt on, but no pants or brief were on. CNA A instructed Resident #1 to roll this way indicating to her right side. Resident #1 was seen to initiate the task slowly and independently, and as Resident #1 was in a face up position, CNA A assisted in turning her to her right side. After providing personal hygiene, CNA A asked Resident #1 to turn (to her left side) and again Resident #1 initiated the task and held on to the left side of bed grab bar with both hands. Resident #1's pelvic area was observed to be at the center of the bed however, her legs were slightly bent forward, not in alignment with her pelvis. While on her left side, Resident #1's thighs were on top of each other while her right foot was behind her left foot. The video showed Resident #1 slowly repositioned her right foot over and in front of her left foot, closer to the edge of the bed. After CNA A removed the fitted bed sheet from the right upper corner of the bed, Resident #1's right leg/foot was seen slipping forward. When CNA A loosened the rest of the right side fitted bed sheet and removed the fitted sheet off the right foot of the bed, Resident #1's right leg was no longer seen on the bed. While Resident #1's right leg dangled off the bed, CNA A was seen rolling and tucking Resident #1's right side sheets toward and behind Resident #1's body. A couple of seconds later, CNA A turned around with his back to Resident #1 and then moved out of video footage, at the same time, Resident #1's right leg dangled off the bed and her left leg was seen slipping off the bed. Once Resident #1's both legs dangled down off the bed, her entire body fell off the bed. Resident #1 was seen to hit her head on the left grab bar of the bed and the left side table. CNA A immediately walked toward Resident #1, carried her off the floor and sat her on the edge of the bed then reached his right hand into his right pocket and pulled out his phone while he held on to Resident #1 with his left hand. Attempted phone interview with CNA A on 04/12/2025 at 4:22 PM, 04/13/2025 at 9:41AM, and 1:07PM. CNA A did not return call prior to exit conference. During a phone interview on 04/12/2025 at 6:39 PM, LVN A stated CNA A notified him that Resident #1 had fallen out of bed and was found on the floor. LVN A stated when he arrived in Resident #1's room, she was not on the floor, but on her bed. LVN A stated he asked CNA A why Resident #1 was on the bed, given that CNA A had just notified him that Resident #1 was found on the floor. LVN A stated CNA A stated, I couldn't just leave her like that. LVN A stated he notified CNA A that Resident #1 should not have been moved prior to LVN A's physical head-to-toe evaluation, as an attempt to ensure that if Resident #1 had sustained an injury, the injury would not be exacerbated by additional movement. LVN A stated CNA A should have engaged the emergency light system that was connected to the call light system and should have waited for LVN A to arrive to conduct a physical assessment on Resident #1. LVN A stated CNA A could have compromised Resident #1's wellbeing by picking her up prior to LVN A's head-to-toe evaluation. LVN A stated he was not given access to the video regarding Resident #1's incident. LVN A stated he did not observe any skin irregularities but given that Resident #1 sustained an unwitnessed fall he sent her for evaluation and treatment to an emergency room. LVN A stated CNA A no longer was employed with the facility. During an interview on 04/12/2025 at 5:02 PM, the DON stated she was made aware of the incident by not only LVN A, but the previous administrator. The DON stated the previous administrator allowed her to watch the evidentiary video regarding Resident #1 from his phone that was not facility owned footage. The DON stated she observed CNA A enter Resident #1's room, followed by CNA A lifting Resident #1 to her bed from the floor. The DON stated the expectation was for all clinical staff to follow facility protocols regarding fall management. The DON stated CNA A should have left Resident #1 on the floor, notified LVN A of the situation, waited for LVN A to arrive to conduct a head-to-toe evaluation, then follow LVN A's directive. The DON did not give a definitive answer as to what potentially could have occurred given that CNA A did not follow fall management protocol. The DON stated in her professional opinion, the reason residents are not moved prior to physical evaluation by the nurses, is to minimize any exacerbation of initial injury. The DON stated LVN A conducted the physical head-to-toe assessment on Resident #1 and did not note any skin irregularities, but due to her unwitnessed fall, she was sent to the emergency room for evaluation and possible treatment. The DON stated CNA A was no longer employed by the facility . In a subsequent interview with the DON on 04/23/2025 at 1:33 pm, who said she viewed footage from Resident #1's in-room camera the previous ADM showed her. She said the footage she saw cut off just before Resident #1 fell off the bed. She said Resident #1 was in her bed and CNA A was repositioning and performing peri care and he stepped away to grab supplies and it was at that time Resident #1 fell off the bed and suffered a fracture. She said Resident #1 was sent to the hospital and did not return to the facility. She said Resident #1 passed away about a month later. She said one of Resident #1's family members told them about her passing. She said CNA A had at least competency training once a year. She said CNA A was qualified for the job of repositioning and performing peri care. She said the previous ADM had a 5-point questionnaire that he asked, and it was in the investigation file. She said the facility conducted various in-services and computer-based training throughout the year in addition to yearly competencies. She said she and the ICP nurse spot checked hand washing, donning and doffing PPE, and dressing changes, but not repositioning. She said there was no specific policy or guideline for 1 or 2 person assists. She said staff utilized a census sheet with specifics for each resident and said if someone was a 1 or 2 person assist, it would be on the census sheet. She said the census sheets were saved on the nurse's computers as live documents and could be accessed by any staff member to modify or add to it. She said there was no way to retrieve past census sheets because the information in them was deleted with every discharge. She said the census sheet was not generated by the electronic charting system, it was an internal document that populated from resident's care plans. She said CNA A was not referred to the NAR (Nurse Aide Registry) that she knew of. In an interview with the ADM on 04/23/25 at 3:05 pm, she said the nursing team led all staff in-services and training, including monitoring after the incident. She said CNA A was fired. In a phone interview with MD on 04/24/2025 at 9:02 am, he said he remembered Resident #1 had a fall and he was notified. He said he did not know Resident #1's outcome because she did not return to the facility. He said Resident #1 was a lovely lady. He said since she hit her head, and broke her femur, an embolism from the long bone fracture could have caused the code at the local post-acute hospital. He said this incident may have exacerbated or caused the outcome or influenced Resident #1's death. He said Resident #1 was quite frail. He said when older people break their femur and cannot get it fixed, they generally do not do well. In a subsequent interview with LVN A on 04/24/2025 at 2:52 pm, he said he was the charge nurse on 09/07/2024 and was in the hall. He said CNA A called his phone to tell him that the Resident #1 had fallen off or rolled off the bed and assumed he meant she was on the floor. He said when he entered Resident #1's room, she was in the bed, not on the floor. He asked CNA A why he moved Resident #1. He said CNA A told him he did not want to leave her on the floor. LVN A said he did not know what CNA A was thinking. LVN A said he assumed CNA A was trained on not moving residents who had fallen or were on the floor because they could have a cervical (neck) injury, or some other injury. He said Resident #1 was normally pretty with it and alert. He said Resident #1 was groggy on his 1st encounter of seeing her on the bedside and could not tell him what happened. He said he noticed CNA A should not have picked Resident #1 up. He said CNA A was reluctant to follow directions. He said CNA A would boast about being a CNA A for 20-30 years. Record review of the facility's 09/07/2024 in-service regarding topics Abuse and Neglect, Reporting injuries of unknown origin, and fall prevention was facilitated ensue of the 09/07/2024 event and revealed CNA A was in attendance. The following staff from the morning and evening shifts were interviewed on the below policies and procedures and in-services: 3 RN's, 4 CNA's, 2 CMA's, 3 HSK, and 2 LVN's . All staff were able to verbalize the identification of abuse, neglect, and exploitation as well as the policies and procedures as per the trainings listed below. Record review of facility documents revealed the following in-services: 06/23/24, 08/13/24, 08/23/24, 09/07/24 Abuse & Neglect; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 07/19/24, 09/07/24, 03/04/25, 04/21/25 Infection Control and Handwashing; To keep staff and resident's safe, not spread germs or infect someone who is not able to fight it off, Different types of isolation-contact isolation for c-diff is important because it can live outside the body for a very long time-that's why you have to use soap and water to clean your hands not just sanitizer. 07/31/24 Never Turn a Hip fracture to the affected side without specific orders; use the log roll method and make sure the resident is in a neutral position (aligned straight) on their back. Have sufficient pillows-minimum of two: between the thighs/knees to avoid misalignment which could cause pain, spasms, or dislocation. 08/13/24, 09/07/24 Injuries of Unknown Origin; reporting bruises, new pain, skin tears, redness, scratches, etc. right away to the nurse and/or administrator. Document. 09/07/24 Dignity; Respect at all times, permission to enter rooms and knocking first, not talking about residents to each other in the hall or elsewhere, keeping computers private, privacy especially when providing personal care-bathing, changing clothes or briefs or wound care, privacy bags on catheter bags. 12/20/24 Transfer Training; Proper use of mechanical lift-2 person at all times, sling straps must be double checked, how to maneuver the lift, resident safety is high priority-all instructions and education must be followed by each staff member. 12/26/24, 01/13/25, 03/05/25 Identifying and Reporting Types of Abuse; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 09/07/24, 01/29/25, 03/04/25 Hand Hygiene; Done before providing care. The number one thing to help prevent spreading germs, everyone has to do it-no exceptions, you can use hand sanitizer unless you know your hands are dirty or if it's c-diff, then you have to use soap and water. Sanitize before and after going in and coming out of the room, if you touch anything in the room and are going to touch the resident or their belongings. You have to lather for at least 20 seconds and use the towel you dry your hands with to turn off the faucet. 02/27/25 Gait Belts; Labeled with each room number for the resident in that room only. They will be sanitized as needed. 09/07/24, 03/04/25 PPE; gowns, gloves, eye protection and face mask. Use it when you do peri care, catheter care, if there's a feeding tube, an IV line, any dressing changes, and isolation. First, you wash your hands, then put on the gown, then the mask, then the eye protection then the gloves last. To take it off, reverse the order. 03/31/25 Foley Catheter care; Clean the catheter and surrounding area skin each shift to prevent bacteria build-up. Drainage bag must always be below the level of the bladder to avoid back flow and always have a privacy bag on the reservoir. Bags should never be touching the floor or placed on the bed. Check for kinks in the tubing. Clean the catheter with every incontinent episode or after toileting. Notify the charge nurse if there are any concerns. 09/07/24 Peri Care; PPE, wash your hands before you start, have all your supplies ready so you don't have to step away from the bedside, keep the resident covered so they don't get cold or if someone walks in, change gloves before you go from clean to dirty, on ladies, wipe from top to bottom and inside to outside, document and let the charge nurse know if you find anything new. 09/07/24 C-Diff; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. 09/07/24, 04/12/25 Falls and Falls with Injury; Fall risk factors such as wet floors, not having non-slip shoes or socks, when they need to go to the bathroom, UTI's (urinary tract infections), some medications, weakness, thinking they can when they can't get up on their own, using 2-person assistance when indicated 04/22/25 Norovirus; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. CNA A's signature was noted on all in-services dated from 06/23/24 to 09/07/24 . Record review of CNA A's yearly competency skills dated 02/24/24 revealed he met competency for Fall Prevention, Peri Care. Record review of CNA A's personnel file revealed a document titled, Understanding Job Expectations dated 09/02/24 revealed CNA A had been reported not using correct hand hygiene when providing resident care. Also noted at times not wearing proper PPE while providing resident care. CNA A was to ensure to wear gloves while providing resident care and ensure to use proper hand hygiene. The document was signed and dated by CNA A on 09/02/24. There were no other disciplinary actions documented in CNA A's personnel file. There was no documentation of CNA A's termination date. An email received from the present ADM stated, CNA A's termination was a progressive process. Our Administrator at the time spoke with him one on one following the incident. After this, we increased supervision of the care provided by providing spot checks. Then, we began to notice gaps in CNA A's performance, so we followed our companies progressive process and moved to term with his last day worked being 12/30/2024. Record review of the facility's Assessing Falls and Their Causes revision dated March 2018 documented, Steps in the Procedure After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accident hazards and supervision on 09/07/24. The facility failed to identify and eliminate a foreseeable fall. CNA A left Resident #1 unattended and did not ensure her body was positioned in a safe manner when providing incontinent care resulting in Resident #1 falling off her bed, sustaining a femur fracture, and her feeding tube to be dislodged. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. This failure could affect residents by placing them at risk for falls, injury, major injury, or death. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Diagnoses included cerebrovascular disease, metabolic encephalopathy (a brain disorder caused by problems with the body's chemistry or metabolism such as liver or kidney disease, nutritional deficiencies .), gastrostomy status (feeding tube), dominant right sided weakness, dysphagia (difficulty swallowing), esophageal stricture (narrowing), malnutrition, abnormal posture, rheumatoid arthritis, seizures, and history of traumatic brain injury. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS Score of 12 indicating moderate cognitive impairment and required substantial assistance with oral and personal hygiene, rolling left or right, sitting up or down, lying to sitting on side of bed, and was dependent or required extensive assistance with toileting, showering, upper and lower body dressing, footwear, and all transfers. She was always incontinent of bladder and bowel. Record review of Resident #1's care plan dated 08/29/24 revealed Resident #1 was dependent on staff assistance for transfers and all ADL's (Activities of Daily Living). o Resident #1 has become more active with activities Date Initiated: 07/15/2021 Revision on: 08/24/2022. o Resident #1 needs assistance/escort to activity functions. Date Initiated: 07/15/2021. Resident #1 has an ADL self-care performance deficit Date Initiated: 01/04/2021 Revision on: 06/20/2023. Resident #1 will maintain current level of function in (ADLs) through the review date. Date Initiated: 01/04/2021. Resident #1 has impaired cognitive function or impaired thought processes r/t short term memory loss Date Initiated: 02/21/2024. Resident #1 has an alteration in musculoskeletal status related to weakness. Date Initiated: 07/10/2024. Record review of PIR (Provider Investigation Report) interview questions dated 09/07/24 asked to CNA A by the previous ADM revealed: Did you witness the fall? answer: Yes, I did. She just shifted her weight and fell forward; she has never done that before. Did you leave the room completely and return to find her on the floor? answer: No, I was in the room, just went to the closet. Why did you pick her up? answer: I didn't know what to do. My first thought was to just help her right away. Why didn't you cover her up? answer: I was just grabbing the sheets from the closet, so I didn't plan on leaving her in that position, I was going to change her sheets right at that moment and continue care. Record review of local hospital emergency room records dated 10-Sep-2024 revealed Right distal femur nondisplaced fracture. Nonsurgical management of nondisplaced femoral fracture.Orthopedic surgery evaluated your fracture and recommended non-operative management. You will need to keep your brace on at all times. Frequently check the skin under your brace for skin breakdown. You will need a Hoyer lift to get into your wheelchair, which should have an elevated rest for your right leg. Primary Impression: Right femoral fracture Secondary Impressions: Fall, Malfunction of percutaneous endoscopic gastrostomy (PEG) tube. Disposition. Reason For Visit: RT FEMORAL FX Problems: Malfunction of gastrostomy tube. Onset: 7-Sep-2024. Impression By: Procedures PEG Tube Replacement. Observation of the personal in-room surveillance video dated 09/07/24 revealed the clock on the wall, located directly in front of Resident #1, showed a time of approximately 8:22 (am or pm not identified), when CNA A was observed to be providing Resident #1 perineal/incontinent care while on her left side. Resident #1 was awake, was seen to move her arms and independently held the grab bars of the bed. Resident #1 had a sleeveless shirt on, but no pants or brief were on. CNA A instructed Resident #1 to roll this way indicating to her right side. Resident #1 was seen to initiate the task slowly and independently, and as Resident #1 was in a face up position, CNA A assisted in turning her to her right side. After providing personal hygiene, CNA A asked Resident #1 to turn (to her left side) and again Resident #1 initiated the task and held on to the left side of bed grab bar with both hands. Resident #1's pelvic area was observed to be at the center of the bed however, her legs were slightly bent forward, not in alignment with her pelvis. While on her left side, Resident #1's thighs were on top of each other while her right foot was behind her left foot. The video showed Resident #1 slowly repositioned her right foot over and in front of her left foot, closer to the edge of the bed. After CNA A removed the fitted bed sheet from the right upper corner of the bed, Resident #1's right leg/foot was seen slipping forward. When CNA A loosened the rest of the right side fitted bed sheet and removed the fitted sheet off the right foot of the bed, Resident #1's right leg was no longer seen on the bed. While Resident #1's right leg dangled off the bed, CNA A was seen rolling and tucking Resident #1's right side sheets toward and behind Resident #1's body. A couple of seconds later, CNA A turned around with his back to Resident #1 and then moved out of video footage, at the same time, Resident #1's right leg dangled off the bed and her left leg was seen slipping off the bed. Once Resident #1's both legs dangled down off the bed, her entire body fell off the bed. Resident #1 was seen to hit her head on the left grab bar of the bed and the left side table. CNA A immediately walked toward Resident #1, carried her off the floor and sat her on the edge of the bed then reached his right hand into his right pocket and pulled out his phone while he held on to Resident #1 with his left hand. In an interview with the ADM on 04/22/2025 at 1:15 pm, she said the FRI (Facility Reported Incident) was cited for falls because CNA A picked Resident #1 up off the floor. Incidentally, he was immediately suspended then terminated because of this incident and for not following policies for peri care/positioning. The ADM said she was not here at the time of the incident on 09/07/24-she started on 12/30/24. She said there was an active lawsuit against the facility at this time. She said they have not yet gone to litigation. She believed they were going to mitigation this summer. In an interview with the ICP/ADON on 04/22/2025 at 1:45 pm, said she had worked here for more than 12 years and almost 4 years as ICP. She said annual competencies included infection control, fall prevention, hand washing, peri care, transfers, etc. She said she had corrected, documented, and educated CNA A 1:1 on several occasions regarding infection control and peri care, but this incident was the last straw. She said he would pass his annual competencies without any problems, but when no one was there to watch him, implying he would not properly use PPE. In an interview with the DON on 04/23/2025 at 1:33 pm, she said she had worked at the facility for 6 years. She said she viewed footage from Resident #1's personal in-room camera the previous ADM showed her. She said the footage she saw cut off just before Resident #1 fell off the bed. She said Resident #1 was in her bed and CNA A was repositioning and performing peri care and he stepped away to grab supplies and it was at that time Resident #1 fell off the bed and suffered a fracture. She said Resident #1 was sent to the hospital and did not return to the facility. She said Resident #1 passed away about a month later. She said one of Resident #1's family members told them about her passing. She said CNA A had at least competency training once a year. She said CNA A was qualified for the job of repositioning and performing peri care. She said the previous ADM had a questionnaire that he asked, and it was in the investigation file. She said the facility conducted various in-services and computer-based training throughout the year in addition to yearly competencies. She said she and the ADON nurse spot checked hand washing, donning and doffing PPE, and dressing changes, but not repositioning. She said there was no specific policy or guideline for 1 or 2 person assists. She said staff utilized a census sheet with specifics for each resident and said if someone was a 1 or 2 person assist, it would be on the census sheet. She said the census sheets were saved on the nurse's computers as live documents and could be accessed by any staff member to modify or add to it. She said there was no way to retrieve past census sheets because the information in them was deleted with every discharge. She said the census sheet was not generated by the electronic charting system, it was an internal document that populated from resident's care plans. She said CNA A was not referred to the NAR (Nurse Aide Registry) that she knew of. In an interview with the ADM on 04/23/25 at 3:05 pm, she said the nursing team led all staff in-services and training, including monitoring after the incident. She said CNA A was fired. In a phone interview with MD on 04/24/2025 at 9:02 am, he said he remembered Resident #1 had a fall and he was notified. He said he did not know Resident #1's outcome because she did not return to the facility. He said Resident #1 was a lovely lady. He said since she hit her head, and broke her femur, an embolism from the long bone fracture could have caused the code at the local post-acute hospital. He said this incident may have exacerbated or caused the outcome or influenced Resident #1's death. He said Resident #1 was quite frail. He said when older people break their femur and cannot get it fixed, they generally do not do well. In an interview with LVN A on 04/24/2025 at 2:52 pm, he said he recalled seeing CNA A in Resident #1's room without PPE. He said he was the charge nurse that day and he was in the hall. He said CNA A called his phone to tell him that the Resident #1 had fallen off or rolled off the bed and assumed he meant she was on the floor. He said when he entered Resident #1's room, she was in the bed, not on the floor. He asked CNA A why he moved Resident #1. He said CNA A told him he did not want to leave her on the floor. LVN A said he did not know what CNA A was thinking. LVN A said he assumed CNA A was trained on not moving residents who had fallen or were on the floor because they could have a cervical (neck) injury, or some other injury. He said his findings during his assessment of Resident #1 were no peg tube (feeding tube), and pain to her right upper leg, and she was groggy. He said Resident #1 was normally pretty with it and alert. He said Resident #1 was groggy on his 1st encounter of seeing her on the bedside and could not tell him what happened. He said he noticed CNA A should not have picked Resident #1 up. He said Resident #1 was on contact isolation at the time for c-diff. He said signage & PPE was outside the door of her room. He said CNA A did not have PPE on. He said we (staff) got trained on infection control and PPE-we just had one (in-service/training) within the last few weeks and last month. He said CNA A had gloves on. He said he knew about the in-room camera. He said he would not be surprised that CNA A did not change his gloves if he forgot the PPE for a contact isolation room for C-Diff and was performing incontinent care. He said CNA A was reluctant to follow directions. He said CNA A would boast about being a CNA A for 20-30 years. LVN A said if he saw staff not wearing proper PPE, he re-educated them on the spot and informed the ICP. The following staff from the morning and evening shifts were interviewed throughout the investigation from 04/22/25-04/25/25 on the below policies and procedures and in-services: 3 RN's, 4 CNA's, 2 MA's, 3 HSK, and 2 LVN's . All staff were able to verbalize the identification of abuse, neglect, and exploitation as well as the policies and procedures as per the trainings listed below. Record review of facility documents revealed the following in-services: 06/23/24, 08/13/24, 08/23/24, 09/07/24 Abuse & Neglect; Identifying abuse as defined as willful, Types of abuse included physical, mental/verbal, Sexual/unwanted touching. 07/19/24, 09/07/24, 03/04/25, 04/21/25 Infection Control and Handwashing; To keep staff and resident's safe, not spread germs or infect someone who is not able to fight it off, Different types of isolation-contact isolation for c-diff is impoortant because it can live outside the body for a very long time-that's why you have to use soap and water to clean your hands not just sanitizer. 08/13/24, 09/07/24 Injuries of Unknown Origin; reporting bruises, new pain, skin tears, redness, scratches, etc. right away to the nurse and/or administrator. Document. 09/07/24 Dignity; Respect at all times, permission to enter rooms and knocking first, not talking about residents to each other in the hall or elsewhere, keeping computers private, privacy especially when providing personal care-bathing, changing clothes or briefs or wound care, privacy bags on catheter bags. 09/07/24, 01/29/25, 03/04/25 Hand Hygiene; Done before providing care. The number one thing to help prevent spreading germs, everyone has to do it-no exeptions, you can use hand sanitizer unless you know your hands are dirty or if it's c-diff, then you have to use soap and water. Sanitize before and after going in and coming out of the room, if you touch anything in the room and are going to touch the resident or their belonging's. You have to lather for at least 20 seconds and use the towel you dry your hands with to turn off the faucet. 09/07/24, 03/04/25 PPE; gowns, gloves, eye protection and face mask. Use it when you do pericare, catheter care, if there's a feeding tube, an IV line, any dressing changes, and isolation. First, you wash your hands, then put on the gown, then the mask, then the eye protection then the gloves last. To take it off, reverse the order. 09/07/24 Peri Care; PPE, wash your hands before you start, have all your supplies ready so you don't have to step away from the bedside, keep the resident covered so they don't get cold or if somone walks in, change gloves before you go from clean to dirty, on ladies, wipe from top to bottom and inside to outside, document and let the charge nurse know if you find anything new. 09/07/24 C-Diff; highly contagious. Can cause nausea, vomiting, diarrhea and/or fever. Hand washing with soap and water is essential. 09/07/24, 04/12/25 Falls and Falls with Injury; Fall risk factors such as wet floors, not having non-slip shoes or socks, when they need to go to the bathroom, UTI's (urinary tract infections), some medications, weakness, thinking they can when they can't get up on their own, using 2 person assistance when indicated CNA A's signature was noted on all in-services dated from 06/23/24 to 09/07/24 . Record review of CNA A's yearly competency skills dated 02/24/24 revealed he was competent to perform Infection Control/PPE, Fall Prevention, Handwashing, Peri Care, Foley Catheter care, Diet Textures, Transfers and Gait Belt, and N95 Fit testing. Record review of CNA A's personnel file revealed a document titled, Understanding Job Expectations dated 09/02/24 revealed CNA A had been reported not using correct hand hygiene when providing resident care. Also noted at times not wearing proper PPE while providing resident care. CNA A was to ensure to wear gloves while providing resident care and ensure to use proper hand hygiene. The document was signed and dated by CNA A on 09/02/24. There was no other disciplinary actions documented in CNA A's personnel file. There was no documentation of CNA A's termination date. An email received from the present ADM stated, CNA A's termination was a progressive process. Our Administrator at the time spoke with him one on one following the incident. After this, we increased supervision of the care provided by providing spot checks. Then, we began to notice gaps in CNA A's performance so we followed our companies progressive process and moved to term with his last day worked being 12/30/2024. Record review of nurse's note evaluations dated 08/15/24 at 12:01 am revealed Resident #1 had no decrease in food intake or weight loss in the last 3 months. Resident #1 was bed or chair bound, had not suffered psychological stress or acute disease in the past 3 months. Resident #1 had severe dementia or depression. Resident #1 was cooperative with transfers but not cooperative with repositioning. Resident #1did not have upper extremity strength, was not able or partially able to assist with transfers from bed to bed. Resident #1 was partially able to assist with repositioning in bed, but not able to assist with repositioning in chair. Resident #1 had parts of her body that lacked sensation. Record review of lab results dated 08/30/24 revealed Resident #1 was positive for c-diff. Record review of nurse's notes dated 09/07/24 at 8:30 am revealed Resident #1 had a witnessed fall at 8:20 am. CNA A called nurse that resident was on the floor. Nurse gowned and entered room with resident. CNA A in front of resident with resident sitting on the side of the bed. PEG tube (feeding tube) was not in place. Resident noted in a daze and was not responding while being conscious. Resident #1 was then repositioned by CNA A. Resident #1 states she rolled out of bed. Did not hit head, complained of pain to right leg. Nurse upon entering room Resident #1 noted in bed after fall. Assessed vital signs, Checked Range of motion, Assessed pain to upper extremities and lower extremities. Pain noted to right hip. 8/10. Blood Pressure:154/64 Pulse:73 Oxygen saturation: 93% Respiratory rate; 18. Peg tube site noted blood. PEG tube was removed during fall. Resident #1 did speak to notify of pain to leg. Notified MD at 8:38 am, Daughter at 8:40 am to 8:43 am till answered. Notified DON, ADON. Called 911 and sent to local ER per family request. Resident #1 picked up 9:03 am. Report called to at 9:06 am. Record review of the facility policy revised August 2021, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of the facility policy revised March 2018, titled, Falls and Fall Risk, Managing under Fall risk Factors 2. Resident conditions that may contribute to the risk of falls include b. infection, c. delirium and other cognitive impairment, e. lower extremity weakness, k. incontinence. 3. Medical factors that contribute to the risk of falls included d. neurological disorders e. balance and gait disorders. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to consult/ notify the physician when the resident experienced a significant change in their physical status for one (Resident #1) of five residents reviewed for physician notification of changes. The facility failed to consult with/notify the physician after Resident #1 displayed significant changes in condition on 05/06/24 such as lethargy, vomiting, a decrease of oxygen saturation of 85%, irregular lung sounds and after requiring resuscitation efforts. Resident #1 expired on 05/06/24. On 05/24/24 at 4:45 PM, an immediate jeopardy was identified. While the IJ was removed on 05/25/24 at 2:35 PM, the facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of a delay in medical treatment, decline in health, and/ or death. Findings included: Record Review of Resident #1's admission Record revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included fracture of the ilium (the large bones of the pelvis/ the hip bones), pubis (the bottom part of the hip bones in the center of the pelvis), and the sacrum (the large triangular bone at the base of the spine), falls, atrial fibrillation (irregular heart beat), heart failure, cardiac pacemaker (a small, battery powered device that helps the heart beat in a normal rate and rhythm), and generalized muscle weakness. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed a BIMS score of 14, which indicated that Resident #1 was cognitively intact. Resident #1 required partial/moderate assistance with personal hygiene, bed mobility, laying to sitting, sitting to standing, chair/bed transfer, toilet transfer, and tub/shower transfer. Resident #1 required substantial/ maximal assist with toileting hygiene, showering/ bathing self, upper and lower body dressing and putting on/ taking off shoes. Record Review of Resident #1's Skilled Nursing Note dated 05/06/24 at 7:35am indicated Resident #1 was alert and oriented x3 (able to answer at least 3 of the questions usually asked (name, place, time, situation) to assess a person's mental status and orientation), communicated verbally with clear speech, and was able to understand and be understood when speaking. Record review of Resident #1's Care Plan dated 04/17/24 and 04/19/24 revealed FOCUS: Resident #1 uses antidepressant medication (Paxil) r/t (related to) Depression initiated on 04/17/24. INTERVENTIONS included Monitor/document/report adverse reactions to antidepressant therapy: nausea/vomiting, fatigue, and appetite loss. FOCUS: Resident #1 has congestive heart failure (CHF) initiated on 04/19/24. INTERVENTIONS included monitor/document/report any signs/symptoms of congestive heart failure: dry cough, weakness and/ or fatigue, lethargy, and disorientation. FOCUS: Resident #1 has bladder incontinence r/t benign prostatic hypertrophy (enlarged prostate). INTERVENTIONS included Monitor/ document for signs/symptoms of UTI (urinary tract infection): increased temperature and altered mental status. Record review of Resident #1's progress notes revealed the following entries: (All entries created by RN A unless otherwise noted) Health Status Note- Effective: 05/06/24 at 4:30pm Created: 05/07/24 at 3:18pm Family member with patient, quite concerned about his lethargy. NP contacted and Paxil order discontinued. Nurse Advanced Skilled Evaluation- Effective: 05/06/24 at 5:00pm Created: 05/06/24 at 11:31pm Mental status: Resident #1 is lethargic. Oriented to person. Lethargic: new. Mood and Behavior: Resident#1 has flat affect. Flat affect- Recent change in mood. Nutrition: Decrease in fluid intake noted. Change in appetite noted. No signs or symptoms of possible swallowing disorder. Health Status Note- Effective: 05/06/24 at 6:00pm Created: 05/07/24 at 3:22pm This note is a follow up to: 05/06/24 at 4:30pm Health Status Note Patient's color is now pink. Still lethargic but talking with family member. Taking PO (by mouth) water well. Awaiting supper. Family member remains at bedside. Grips remain strong and equal. Opens eyes better, more vocal. Health Status Note- Effective: 05/06/24 at 6:36pm Created: 05/07/24 at 12:37am Family member here at bedside. Concerned about Resident #1s status. SBAR Summary for Providers- Created by LVN D- Effective: 05/06/24 at 6:49pm Created: 05/10/24 at 11:31am Situation: The change in condition reported on this CIC (change in condition) Evaluation are/were: Altered mental status. At the time of evaluation resident vital signs were Respiratory rate: 24, Temp 100.6. Outcomes of Physical Assessment: Positive findings reported on the resident evaluation of this change in condition were: Mental Status Evaluation: Altered level of consciousness. Functional Status Evaluation: Decreased mobility. Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: What do you recommend Health Status Note- Effective: 05/06/24 at 7:35pm Created: 05/06/24 at 11:15pm Called to patient's room. Patient choking on emesis and also coughing up partially digested drink from earlier in the evening. (Not currently eating or drinking anything.) Health Status Note- Effective 05/06/24 at 7:45pm Created: 05/07/24 at 3:31pm After briefly returning to the desk, checking texts for phone messages, doctor's recommendation-called directly back to room. Health Status Note- Effective: 05/06/24 at 7:48pm Created: 05/07/24 at 3:37pm Patient looking pale, encouraged to deep breathe, and cough. Following commands. Family member concerned, states that she does not want Resident #1 resuscitated if he should need it. States that she has the paperwork in her apartment in IL (Independent Living). Health Status Note- Effective: 05/06/24 at 7:51pm Created: 05/06/24 at 11:18pm Patient having difficulty coughing. O2 (oxygen) sat (saturation) drop to 85%. O2 brought into room at 4-6 l/min (liters per minute) via nasal cannula. Suction equipment brought to room. Health Status Note- Effective: 05/06/24 at 7:56pm Created: 05/07/24 at 3:46pm Losing all color, suction and respiratory breathing started. Family member remains adamant about not reviving him, however no paperwork reflects this in skilled paperwork. No out of hospital decisions on CPR/ -no code status. Resident #1's status is full code. Still has pain response. CPR started and heart resuscitation started. Pacemaker beats felt. Health Status Note- Effective: 05/06/24 at 8:00pm Created: 05/06/24 at 11:19pm CPR in progress. 911 called. Health Status Note- Effective: 05/06/24 at 8:05pm Created: 05/06/24 at 11:21pm CPR started by EMS after detecting pacemaker only functioning on patient's own rhythm. Health Status Note- Effective: 050624 at 8:06pm Created: 05/07/24 at 3:48pm Family member gone to apartment with second family member to obtain paperwork. She told EMS that she did not wish for CPR to be continued. Health Status Note- Effective: 05/06/24 at 8:37pm Created: 05/06/24 at 11:11pm All measures stopped at 8:37pm by EMS team. Last correspondence to the MD about Resident #1's condition was on 5/6/24 at 6:49pm and stated, Resident #1 had a cough and lethargy. On 5/6/24 at 6:58pm the MD responded; however the response was not seen by facility staff until after 8:37pm on 5/6/24. In an interview with the family member on 5/17/24 at 10:46am, the family member presented paperwork for Resident #1 that included a Living Will that stated Resident #1 would not want artificially supplied food and water or other life-sustaining procedures should he have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death. Family member presented an Out of Hospital Do Not Resuscitate Form for Resident #1, however it was not filled out or signed. The facility did not have a copy of Resident #1's Living Will and did not have a completed Out of Hospital DNR form. In an interview on 05/17/24 at 1:43pm, LVN B stated on 5/6/24, sometime before 8:00pm, she was getting things together for her hall when RN A told her that Resident #1's oxygen saturation was dropping and she was looking for an oxygen concentrator for him. LVN B stated RN A got a portable oxygen cylinder and went back to Resident #1's room. LVN B stated she finished putting stuff in her cart and locked it and went to Resident #1's room. LVN B stated when she walked into the room, RN A was on the opposite side of the bed with the pulse oximeter on Resident #1's hand that was closest to her. LVN B stated that Resident #1's breathing sounded like a boiling pot of water and that RN A told her the oxygen saturation was getting better. LVN B stated she told RN A that they should probably transfer Resident #1 to the hospital because he probably needed more suction than the facility could do. RN A told LVN B to call 911. LVN B stated she went out to the desk to call 911 so she would be able to read his information directly off the computer to the 911 operator. LVN B stated once she got off the phone with 911, she went back into the room to help with Resident #1. LVN B stated when the paramedics arrived, she left the room. In an interview on 05/17/24 at 2:21pm, RN A stated that on 5/6/24 at around 4:15 to 4:30pm, Resident #1's family member had told her that she was concerned about him because the last two days (the 5th and 6th) he had been more lethargic than she had noticed before and that he was not responding to her when she talked to him. RN A stated that she went in to check on Resident #1 and he did respond to her. RN A stated Resident #1 had one episode of nausea and vomiting around 5:00pm but then he was ok and drank some water. RN A stated that at about 7:35pm, Resident #1's family member came out to the nurse's station and asked RN A to come into Resident #1's room because she thought he was choking. RN A stated she had no doubt that Resident #1 aspirated because the head of his bed was down and he had vomited. RN A stated she put the head of the bed almost straight up and Resident #1 was projectile vomiting and was coughing. RN A stated at about 7:45pm, she thought that he was just about over it but then he started looking like he was not doing well, and his oxygen saturation was getting low in the 80s, so she went to get some oxygen and checked the message from the MD. RN A stated she did not take the phone with her back to the room. RN A stated that LVN B came into the room with the suction and crash cart. At approximately 8:00pm, LVN B went out to call 911 from the desk phone then went back into the room to help with CPR (Cardiopulmonary resuscitation). RN A stated the paramedics arrived at about 8:05pm and continued CPR and Resident #1's family members went to the wife's apartment on the independent living side of the facility to get Resident #1's DNR (Do not resuscitate) paperwork. The paramedics were on the phone with medical control (a physician at a local emergency room that will give the paramedics at the scene specific orders for treatment if/ when necessary) while doing CPR on Resident #1. RN A stated that the paramedics stopped doing CPR and pronounced Resident #1 deceased at approximately 8:37pm at the direction of Medical Control. RN A stated the paramedics then left and she cleaned up the resident for the family. RN A stated she contacted the NP prior to 5:00pm about Resident #1's lethargy and first episode of vomiting and the NP discontinued the Paxil. RN A stated she texted the NP after 5:00p because she wanted to get lab and x ray orders because of Resident #1's fever but did not get an answer so she the texted the MD from the work phone. RN A stated the MD's answer was, What do you recommend, but that she did not see that until after the code at 8:37pm. RN A stated that she stated in her text to the MD that Resident #1 had had an episode of nausea and vomiting and that he had a low grade fever for two days on her shift and requested some lab work or x rays. RN A stated she was surprised when the MD texted back with, what do you recommend. RN A stated she did not try to call the MD because she did not have the phone with her. RN A also stated she did not direct LVN B to contact the physician because LVN B was busy with contacting 911 then with helping with Resident #1. In a phone interview on 5/17/24 at 4:11pm, the MD stated that he had gotten a text message from the facility on 5/6/24 at 6:49pm that said, Resident #1 has cough and lethargy'. The MD stated he texted back and asked, what do you recommend? hoping that the facility would give him some more information because the first text was very vague. The MD stated the next text he received was at 8:43pm and stated, Resident #1 suddenly aspirated and 911 was called. The MD stated he then received a text at 8:45pm that said, Resident #1 was coded for 37 minutes and deceased . The MD stated the next and final text message he received at 9:37pm stated, ER (Emergency Room) stopped CPR at 8:37pm. The MD stated that he did not understand the aspiration because he was not aware and had not been told that Resident #1 had been vomiting. The MD stated that was the only communication he received from the facility and that he did not see a missed call from the facility before the first text message at 6:49pm. In a phone interview on 5/24/24 at 9:14am, the MD stated in this situation, he would have expected to be contacted when the resident was looking worse and about Resident #1 being a full code and the family member not wanting CPR done. The MD also stated he would expect the facility to contact the NP or on call person as soon as there had been a change in Resident #1's condition. The MD stated if the NP or on call person was unavailable, the facility should have contacted him directly after Resident #1 aspirated and his condition was worsening. The MD stated if he had the information that was initially sent to the NP on Resident #1's condition, he would have asked for labs, and asked further questions as more information would have been needed at that time. The MD further stated if the facility had contacted as soon as Resident #1 aspirated, he would have had him sent to the emergency room immediately to be treated. The MD stated he was not certain that sending Resident #1 to the emergency room would have had a different outcome, but it was possible. In an interview on 5/17/24 at 5:15pm, the DON stated that she had taken a picture or screen shot of the text messages from the facility phone from 5/6/24 and had them on her phone. The DON read the text messages with times and content out loud to this state surveyor but did not allow visual confirmation. The following was what was read: 5:12pm the NP was notified about Resident #1's lethargy, that he had been started on Paxil a week ago, and the family wants to discontinue it. Also, Resident #1 running low grade temp. Flu and COVID negative. 5:22pm the NP texted back, Yes, that's fine. 5:46pm text to NP, Update temp of 100.6, has had cough. Incontinent, not new, has several wounds that require care, not particularly new. 5:48pm text to NP, Do you want labs or x ray done? (There was no response from the NP to the 5:46pm or 5:48pm texts) The DON stated, there was possibly an unanswered phone call placed to the MD, between 5:48pm and the next text that was sent. 6:49pm text to MD, Resident #1 has cough and lethargy. 6:59pm response text from MD, what do you recommend? The DON stated, I'm speculating here that the wording on the 6:49 text was just very basic cough and lethargy because Resident #1 at that point was already having some increased trouble and RN A was back in the room taking care of the resident, educating the family, and was trying to get some guidance from the NP or MD. The DON stated that there was a mobile phone belonging to skilled nursing that was supposed to be carried by one of the nurses. The DON explained if the desk phone rang and no one answered within a few rings, it would forward to the unit's mobile phone so the nurses can still be communicated with. The DON stated the phone was not specifically assigned to someone; the nurses just decided between them who would carry it. The DON stated that it appeared that no one had the phone with them that evening. The DON stated there was no policy regarding carrying the mobile phone, it was just a verbal thing that one of the nursing staff has that phone. The DON stated she felt that RN A had attempted to contact the physician prior to 7:35pm but did not follow up because she was busy with Resident #1 and did not have the phone with her. Review of the facility's Change in a Resident's Condition or Status Policy dated 02/2021 read in part: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/ mental status; g. need to transfer the resident to a hospital/ treatment center; i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself with intervention by staff or implementing standard disease- related clinical interventions (is not self-limiting) b. impacts more than one area of the resident's health status. c. requires interdisciplinary review and/ or revision to the care plan. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status. On 5/17/24 at 5:45pm, the ADMIN was asked for the facility's training or in-service information on physician notification or resident change in condition but did not provide it. When asked for it; however, the ADMIN gave me a sheet of paper that read: Mandatory Nurse Training May 24th at 1:30pm AL (Assisted Living) Board Room Change in Condition SBAR documentation *Please plan on attending; class should be approximately 30 minutes in length* The ADMIN stated that this training had already been on the schedule prior to this investigation. This was determined to be an immediate jeopardy on 5/24/24 at 4:45 PM. The administrator was notified. The administrator was provided with the IJ template on 5/24/24 at 4:45 PM. The following Plan of Removal submitted by the facility was accepted on 5/25/25 at 11:00 AM and indicated the following: Facility Plan of Removal 1. Surveyors identified the physician notification policy was not followed, and the physician for one resident was not notified of changes in condition. 2. All Residents were at risk for being affected by the same deficient practice. An audit was conducted to identify residents with Advanced Directives specifically who has DNR orders versus Full Code Orders and a binder created to easily identify these residents in the event of an emergency. All residents and/or their responsible parties are being interviewed to determine if they have experience similar delays in service as a result of communication deficits. 3. The Director of Nurses was educated by the Administrator on the facility Policy and Procedure for Notification of Changes to the Physician including the When to Call and Care Pathways resources. The remaining Facility Nursing staff will be educated by the Director of Nurses/Designee on the Policy and Procedure for Notification of Changes to the Physician via live training, and distance training to complete will all LVN's and RN's. Any Nursing Staff employee who cannot be contacted will be immediately removed from the schedule until which time they were contacted or prior to their next scheduled shift, whichever was sooner. 4. The education effectiveness will be monitored by conducting Mock Code Drills, with various shifts, to determine if the correct procedure was followed. A Mock Code Drill will occur once on each shift the first week (05/24/2024 through 05/30/2024) for a total of three drills, and then once weekly on one of the three shifts for three weeks. After this a Mock Code Drill will be conducted on a random shift once monthly every month. These drills will be documented on the attached form and filed in the Mock Code Drill Log. The Mock Code Drills will be conducted by the Director of Nurses/Designee. 5. The Plan of removal (including all education) will be completed by 11:59 PM on 05/24/2024. Record Review on 5/25/24 revealed: DON Education by Administrator SBAR/Change in Condition Evaluation/Notification to Physician ? Any change in condition noted on any resident requires proper assessment, documentation, and notification as follows: o Full nursing assessment to include V/S o Initiate an e-interact change in condition evaluation o Notification by phone call is the facilities preferred method of communication and the first attempt is made to both the physician and NP, if leaving a recorded voice message is an option, a detailed message including the changes in condition will be recorded. o The next attempt in communication will be a text message stating the resident has had a change in condition and request for a call back for full details. o When a call back has been requested, the nurse will keep the mobile phone with them until the call back is received. o Except in emergency situations, the nurse will attempt to call again within 30 minutes. In emergency situations requiring immediate intervention, the nurse will initiate 911. o All emergency situations will be reported to the physician and NP. o Notification of responsible party/family member o Document all findings and conversations in the appropriate location in the SBAR. o Each shift should provide follow up documentation until the change of condition is resolved. o Refer to the When to Call Binder for Guidance and Care Path Assessments. ? If the physician or NP provides orders to send the resident to the ER for evaluation, you are to initiate and complete an E-interact transfer to hospital evaluation. ? Once completed, print the transfer form, and send it with other documents with the resident. If unable to send with resident, obtain the fax number when you call report to the hospital and send via fax. ? Watch the following video on completing an E-Interact Change in Condition Evaluation/SBAR (or watch by clicking the link if remote). Interviews on 5/25/24 with licensed staff that worked on various shifts included: 12:25 PM - RN E 12:28 PM - RN F 12:55 PM - LVN G 1:17 PM - RN H 1:26 PM - LVN I 1:35 PM - LVN J 1:38 PM - LVN K 1:44 PM - LVN L 1:50 PM - RN M 2:58 PM - RN A All licensed staff interviewed were able to identify the process for changes of condition, notifying the physician on resident change of condition, and that the preferred physician contact was by telephone, not text. All staff stated they were to carry the phone with them if they placed a call to the physician that was not answered or if there was a resident in critical condition. Staff stated that if they were not able to contact a physician and it was an emergent situation, they would call 911. Staff stated if there was a resident emergency situation, the charge nurse would take the lead role, and delegate tasks to assisting staff members. All staff stated they had participated in a mock code drill. Interviews on 5/25/24 with unlicensed staff that worked on various shifts included: 12:59 PM - CNA N 12:59 PM - CNA O 1:04 PM - CNA P All unlicensed staff interviewed stated if a resident had an emergent situation, they would pull the call light to get a nurse and check for a pulse. The charge nurse would go in and take charge and delegate tasks to the assisting staff. All staff stated they had participated in a mock code drill. Verification of Plan of Removal on 5/25/24 revealed: 1. Record review of all resident's code status who were at risk for being affected by the same deficient practice was conducted. Record review of audits that were conducted to identify residents with advanced directives specifically residents who had DNR orders versus full code orders. A binder was created to easily identify these residents in the event of an emergency. Record review of the code status binder was reviewed which have been placed at the nurse's stations. 2. Through interviews and record review, the Director of Nurses was educated by the Administrator on the facility Policy and Procedure for Notification of Changes to the Physician including the When to Call and Care Pathways resources. The remaining Facility Nursing staff was interviewed on the educated conducted by the Director of Nurses/Designee on the Policy and Procedure for Notification of Changes to the Physician. Through interviews nursing staff employees who could not be contacted was immediately removed from the schedule until they were trained on the policies and procedures for Notification of Changes, and when to call the physician. 3. Record review of in-services was of the Mock Code Drills, of various shifts was conducted. Through interviews, A Mock Code Drill will occur once on each shift the first week (05/24/2024 through 05/30/2024) for a total of three drills, and then once weekly on one of the three shifts for three weeks. After this, a Mock Code Drill will be conducted on a random shift once monthly every month. These drills will be documented on the attached form and filed in the Mock Code Drill Log. The Mock Code Drills will be conducted by the Director of Nurses/Designee. Interviews were conducted with staff members on various shifts on the Mock Code Drill and all staff members were able to identify the procedures put into place if a resident were to code. Record review of the Mock Code Drill binder was conducted. In an interview on 5/25/24 at 12:00pm, the Administrator stated that in-service began on 5/24/24 with staff and no staff were allowed back on the floor until training on resident change of condition/SBAR, preferred MD notification which was by phone and not through text and staff have conducted a mock code drill which was conducted yesterday and another one was scheduled for 5/30/24. The administrator stated that if a nurse has placed a call to the physician, then that nurse was to keep the phone on them until physician contacts that nurse back with directions. The Administrator stated that the Mock Drill binder would be kept by nursing administration/IDT (Interdisciplinary Team) and a mock code drill would be conducted and reviewed monthly after the second mock code drill was conducted. The Administrator stated if concerns were identified it would be discussed immediately and addressed as it would become part of the QAPI meeting discussions. The Administrator was informed the Immediate Jeopardy (IJ) was removed on 05/25/24 at 2:35 PM. The facility remained out of compliance at a scope of pattern with a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.