**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents in facility received adequate supervision and assistance devices to prevent accidents 1 of 5 residents (Resident #10) reviewed for accidents and supervision. The facility staff member failed to follow the facility's No Lift policy, which indicated the total mechanical lift will be used for individuals who can bear weight on their legs and can only offer minimal assistance with their transfers/lifts. The facility failed to provide assistive devices (mechanical lift) during transfers as required per their No Lift policy and after requested by Resident #10 and her POA on 04/04/24. After the inappropriate transfer, Resident #10 had uncontrolled pain (even after administration of opioid analgesic), was sent to the hospital via 911 and was diagnosed with a fracture. The facility failed to obtain accurate transfer status information from the referring facility prior to admission. On 4/04/24 Resident #10 was inappropriately transferred resulting in a right distal tibial spiral fracture. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 10/01/2024 at 1:36 PM. The IJ was lifted at 10/02/2024 at 7:00 PM. the facility remained out of compliance at a severity level of actual harm and scope of isolated, due to the facility's continued monitoring of the effectiveness of their plan of removal. This failure could place residents at risk of serious injury resulting from improper transfer technique. Findings Included: Record Review of Resident #10's Face Sheet dated 03/29/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included osteoarthritis, hemiplegia and hemiparesis affecting her left side resulting from a stroke (unknown date, but not recent). She had a surgical history of knee replacement to her right knee 20 years prior. Record review of referral information from previous facility indicated that resident #10 was a moderate assist of 1 or 2 persons and that she was only able to provide minimal assistance due to left sided hemiplegia (weakness to left side). No incident report was completed by the facility staff for this incident per the DON due to the resident's transfer to the hospital for evaluation, and no incident report was completed after the incident. Record review of Resident #10's admission Minimum Data Set (MDS) dated [DATE] revealed her cognition was intact with a Brief Interview of Mental Status (BIMS) score of 15. She was impaired of upper and lower extremities on one side. She was dependent for total assistance for sit to stand and transfer from chair/bed transfers to bed. She was wheelchair bound and required total assistance with shower/bathing and personal hygiene. Resident #10 was always continent of bladder and bowel. Record review of Resident #10's Care Plan Review, dated 04/03/2024, revealed she had limited mobility, hemiplegia, musculoskeletal impairment, impaired balance, pain, limited range of motion, stroke, she was at risk for falls related to gait balance problems, she had acute/chronic pain related to arthritis, and persistent right knee pain with a history of total knee arthroplasty (a surgical procedure that replaces a damaged knee joint with prosthetic components. ) which was over twenty years ago. Physical examination by the facility medical director 0on 04/04/24 noted that she may have been experiencing excessive wear of hardware, and possible loosening of hardware. It was recommended she follows up with orthopedic provider a to formally evaluate right knee with imaging and full evaluation. Other recommendations included Patient will continue Norco (hydrocodone) regimen per facility attending (physician). Record review of Resident #10's Progress Note by LVN F, dated 04/03/2024 at 6:13 PM, revealed: Resident transferred via WC with attendant from a transport service. with belongings. Vitals at this time is T-98.3, P-78, R-17, BP-145/76. O2 @ 96% on room air. Meds verified with the AP (Attending Physician) to see resident tomorrow. no complaints of pain at this time, head to toe done skin intact, clean, and dry, resident is incontinent of bowl [sic] and bladder. alert and oriented x 2. resident oriented to facility at this time. bed in lowest possible call light within reach. Record review of Resident #10's Progress Note by LVN F, dated 04/04/2024 at 9:26 PM, revealed: Change in Condition: Symptoms or signs noted of Condition change: Pain (uncontrolled) Vital Signs: BP 151/66 - 4/4/2024 11:23 Position: Lying r/arm, P 79 - 4/4/2024 11:23 Pulse Type: Regular, R 17.0 - 4/3/2024 18:43, T 98.3 - 4/3/2024 18:43 Route: Forehead (non-contact), O2 96.0 % - 4/3/2024 18:43 Method: Room Air Notifications: Reported to primary care clinician: Physician's Assistant (PA), Date and time of clinician notification: 04/04/2024 4:09 PM, Name of family member or resident representative notified: Power of Attorney (POA) (at bedside), Date and time family or representative notified: 04/04/2024 4:00 PM. Record review of Resident #10's Progress Note by LVN F, dated 04/05/2024 at 11:19 AM, revealed the resident was hospitalized . Review of Resident #10's clinical records from 09/30//24 to 10/02/24 revealed there was no assessment completed PT/OT to determine her weight bearing status during her stay at the facility nor prior to her discharge to the hospital . Record Review of page 1 of the Discharge Summary Brief Overview from the hospital dated 04/16/24, revealed the resident was admitted on [DATE] and discharged on 04/16/2024. Primary Discharge Diagnosis was Fracture of right tibia. Record Review of page 14 of the Discharge Summary Brief Overview from the hospital dated 04/16/24, revealed the report from Radiology: X-ray Ankle 3+, Result Date: 4/6/26 IMPRESSION: 1. Spiral fracture of the distal shaft of the tibia Finalized by MD on 04/06/2024 4:03 X-ray Tibia Fibula 2 View Right, Right, Result Date: 4/6/2024, Result Date: 4/6/2024, IMPRESSION: 1. Spiral fracture of the distal shaft of the tibia. Record review of Details of Hospital Stay dated 04/16/24 revealed Resident #10 had an elevated risk for surgery due to Cardiac disease. As a result of her cardiac risk, the orthopedic specialist opted to pursue nonoperative management of her fracture and placed a brace on her right leg and ordered non-weight bearing status for 6- 8 weeks. In an interview on 09/27/24 at 3:08 PM with Resident #10's Family Member, she stated on 04/04/24, Resident #10 was complaining about the mattress on her bed. Then a short, dark skinned African guy brought in another mattress, and he began to try to pick her up by lifting her up under her arms. She stated when she saw how he was going to try to get her up, she told him that he could not do it like that, because it was not safe, and he needed to get someone to help him or get a lift and the resident agreed with her. She stated he said, I'll do it, I can do it. She stated he continued to get her up by lifting her under her arms and when he got her up, he almost dropped her. She stated he hurried up and twisted her around to get her in the chair and he basically dropped her into the chair. She stated right then, she hollered out and said she felt something pop and she was screaming and crying really bad. She stated it made her cry. She stated a middle-aged woman was present in the room and she was attending to another resident who was in the room. She stated a little white or Hispanic man was standing in the doorway. She stated once he got her in the chair, he left the room. She stated he did not try to see about Resident #10, he just walked out of the room. She stated neither the female staff nor the guy in the doorway came to see about Resident #10. She stated a little bit later, the man who was in the doorway came back with a pain pill and gave it to the resident. She stated he then went and called 9-1-1 and the paramedics came to take the resident to the hospital. She stated she arrived at the facility to visit Resident #10 around 2:30 PM. She stated the transfer happened close to 4:00 PM. In a follow-up interview on 09/27/24 at 3:45 PM with Resident #10's Family Member, she stated she called the next day and spoke to a lady, but she did not remember the name or title. She stated she told the lady that Resident #10 was in the hospital and the lady told her that someone would call her back the next day, but no one ever did, and she did not try to call the facility back. In an interview on 09/30/24 at 1:50 PM with Resident #10, she stated she did not know why the guy was bringing another mattress to her. She stated she just knew that it was a dark, heavy-set guy. She stated he was a big guy. She stated he was tall to her. She stated he came in with a mattress and he said she would have to get out of the bed, so he could change out the mattresses. She stated he then started pulling her up with his hands. She stated he was pulling her up by holding her under her arms. She stated he was moving too fast, and she was telling him that he needed to get a slip for her and use the lift. She stated her family member also told him the same thing. She stated he did not listen to her either. She stated she kept telling him not to bend her leg, but he did it anyway and that was when she felt the pop. She stated she could not remember what time of day it was. She stated after thinking about it, she believed it happened during the middle of the day, around 2:00 PM. She stated she knew for sure that she was lying in bed and her family member was sitting near the bed. She stated she was not in pain prior to man getting her out of bed. She stated she and her family member were just sitting there talking prior to the guy coming in the room. In an interview on 09/30/24 at 9:38 AM with the Central Supply Clerk, she stated if a resident needed something like a mattress switched out, it would go through her. She stated the nurse would verbally communicate that request to her and then she would locate another mattress and bring it to the floor and change it out. She stated if the mattress was somewhere further away from the room which it needed to go to, then one of the maintenance staff would assist by retrieving the mattress and bringing it to the floor of the room and then she would be the one to take it to the room and change it out. She stated only herself would be the one to change the mattresses. She stated that was her sole responsibility. She stated there have been times when she has instructed the maintenance staff to meet her at the room and then they might bring the mattress into the room, and she would still be the one to remove the current mattress and then replace it with the one which was brought to the room. Then they would take the old mattress out and store it. She stated she remembered Resident #10 and she stated the maintenance staff, who did not match the description of the person who transferred Resident #10, did bring it to the room and she was the one who placed it on the bed frame. She stated when she entered the room, the resident was sitting in a wheelchair and so she went ahead and took the air mattress off the bed frame and when the replacement mattress was brought in, she was the one who put it on the bed frame. She stated she removed the air mattress from the room. An interview with the Administrator on 09/25/24 at 12:05 PM, he stated when they have a new admission, the care information was obtained by the nurses. He stated they are responsible for communicating with the previous facility or hospital from which the resident was coming from. He stated information was shared with the aides. He stated they have been doing it this way for a very long time and there had not been any incidents. He stated the information was placed where any of the staff could access it and know how to care for the new resident. He stated the Progress Notes which they received from the previous facility stated the resident was moderate assist x1, which meant the resident only needed one person. He stated C.N.A. G had never had an incident while transferring residents. He stated they go by what was done at the previous facility or hospital, until facility staff can complete their own assessments. Then that information was entered into the system and shared with other staff. He stated they did not have a policy for this process, because there has not been a need to have one for this issue. He stated based on the information which they received from the previous facility, he believed C.N.A. G did what he was supposed to do. An interview with the DON on 09/25/2024 at 12:09 PM, she stated she was not familiar with Resident #10, and she needed to see the resident's records. She stated LVN F was the floor nurse who entered the assessments for the resident. She stated LVN F was no longer at this facility but was working at a sister facility. She stated he did not report anything to her about the resident's injury. She stated had the resident been injured, it would have been documented in Progress Notes and it would have been reported to Health and Human Services Commission (HHSC). She stated the records from the hospital or facility, which the resident transferred from, would have gone to the nursing department. She stated the Social Workers (SW) would have done initial assessments with the resident, upon admission. She stated when a resident comes from a hospital or another facility, they would refer to those records for indications on the resident's care, until they could complete their own assessments. She stated transfer needs would be included in what they would reference from the hospital or former facility's records. She stated that the resident's transfer information would be in LVN F's notes and/or could probably be obtained from the Director of Rehabilitation. An interview with the SW on 09/25/2024 at 12:33 PM, she stated she did not remember the resident. She stated she would have to look at her notes. She then stated the SW would conduct an initial assessment by speaking with the resident or their representative. She stated the assessment is a collection of information which they get during that interview. She stated those notes are taken and translated into a Social Services Progress Note. She stated any transfer needs would be provided by the Director of Rehabilitation. An interview with the PA on 09/25/2025 at 3:55 PM, She stated she did not remember the incident. She stated by looking at the Progress Notes, she was notified, but she did not remember it. She stated she was not familiar with Resident #10 because she never got the chance to see her. She reviewed the resident's chart and stated given her being hemiplegic and her size, and the fact that she had not ambulated for a number of years, she would imagine that the resident would require adequate assistance for transfers and mobility. She stated staff should have referred to the transfer notes from the resident's previous facility. She looked through the notes from the previous facility and could not find anything referencing transfers. She stated staff should have at least listened to the resident, given that her cognition was intact, and she was able to communicate to the staff who was assisting her, that he should have help with assisting her with her transfer to the wheelchair. She stated, especially since there was no documented reference as to how to transfer her, CNA G should have listened to the resident. She stated with Resident #10 being overweight, paralyzed on the left side and the right knee was problematic and the notes under Functional Performance, dated 04/03/2024 revealed, the resident was non-weight bearing on her right leg, she should have at least had a two-person assist with transfers. In a follow-up interview on 09/26/2024 at 11:12 AM with the DON, she stated the floor nurse was supposed to ask for specifics, such as ADL care, including transfers when considering new admissions. She stated if they have someone new come in, they should 1.) use information from where the new admit came from, and 2.) use clinical decision making. She stated depending on the resident's cognition level, the resident could also tell them how they have received care previously. She stated if staff do not use informed methods to transfer a resident, injury could occur. In an interview on 09/26/24 at 12:32 PM with the ADON, he stated when a new resident is coming in, they take a verbal report from the facility that they are coming from. He stated they have a temporary report sheet which they write the information on. He stated this template was only used for their initial assessment and getting information that they need to know about the in-coming patient. He stated it includes everything about the patient, including when they had their bowel movement, are they mobile, do they used some type of device, or do they ambulate independently. He stated whatever they need to relate to the Certified Nurse Aides (C.N.A.) and the rest of the staff, was then shared from that report sheet. He stated the report was usually done prior to the resident coming to the facility. He stated once the resident comes to the facility, they also use that report sheet to do their head-to-toe assessment. He stated the assessment includes if they can stand, ambulate, how far can they ambulate, and do they require a device to ambulate. He stated if he does not know anything about the person, when he walks into the room, and if that person cannot tell him how they need to be transferred, he is going to assume they are a two-person assist or a two-person lift. He stated a two-person lift means they are going to use a mechanical lift. He stated if he saw a sling underneath the resident, that would tell him that the resident requires a two-person lift and he would go get the mechanical lift and call for a co-worker. He stated if he did not see a sling under the resident, he would assume they are a one-person assist and could stand or give some type of assistance with pivoting. He stated when he went to the room to introduce himself, Resident #10's family member was present. He stated he thought she had an immobilizer on her right leg; however, he could not be sure. He stated the resident's family member told him that even though she had an immobilizer on her right leg (unsure if it was right or left leg) the resident could stand a little bit and bear weight. He stated the family member told him that she was having some pain and that the previous facility had had an X-ray on the resident's right knee done just a few prior to her coming to this facility. He stated the resident's family member told him that the resident could stand a little bit, by standing on her right side, but not for long. He stated he was assuming that maybe that was what CNA. G used, to determine how to transfer Resident #10, however, he was not sure if that was true. He stated when he met Resident #10, he did not see CNA G. He stated LVN F may have relayed that information from the resident's family member to CNA G. He stated when he met her, she was not complaining of pain to him. He stated he knew she was taking was taking Norco and was taking it routine and prn. He stated if nursing staff did not have the information on the resident prior to them arriving to the facility, or if no one told him how to transfer a newly admitted resident, and they had not received the report from the previous facility, he stated he would go by what the resident told him. He stated he would ask if the resident was able to stand and/or walk, if the resident was alert and oriented, he would ask them. He stated the questions staff could ask a new resident are, Can you stand? Will you be able to help me, get you over there or to the wheelchair? He stated if the resident were to say, No, then staff would need to ask the resident to wait and then the staff should go get a co-worker to assist. He stated if Resident #10's family member did tell C.N.A. G that the resident could help him transfer her and he was unsure, he could have asked the resident some clarification on her abilities and requirements before trying to transfer her alone. In an interview on 09/26/24 at 2:02 PM with the Attending Physician, he stated he referred to the Progress Notes from the previous nursing facility and stated the notes read that Resident #10 was mod assist x1 with functional transfers. He also stated that the notes read that Resident #10's legs would swell when she tries to stand, so they (facility) knew that she could put weight on her legs. He stated Resident #10 told him that she could not walk, which made sense, but as far as transfers are concerned. He stated she complained of right knee pain and the notes spoke of multiple negative X-rays of the right knee; however, the X-rays were only of the knee. There were also notes from the doctor, which read that she needed to be seen by an Orthopedist for possible hardware loosening. He stated when he saw her, she did not say anything about that, as bothering her, in particular. He stated she was pleasant and interactive. He stated she had chronic pains, but she did not focus on that leg during their interview. He stated she did tell him about her shoulder and knee pains and that she could not push on a wheelchair. She stated her shoulder limited her from self-propelling in a wheelchair. He stated she did not say anything about how she usually transfers. He stated he specifically asked her when the last time was that she walked, (because that tells him a lot about how functional a person was going to be. He stated it told him whether they will be wheelchair dependent.) He stated she told him that she had not ambulated, meaning walking, in years. He stated he did not see an immobilizer on her leg when he talked to her. He stated she was sitting in a couch-like chair, watching tv. He stated if there was no other information to go by, it was reasonable to believe that a one-person transfer was feasible. He stated the notes reflected that she was standing at the other facility, and she was moderate assist x1. He stated he did not see why she could not transfer her with one person. He stated there was no trauma reported, meaning just because there was a fracture, it did not mean it came from being plopped down into a chair. He stated given that only the knee was X-ray at the previous facility, while she had been complaining about knee and leg pain, who is to say that the fracture did not happen at the previous facility. He stated, it's the chicken vs the egg kind of thing because he did not know if the fracture was already there or not. He stated given the location of the fracture (distal tibia); it would not have been seen on a knee X-ray. He stated they (facility) did not get very clear information from the previous nursing facility, about activity in terms of whether she needed assistance, or whether she needed a Hoyer. He stated what was provided revealed she was doing standing with therapy, because the notes indicated that her legs got swollen while she was standing. He stated also, the notes stated she was moderate assist x1; which tells us that she was able to bear weight on both her legs. He stated if the resident was able to bear weight and was transferred incorrectly it could have prompted a new fracture, a refracture, or exacerbated an existing fracture that anyone was even aware of. He stated she was not at the facility long enough (facility) to decipher what was going on with her. He stated there are multiple dependent to factors when a new patient was admitted to the facility. He stated what does the paperwork say, was the patient oriented, can they tell what was necessary and what is not. He stated days before Resident #10 arrived at the facility, the notes provided from Occupational Therapy (OT) stated she was moderate assist x1 with transfers. He stated in worst case scenario, you do not know if there was hesitancy for anything then yes, wait until therapy can evaluate. He stated he has had patients who can just get up and go with a walker, but they are obviously demented. He stated there are a lot of factors that come into play when you are making a decision. He stated he could not be more help because he only saw her once. He stated if she had been there longer, who is to say that while she was at the facility, they would not have X-rayed her leg. He stated he did not know why the former facility did not X-ray more than just the knee. He stated you can have radiating pain. He stated you can have hip pain radiating to the knee, you can have ankle pain radiating to the knee. He stated he did not know why they only focused on the knee and not anywhere else, especially since the pain was persistent. He stated the notes indicated that the resident's activity had decreased. He stated the physician made note that he had referred her to an Orthopedist, but she never got to go because she left the facility. He stated the Orthopedist probably would have X-rayed her leg. In an interview on 09/26/24 at 2:59 PM with C.N.A. G, he stated he started his shift at 2:00 PM. He stated about 2:30 PM, a female C.N.A. was standing at the door of Resident #10's room and called for him to come help her. He stated when he came to the room, the female aide left to get something, but he was not sure what. He stated the family member told him the resident could help him get her into bed. He stated Resident #10 then said she could stand a little and could help him. He stated when he entered the room, Resident #10 was sitting in the wheelchair and it was near the bed, but not right next to the bed. He stated her family member was standing next to her, kind of between the chair and the bed. He stated the family member told him that the resident wanted to get back in bed because she was in pain. He stated she was not crying, but she was whining and grunting. He stated her family member was rubbing her side and back and telling her it was ok and that she was about to be put back in bed. He stated he moved the wheelchair next to the bed and then he used a gait belt to help lift her from the chair and then he helped her into bed. He stated the resident had already started to try to push herself up on one side and he told her to wait for him to help her. He stated the resident was holding on to his arms and the gait belt was still behind her and he held it to help him steady her. He stated she took about two steps and then she was turned to where her back was to the bed, and she was against the bed. He stated she had to step to the left to get to the bed. He stated the bed was low, so she was able to just sit on the bed without having to have to scoot back onto it. He stated when he came in the room, she was already whining, and her family member said she was in pain. He stated when he finished transferring her into bed, he went and told the nurse that she was complaining of pain. Then he went to answer another call light. In an interview on 09/27/24 at 11:15 AM with LVN F, he stated he did not have many interactions with Resident #10. He stated he was the admitting nurse. He stated she was quiet when she arrived. He stated he remembered having to call her previous nursing facility several times to get report on her because they were not returning his calls. He stated he finally received report on her after she was admitted . He stated one person brought the resident into the facility and she was in a wheelchair. He stated he and an aide transferred the resident to the bed. He stated he could not recall what the paperwork stated as far as how many people were required, but he used two people just to be safe. He stated Resident #10 told him that she was uncomfortable in the wheelchair after a while, and that's when he and an aide transferred her onto the bed. He stated his shift ended at 10:00 PM on 04/03/24. He stated she was still in bed when he got off shift. He stated on 04/04/24, his shift started at 2:00 PM. He stated the off-going nurse reported to him that Resident #10 was out of bed and in her wheelchair. He stated the nurse told him that the resident had been uncomfortable on and off but not to the point of excruciating pain. He stated when he went to see her for the first time that day, the resident told him that she wanted to get back in bed. He stated she did not ask for any medications at that time. He stated there were two aides on shift, and he called for them to transfer her back into bed. The female came first, but then he told C.N.A. G to do it. He stated he was ok with C.N.A. G transferring her alone, because he himself had had time to review her admission paperwork and it said that she was a x1 person assist. He stated when C.N.A. G finished transferring her, he (C.N.A. G) came to him and told him that the resident was in pain from being uncomfortable in the chair. He stated he went to assess the resident and she told him that she was in pain, so he went to get the medication for her. He stated the way she was expressing her pain; he could see that it was more intense than the day before. He stated he checked her orders and then administered pain medication first, then he contacted the PA. He stated the PA told him to send her to the hospital. He stated the admission process was that the nurse would receive a report from the facility or hospital that the new resident was coming from. He stated they verify the transportation method, which the resident would be arriving in. He stated the ADONs enter the care information in the Kardex. He stated some stations enter it in a binder, while others enter it into the system. He stated the C.N.A.s and other nurses receive report from the admitting nurse or the ADON. He stated the kitchen was notified of the new resident's dietary needs. He stated medications are ordered. He stated housekeeping was notified, so they can make sure the room is ready. He stated when the new resident arrived, the admitting nurse will greet them and take them to their room. Then the residents are interviewed, and vitals and weight are taken. Then they see if the resident wants to remain in their wheelchair or get in bed. He stated once the resident was made comfortable, then the nurse was to document the information which they received from the resident during that initial interview. Then the nurse will begin assessments on the resident. Record review of the sign-in schedule for all shifts from 04/03/24 and 04/04/24, revealed six of nine staff who were responsible for the resident, no longer worked at the facility. In an interview on 09/27/24 at 12:48 PM with CMA I, she stated she was on shift when Resident #10 was admitted on [DATE]. She stated she thought it was around lunch time when Resident #10 arrived at the facility, she introduced herself to the resident to make her feel welcome. She stated a lady from the transport service brought the resident into the facility. She stated she was sitting in a wheelchair. She stated the transport driver was talking to LVN F for a little while. She stated staff brought the rest of the resident's belongings in and LVN F took her to her room. She stated the resident was calm and was not complaining of pain at that time. She stated LVN F returned to the nurses' station and entered her information in the system. She stated a little later on, the resident asked for a pain pill, and she checked the system and saw that it was time for another pain pill, so she administered the medication to her. She stated the resident had been getting that pain medication twice a day at the other facility. She stated the aides had put her in bed and she was asleep, by the time she got off shift at 8:00 PM. She stated to her knowledge, the resident had not complained of pain the rest of the night. She stated when she came to work the next day, the resident had already been sent to the hospital. On 09/27/24 at 1:20 PM a call was made to LVN J, there was no answer. A voice message was left. In a follow-up interview on 09/27/24 at 5:00 PM with C.N.A. G, he stated he was in the hall and was called to the room by the older female aide. He stated the female aide started talking to the roommate when Resident #10 and her family me[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of eight residents reviewed for abuse. -The facility failed to have interventions in place to prevent Resident #1 from being abused by Resident #2, who had a history of being aggressive with no interventions care planned until 06/06/24, after the incident. On 06/05/24 Resident #1 wandered into Resident #2's room where he was physically attacked and sustained a serious injury. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries was noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified. 2. Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). Record review of Resident 2's PPS MDS assessment, dated 05/07/24, reflected his BIMS score was 13, which indicated cognition was intact. Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted . Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024. In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit. An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. In an interview on 06/07/24 at 1:21 PM., LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room. LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in . LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. In an interview on 06/07/24 at 1:48 PM, the SSD stated she was in the process of finding placement for Resident #2 to be discharged . She stated she had sent out referrals to different facilities and the family agreed with the discharge. The SSD stated the family felt an assisted living environment would be more appropriate for Resident #2 because it would provide more space and privacy. The SSD stated Resident #2 had not exhibited aggressive behaviors prior to the incident to her knowledge; however, the facility still thought it was best to discharge him for the safety of everyone. In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for 30 years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that was why Resident #1 would get confused and wander back into that room. In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman . The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of in-service titled Dealing with difficult behaviors/Abuse, Neglect & Exploitation, dated 06/06/24, reflected all staff were educated by the DON on how to identify and report abuse/neglect and protocols for dealing with behaviors. Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. Record review of incident/accident reports, from 05/07/24-06/07/24, reflected no other resident-to-resident incidents regarding abuse. Interviews were conducted on 06/10/24-06/07/24 with DON, ADON, MDS Coordinator, and staff who worked with residents on secured unit with behaviors: LVN A (1st shift), CNA B (2nd shift), CNA C (2nd shift), and LVN D (1st shift), CNA E (1st shift), CNA L (2nd shift). All staff were able to provide competency regarding in-service over abuse/neglect and dealing with difficult behaviors. All staff were able to provide examples of abuse/neglect, appropriate interventions, and when and who to report it to. All staff were also able to provide appropriate interventions and protocols to manage aggressive behaviors and behaviors related to dementia. Staff stated they were made aware of any changes in condition or new behaviors by the charge nurses, DON, and also by access to care plans. Record review of the facility's policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment: Freedom from abuse, neglect, exploitation, revised 12/2023, reflected in part the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect misappropriation of resident property, exploitation, and mistreatment Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported immediately 2.Ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injury of unknown origin and misappropriation of resident property, are reported to: a. The Administrator of the facility b. The State Survey Agency c. Adult Protective Services 3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). 4. Ensure that the results of all investigations are reported within 5 working days of the incident. 5. Ensure that if the alleged violation is verified, appropriate corrective action is taken. .

**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 resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 (Resident #1and Resident #2) of 8 residents reviewed for care plans. - The facility failed to document measurable objectives, interventions, or timeframes to address Resident #1's wandering behavior r/t diagnosis of dementia. On 06/05/24 Resident #1 wandered into Resident #2's room and was physically attacked and sustained a serious injury. -The facility failed to document measurable objectives, interventions, or timeframes to address Resident #2's aggressive behaviors after he exhibited combative behaviors in 12/2023. Interventions were not documented on Resident #2's care plan until after an incident occurred on 06/05/24 where he was physically aggressive with Resident #1 and caused serious injury. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. This failure could place all residents at risk of not receiving appropriate care and services to meet their needs. Findings included: 1. Record review of Resident #1's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (loss of memory and thinking), traumatic brain injury, dysphasia (difficulty speaking), unsteadiness on feet, and age-related physical debility (weakness caused by age). Record review of Resident #1's quarterly MDS assessment, dated 03/0724, reflected his BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #1's care plan, revised 01/30/24, reflected the resident was at risk for impaired thought processes r/t traumatic brain injury with cognitive deficit, new facility, and seizure disorder, with interventions that included communication (identifying self at each interaction, face when speaking, reduce distractions, use simple directives, and provide necessary cues-stop and return if agitated). Further review of the care plan revealed Resident #1 did not have interventions in place to address his wandering behavior. Record review of Resident #1's hospital records, dated 06/05/24, reflected the following: [Resident #1] is a [AGE] year-old male who presents s/p being pushes at his nursing facility in which patient hit his head. Patient has a history of prior head trauma for which he underwent craniectomy and cranioplasty. His [family] was at bedside to help provide history. [Family] reports that he is more confused than usual because he cannot remember his birthdate. On exam, he is able to tell us the date and month of his birthday but mixes up the year. [Resident #1] denied pain and had no obvious signs of trauma. Further review reflected results from a CT scan completed on 06/05/24 with findings of an epidural hematoma (bleed between skull and brain matter and postsurgical changes of right frontal craniotomy (surgical opening of skull) and left pterional craniectomy (brain surgery). Record review of Resident #1's progress note, dated 06/05/24 by LVN A, reflected the following: At about 6:00pm, this writer heard a sound of a fall in the hallway. Upon getting there, found [Resident #1] on the floor lying on his back unconscious with [Resident #2] standing over him. The [Resident #2] said 'I pushed him because I don't want him coming in my room'. Head to toe assessment was done. [Resident #1] was unconscious, no visible injuries were noted unable to follow commands. Respiration even labored, unable to move extremities. EMS was called. [Resident #1] regained consciousness at about 6:15PM before 911 arrival . [Resident #1] then was transported to [local hospital] for treatment and evaluation. NP on-call, DON, ADON, Administrator and family notified. 2. Record review of Resident #2's face sheet, dated 06/10/2024, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), cerebral infarction (stroke), congestive heart failure (weakened heart condition that cause a buildup of fluid in the body), chronic kidney disease, and embolism of pulmonary (blood clot in lungs). Record review of Resident 2's PPS MDS assessment, dated 05/0724, reflected his BIMS score was 13, which indicated cognition was intact. Record review of Resident #2's care plan, revised 06/06/24, reflected the resident had the potential to demonstrate physical behaviors r/t dementia, poor impulse control with intervention which included: monitor/document/report to MD of danger to self or others., psychiatric consult as indicated, and transfer to hospital for evaluation and treatment for other medical conditions. Further review reflected there were no interventions in place to address Resident #2's aggressive behaviors prior to 06/06/24. Record review of Resident #2's progress note, dated 12/21/23 by LVN A, reflected the following: [Resident #2] tried to exit the facility twice through the back gate and also through the fence by the dining area. After being stopped twice, he became upset and frustrated. This [nurse] redirected [Resident #2] back to his room. Un [sic] getting there, [Resident #2] saw [Resident #3] and kicked him and [Resident #3] yelled out saying 'He kicked me' and Thia [sic] writer went into the room and removed the attack resident from [Resident #2] room, assessed [Resident #3] from head to toe no injuries and no bruises noted . Record review of Resident #2's EHR reflected the resident was assessed by psychologist on 09/30/23, when he first admitted to the nursing facility, to address adjustment to facility, memory loss and appetite disturbance for an estimated frequency/duration of 4 times a month for 3 months. Further review reflected Resident #2 was evaluated again on 1/10/24 to address mood and aggressive behaviors. Resident #2 was discharged from psychological services in 03/2024. In an interview on 06/07/24 at 9:45 AM with the DON and the Administrator, the DON stated she worked at the facility for 8 years. She stated during dinnertime on 06/05/24 it was reported that the CNAs were assisting residents with eating and LVN A had Resident #1 close to her as he was known to wander; however, she turned to get Resident #1 some water and he wandered into Resident #2's room. The DON stated LVN A heard commotion coming from the room and found Resident #1 on the floor. The DON stated the incident was unwitnessed and she could not state if Resident #1 was pushed to the floor or fell on his own. She stated Resident #2 was alert enough to make some decisions, but he had impulsive thinking. The DON stated Resident #2 would get upset around the 1st of the month because he would get confused and think he needed to leave the facility to go pay his bills, he also thought people were trying to take his money which was why he did not like anyone in his room. The DON stated both Resident #1 and Resident #2 resided on the facility's secured unit for behaviors related to dementia. The Administrator stated he worked at the facility for 1.5 years. He stated the plan was to discharge Resident #2 and there was a discharge meeting with the family scheduled. He stated Resident #2's family agreed to provide 1:1 monitoring of the resident until the facility could find placement. The Administrator stated the facility did not have residents who had aggressive behaviors in general, but any resident who exhibited any type of behaviors, it was related to dementia, and they resided on the facility's secured unit. An attempted interview on 06/07/24 with Resident #1 was unsuccessful due to him being in the local hospital and unable to communicate for an interview. Resident #1 was expected to be discharged from the local hospital and return to the nursing facility on 06/10/24; however, he did not arrive by time of Investigator's exit on 06/10/24. An attempted interview on 06/07/24 with Resident #2 was unsuccessful due to him being in the community with family and not responding to phone call. Resident #2 was discharged from the nursing facility on the evening of 06/07/24 and unable to be observed/interviewed when Investigator returned to the facility on [DATE]. In an interview on 06/07/24 at 1:21 PM. LVN A stated she worked at the facility for almost 5 years. She stated she worked on 06/05/24 when Resident #2 attacked Resident #1. LVN A stated the incident happened during dinnertime when the aides were busy assisting other residents. She stated Resident #1 had finished his meal and she had him near the nurses' station to monitor him closely due to wandering behavior. LVN A stated she turned to get Resident #1 some water when he got up and wandered into Resident #2's room LVN A stated she heard commotion coming from the room and when she rushed there, she found Resident #1 unconscious on the floor with Resident #2 standing over him. She stated Resident #2 did not like anyone in his room and he informed her that he pushed Resident #1 down for coming in. LVN A stated Resident #2 would sometimes become verbally aggressive towards other residents for going into his room, but she had never seen him get physically aggressive. LVN A stated the other residents did not report or appear to be afraid of Resident #2. In an interview on 06/07/24 at 1:55 PM, CNA C stated she worked at the facility for 30 years on 2nd shift, 2:00 PM-10:00 PM. CNA C stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner and did not witness the incident; however, LVN A informed her of what happened. CNA C stated Resident #1 always wandered into Resident #2's room because it used to be his room and he would get confused due to dementia and think that was still his room. She stated the staff would always redirect Resident #1 to his room. CNA C stated Resident #2 would get upset when other residents went into his room, but she had never seen him become physically aggressive. In an interview on 06/07/24 at 2:12 PM, CNA B stated she worked at the facility for 7 months on 2nd shift, 2:00 PM-10:00 PM. CNA B stated she worked on 06/05/24 during the incident between Resident #1 and Resident #2. She stated she was assisting other residents with dinner when she heard a noise and the LVN A yelled for her to come in Resident #2's room to help. CNA B stated when she got in the room, she saw Resident #1 on the floor, and he was unresponsive. She stated Resident #2 was known to have a bad temper and would curse and get upset if a resident went into his room; however, she never observed him become physically aggressive towards anyone. She stated Resident #2 was mostly quiet and stayed to himself in the room. CNA B stated Resident #2's family stayed at the facility with him to help with his behaviors. She stated Resident #1 previously stayed in the room but was moved for Resident #2's family to stay there, and that is why Resident #1 would get confused and wander back into that room. In an interview on 06/07/24 at 3:05 PM, Resident #2's family member stated the facility notified her that Resident #2 had pushed Resident #1 down for entering his room. The family member stated Resident #2 was not usually physically aggressive and knew better then to put his hands on anyone. She stated Resident #2's friend began residing at the facility with him in 12/2023 after Resident #2 attempted to elope from the facility. She stated that was the facility's way of managing Resident #2's behaviors. She stated the facility was not good at implementing interventions and she expressed concerns about Resident #2' care plan to the ombudsman/ The family member stated the facility wanted to discharge Resident #2 back in 01/2024 for behaviors but the ombudsman was able to stop it due to the care plan not properly addressing all of Resident #2's needs. In an interview on 06/10/24 at 8:45 AM, the Administrator stated Resident #2 had been discharged to one of the company's assisted living facilities. He also stated the hospital reported that Resident #1 was stable and expected to be discharged back to the facility on this date. The Administrator stated although Resident #2's care plan did not reflect interventions to address his aggressive behaviors, the facility had interventions in place that included psychological services, training staff on dementia related behaviors and abuse/neglect, and staff knowing to closely monitor redirect all resident away from Resident #2's room. The Administrator stated staff also knew to monitor and redirect Resident #1 from wandering into rooms. In an interview on 06/10/24 at 09:52 AM, Resident #1's family member stated she visited the resident on 06/05/24, prior to the incident and he did not seem like himself as he was not talking as much. The family stated later after she had left the facility, she received a call informing her that Resident #1 had been taken to the emergency room after being pushed down by another resident and hitting his head. The family member stated Resident #1 had a previous brain injury and testing showed the recent incident caused further injury. The family member stated she did not have any concerns for abuse or neglect prior to the incident; however, now had concerns about there being enough staff to properly monitor residents to prevent incidents like that from occurring again. She stated Resident #1 often wandered into Resident #2's room because that used to be his room until they moved him. She stated Resident #1 had good rapport with his new roommate and family, and there had been no issues between them. In an interview on 06/10/24 at 11:50 AM, the MDS Coordinato r revealed she worked at the facility for one year. She stated it was her responsibility to initiate care plans when a resident admitted and to update them as needed; however, the DON also assisted with the task due to the large number of residents. She stated care plans needed to be updated at least quarterly and if there was a significant change in a resident's condition/behaviors. The MDS Coordinator stated any changes in condition/behaviors had to be addressed on the care plan immediately after the first occurrence. She stated any changes or issues with the residents were discussed during morning meeting every day, that was when she received knowledge of any changes that needed to be updated on the care plans. The MDS Coordinator stated she could not recall receiving reports that Resident #2 exhibited any aggressive behaviors and did not update his care plan to reflect so. The MDS Coordinator stated the DON would sometimes be aware of changes in condition that she was not aware of, and the DON would update the care plan herself. The MDS Coordinator stated the importance of a care plan was for nursing staff to know how to provide proper care to each individual resident. She stated the risk of not updating care plans as needed could be improper care being provided to the residents, and in Resident #2's case, his aggressive behaviors were not being addresses and placed other residents in danger. In an interview on 06/10/24 at 4:35 PM with the Administrator and the DON, the DON stated the staff were trained on behaviors related to dementia and knew to monitor for signs and redirect residents when wandering, especially into Resident #2's room. The DON stated Resident #2 was also seeing a psychologist for his behaviors. The DON stated those interventions should have been on Resident #2's care plan; however, she believed that they were care planned back in 12/2023 because she was very thorough and normally care planned any changes immediately. The DON stated she and the MDS Coordinator were very experienced with care planning, and both understood the importance of keeping it updated; however, this was an oversight. The DON stated she may have accidentally erased previous interventions for behaviors when she updated the care plan after the incident occurred on 06/05/24. The DON stated the risk of not having interventions in place to address aggressive behaviors could result in a negative outcome for residents. The Administrator stated his expectation was that care plans addressed all needs for the residents and was updated whenever there was change in condition/behavior to provide staff with interventions on how to provide appropriate care. The Administrator stated the risk of not updating care plans could be not catching something regarding the care of residents. He stated the facility now ensures that all changes in condition/behaviors are captured during daily morning meetings, and the DON and MDS Coordinator work together to make sure everything is addressed. He stated he is also becoming more involved in the care planning process to verify that care plans are updated per policy. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey : Record review of Residents #1, #2, #3, #4, #5, #6, #7, and #8'S EHR revealed their care plans were updated and had interventions to address all care needs. Interviews on 06/10/24 at 12:30 PM were conducted with the DON and MDS Coordinator revealed they conveyed the understanding that care plans had to be developed at the time of a residents' admission, then updated quarterly and when there was a significant change in a resident's condition and/or behavior. Review of the facility's policy titled Nursing Administration: Care Planning, revised 07/2020, revealed in part the following: Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Procedures: . 9. The resident's plan of care-focus, goals, and interventions-are communicated and implemented by the members of the health care continuum accordingly. 10. The residents' plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in a 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 five residents reviewed for changes in condition. RN A failed to notify the physician when Resident #1 complained of numbness to the left side of the face on 01/27/23. RN A notified the NP via text message of the change in condition instead of the physician and when the nurse did not receive a response from the NP the resident remained in the facility without the physician being notified. Three days later (01/30/23), Resident #1 was assessed with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on [DATE] and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). An Immediate Jeopardy (IJ) was identified on 02/16/ at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents at risk for preventing the physician an opportunity to intervene on their behalf, delays in medical treatments and care which could result in clinical complications, disability, and/or death. Findings included: Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged on 01/31/23. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A cerebral infarction-stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form did not reflect the physician had been notified. Interview with the DON on 02/14/23 at 11:18 a.m., in the presence of the Administrator, revealed she stated she had provided in-service training to all nurses related to always obtaining a response when they called the physician or NP and to call the physician/NP back or send the resident out if necessary and administration would take care of it later as far as an order was concerned because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. RN A further stated she made no further attempts to contact the NP and did not notify the physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable. Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23. Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in the ER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23. Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed. Interview with the NP on 02/15/23 at 10:46 a.m. revealed she received a text message from RN A on the afternoon of 01/27/23. The NP stated the text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on [DATE] because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke. Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 as the resident slept throughout the night shift. Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again. The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following: The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance. Immediate Action 1. The Medical Director, [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47 p.m. 2. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on 2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff. 5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon. Identification others Affected 6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice. Systemic Change to Prevent Re-occurrence 7. Education was initiated with Nurses on 2/16/2023 at 5:00 p.m. and will be completed on 2/16/2023 at 10:30 p.m. by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing. 10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring 11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. 12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should? o Get a full set of vital signs o Notify the attending physician Notify Family o Notify nurse management o Follow the facility policy o All of the above o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary. o True o False o Signs and Symptoms of a stroke include: o Facial droop, weakness on one side, slurred speech o Bilateral leg weakness, pain in legs o Abdominal pain, foul smelling urine, sediment in urine o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call: o The physician o Calf 911 for medical emergency o The family to come talk to them o If a resident has a change of condition the care plan must be updated with the interventions. o True o The nurse should document the change of condition using the e-lnteract change of condition form? o True o False If the attending physician is unavailable who do you contact o Nobody o Medical Director o Another Nurse 13. Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications. 16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician. Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician. The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of four residents reviewed for quality of care. Facility staff failed to recognize and respond when Resident #1 complained of numbness to one side of the face on 01/27/23. RN A notified the NP of a change in condition on 01/27/23 at 12:43 p.m. via text message. When RN A did not receive a response to her text message, she did not follow-up for orders, instructions or monitor the resident's condition. Resident #1 was noted three days later on 01/30/23 with numbness to the face, slurred speech, and drooling. Resident #1 was transferred to the hospital on [DATE] and admitted with diagnoses of acute stroke (A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts and can cause parts of the brain to die off). An Immediate Jeopardy (IJ) was identified on 02/16/23 at 4:13 p.m. and the facility was provided the IJ template on 02/16/23 at 4:28 p.m. While the IJ was removed on 02/17/23, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures could place residents at risk for delays in medical treatments and care which could result in clinical complications, disability, and/or death. Findings included: Review of Resident #1's undated admission record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. Physician's active order summary dated from 12/29/22 to 01/27/23 reflected diagnoses included cerebral infarction (A stroke). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was always incontinent of bowel/bladder, required extensive physical assistance of two or more persons for bed mobility and transfers. The assessment reflected the resident used a wheelchair for mobility, required extensive physical assistance of one person for dressing/personal hygiene and had functional limitations in range of motion in the upper and lower extremities on one side of the body. Review of Resident #1's change in condition form dated 01/30/23 and authored by RN A revealed the resident was assessed with increased weakness and numbness on the left side. The form further reflected the change in condition was first noted during the afternoon of 01/27/23 at 12:43 p.m. and the NP had been notified on 01/27/23. The form reflected no interventions were implemented on 01/27/23 and the RN had been awaiting a response from the NP. Record reviews of nurses' notes, progress notes, reflected no documentation of a change in condition, neurological checks, or assessments of Resident #1 after his complaint on 01/27/23, 01/28/23 or 01/29/23. Review of progress notes dated 01/30/23 reflected the NP assessed Resident #1 on 01/30/23 (Monday) with slurred speech and facial drooping. The notes reflected the NP ordered the resident be sent to the hospital for neurological workup on 01/30/23. Review of Resident #1's hospital records dated 01/30/23 revealed the resident was admitted on [DATE] with a diagnosis of acute stoke. The resident's neurological assessment in the ER on [DATE] reflected drool in left corner of the mouth, no facial droop and sensation on the left side was decreased. The resident was treated with an anticoagulant (decreases the blood's ability to clot) and discharged to another facility on 02/14/23. Interview with the NP on 02/15/23 at 10:46 a.m. revealed she provided her phone for review that reflected she received a text message from RN A on the afternoon of 01/27/23. The text message reflected Resident #1 had mild drooling, facial numbness and a blood pressure that was a little elevated. The NP stated she recalled responding to the text and ordered Resident #1 be sent out to the hospital for evaluation. She stated she does not know why RN A did not receive the text message response and was not sure if she had pressed send after typing in her response. The NP stated RN A did not provide any blood pressure or vital sign results and due to Resident #1's symptoms she did not need blood pressure or vital signs results to make the decision to send the resident to the hospital. The NP stated when she arrived at the facility on Monday (01/30/23) she was surprised to find Resident #1 still in the facility as she thought the nurse had received her text to send the resident out on Friday (01/27/23). She stated her expectation was for facility nurses to call the 24-hour answering services and not send text messages. The NP further stated if the nurse's assessment determined a resident needed to go to the hospital or if they did not receive a call back within 10 to 15 minutes, she and the physician expected facility nurses to send residents to the hospital and not wait for a response/call back. Additionally, the NP stated it was important for Resident #1 to go to the hospital on [DATE] because better and acute care could be provided in the hospital, diagnostics and labs were more readily available in the hospital and there was a four-hour window to use a clot buster medication if needed as the medication could not be used past four hours and other methods of treatment would need to be considered. The NP stated Resident #1's symptoms on 01/27/23 could have indicated a new onset stroke. Interview with RN B on 02/15/22 at 6:25 p.m. she stated she provided care for Resident #1 during the night shifts (10:00 p.m. to 6:00 a.m.) on Friday 01/27/23, Saturday 01/28/23 and Sunday 01/29/23. RN B stated RN A told her something about Resident #1 drooling. RN B stated she did not contact the physician or NP because RN A told her the physician was aware. RN B further stated she did not notice any changes in Resident #1 and provided no additional monitoring other than her normal rounds every two-hours. Interview with DON on 02/16/23 at 10:39 a.m. revealed in-service training related to changes in condition, physician notification and S/S of stroke had not been completed for all facility nurses. The DON stated the facility used agency nurses and she had planned to in-service agency nurses before they worked in the facility again. Review of the in-service training records provided by the DON on 02/14/23 and dated 01/31/23 related to changes in condition, physician notification and S/S of stroke reveled RN A was listed as having received the training, but RN B was not listed. Interview with the DON on 02/14/23 at 11:18 a.m. revealed expectations were for nursing staff to send residents out to the hospital if necessary because if a resident was experiencing a change in condition, they should be sent out to the hospital immediately. Interview with the DON on 02/15/23 at 4:30 p.m. revealed she was unable to locate any assessments, neurological checks or change in condition forms prior to 01/30/23 to address Resident #1's change in condition exhibited on 01/27/23. On 02/16/23 at 12:00 p.m. the facility's 24-hour nursing report dated from 01/27/23 through 01/30/23 was requested from the DON. The DON stated Resident #1 was not listed on the report and she was not sure why. She stated that it was possibly due to the resident being discharged . She stated the way the electronic system worked the 24-hour report would just be a duplicate ot the resident's nurse's notes. Interview with Resident #1's physician on 02/16/23 at 12:15 p.m. he stated the NP made the correct decision to send Resident #1 out to the hospital on [DATE] (Friday). He stated it was better for the resident to have been evaluated at the hospital out of an abundance of caution. The physician stated strokes could potentially be fatal due to complications and timely evaluation and treatment was essential because if you don't go you don't know. He stated complications of a stroke included lasting neurological damage and/or increased cranial hemorrhage. He further stated complications of a stroke could lead to death. Interview with RN A on 02/17/23 at 12:55 p.m. she stated she did not obtain a measurement of Resident #1's blood pressure or vital signs on Friday during the time the resident complained of numbness. She stated the blood pressure she was referring to in the text message to the NP was obtained during the morning hours around 7:00 a.m. before the resident's change in condition. RN A stated she did not know she needed to perform a full assessment on 01/27/23 that included vital signs as she did not associate the resident symptoms with a need to obtain vital signs. The facility's P/P entitled Significant Change in Condition, Response, dated revised 01/2022 and identified as current by the DON. The P/P reflected in part: 1. If at any time, it is recognized by any one (sic) of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. (SBAR-situation, background, assessment, and recommendation is a tool used to aid in facilitating and strengthening communication between nurses and prescribers-change in condition form). 5. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event the Attending Physician or on-call Physician cannot be reached. The P/P did not reflect a specific method to use when contacting the physician. The Administrator and the DON were notified on 02/16/22 at 4:13 p.m. that an Immediate Jeopardy (IJ) was identified. The IJ template was provided 02/16/23 at 4:28 p.m. and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The Facility's Plan of Removal was accepted on 02/17/23 at 12:39 p.m. and reflected the following: The facility failed to notify the physician of the resident's change in condition on 1/27/23 or at any time prior to 1/30/23. An in-service was initiated on 1/30/23, however, all facility nurses had not received the in-service training prior to 2/14/23, upon the surveyor's entrance. Immediate Action 1. The Medical Director [Medical Director's name] was notified of IJ on 2/16/2023 at 4:47pm. 2. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on 2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource. The training included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head-to-toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 3. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 4. This education and knowledge check will be completed with facility nurses on 2/16/2023 and 2/17/2023, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency/ PRN staff. 5. An ad hoc meeting regarding items in IJ template will be completed on 2/16/2023 at 6:00pm. Attendees included Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and agreed upon. Identification others Affected 6. Currently there are 113 residents residing in the facility. All residents could have been affected by the deficient practice. Systemic Change to Prevent Re-occurrence 7. Education was initiated with Nurses on 2/16/2023 at 5:00pm and will be completed on 2/16/2023 at 10:30pm by the DON, ADON and Clinical Resource which included Nurse Assessment, Signs and symptoms of a stroke, Change in Condition Process / Policy, vital sign documentation, documentation of the change in condition, notification to the physician, reviewing the resident's health condition with the attending physician; and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs and Clinical Resource used facility policy on change in condition, facility procedures on head to toe assessment, signs and symptoms of a stroke and clinical examples to ascertain understanding of the material and a knowledge check form was created. 8. A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 2/16/2023 and will be completed for all nurses either in-person or via telephone on 2/16/2023. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 9. The DON and ADON initiated a monitoring form on 2/16/2023 to track all changes in condition daily on weekdays and weekends via review the electronic 24-hour reports found on PCC, new orders, new medication orders, hospital transfers and nursing documentation of a change in condition and notification to family and physician. Follow up on interventions and updates to the plan of care will be completed by the DON and ADON. The daily monitoring by the DON and ADON began 2/16/2023 and will be ongoing. 10. Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians. Monitoring 11. Knowledge checks were initiated on 2/16/2023 will be completed on all nurses by 2/17/23 either by phone or one on one conversations by the DON, ADONs or Clinical Resource. These knowledge checks will be ongoing throughout the Quality Assurance process, reported weekly to the QAPI committee meeting for 4 weeks or until substantial compliance is established and then monthly for 90 days. 12. This knowledge check will be completed for 5 random nurses weekly by the DON, ADONs or Clinical Resource. The knowledge check questions include: o If a resident has a change of condition the nurse should? o Get a full set of vital signs o Notify the attending physician Notify Family o Notify nurse management o Follow the facility policy o All of the above o If a resident develops a change of condition the nurse must document for 72 hours or longer if necessary. o True o False o Signs and Symptoms of a stroke include: o Facial droop, weakness on one side, slurred speech o Bilateral leg weakness, pain in legs o Abdominal pain, foul smelling urine, sediment in urine o If the resident develops signs of a stroke and has abnormal vital signs, it is best to call: o The physician o Calf 911 for medical emergency o The family to come talk to them o If a resident has a change of condition the care plan must be updated with the interventions. o True o The nurse should document the change of condition using the e-lnteract change of condition form? o True o False If the attending physician is unavailable who do you contact o Nobody o Medical Director o Another Nurse 13. Daily review of all changes in condition daily via review of 24-hour report, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation by the DON and ADONs. This information will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance is established, then monthly for 90 days. 14. Weekly clinical meetings to discuss changes in condition and hospital transfers. Meeting attendees will include the Clinical IDT; DON, ADON, Administrator, MDS, Dietary Manager, Activities Director, Social Services, and Rehab Director. Meeting minutes will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. QAPI meetings content will include changes in condition, hospital transfers and residents requiring antiseizure medications. 16. Follow up on IJ Plan of Removal and monitoring will be verified by the DON and the Administrator by review of change on condition documentation through the weekly clinical meeting, review of nurse knowledge check obtained throughout the week, hospital transfer logs, and the weekly QAPI meeting. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interview with RN A on 02/14/23 at 12:25 p.m. revealed she was the charge nurse providing care for Resident #1 during the day and evening shifts (6:00 a.m. to 10:00 p.m.) on 01/27/23, 01/28/23 and 01/29/23. She stated during the afternoon on Friday 01/27/23, Resident #1 complained of numbness to the left side of his face. RN A stated she rubbed a toothpick alone the side of Resident #1's face and the resident told her he was able to feel it. She stated she did not perform a complete neurological assessment to include assessing the resident's hand grips. She stated the resident's blood pressure was ok but was not able to recall the results. RN A further stated she texted the NP that Resident #1 was complaining of numbness to his face but never received a response/call back from the NP. Additionally, RN A stated she checked on the resident frequently throughout the weekend and the resident was stable, vital signs including blood pressure readings were stable and the resident voiced no further complaints. RN A stated she expected some type of response from the NP even if it was just an ok to acknowledge the message was received. RN A stated she made no further attempts to contact the NP or physician. RN A provided no explanation as to why she did not follow-up with the NP or physician regarding Resident #1's change in condition. When asked why, she stated the resident was stable. RN A stated on Monday 01/30/23 Resident #1 complained of numbness to his forehead and to his face. The NP was in the facility on 01/30/23 and ordered the resident to be transferred to the ER. RN A stated she did not recognize Resident #1's signs/symptoms could have been related to the resident having another stroke. She further stated she had received training after the resident was transferred to the hospital on signs and symptoms of stroke and if she did not receive a response after contacting the physician or NP, she should call again within 30 minutes. RN A was able to verbalize she was now aware that signs and symptoms included numbness/weakness, on one side of the body, headache, change in mental status, facial drooping, or problems with speech. Review of the in-service training records dated 02/16/23 revealed licensed nurses staff received training related to completing head-to-toe assessments, who to notify when residents experienced changes in condition, S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, summoning 911 if changes in condition were emergent and contacting the Medical Director if they were unable to reach the primary physician. Review of knowledged check tests reveled all nursing staff had completed and passed the knowledge check. Interviews were conducted with 11 licensed nurses (LVN G, RN D, LVN E, LVN F, RN G, LVN H, LVN I, LVN J, RN K and LVN L) across multiple shifts on 02/17/23 from 12:42 p.m. to 1:50 p.m. and from 3:00 p.m. to 3:10 p.m. The nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on S/S of a stroke, completing a full assessment to include obtaining a full set of vital signs for residents with changes in condition, contacting the primary physician, and contacting the Medical Director if they were unable to reach the primary physician. The Administrator was notified on 02/17/23 at 4:00 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/17/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.