**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 26 residents (Resident #1, #2, and #3) reviewed for accidents and hazards supervision, in that: 1. Resident #1 was found in in another town about an hour's drive from the facility. 2. Resident #2 was spotted going down looking (sic) at cars outside of the facility and had not been supervised the whole time she was outside of the facility. There were no assessments (to include skin assessments) done for Resident #2. 3. Resident #3 eloped and was found walking down the street. Resident #3 had a wander guard but nursing staff did not hear any door alarm with this exit. An IJ was identified on 01/16/25 at 04:45 PM, The IJ template was provided to the facility on [DATE] at 05:45 PM. While the IJ was removed on 01/19/25 at 01:06 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on supervision and elopement. This deficient practice could result in a risk to the residents' health and safety and placed the residents at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. The findings included: 1. Record review of Resident #1's admission record, dated 01/15/25, reflected a [AGE] year-old male with admission date 08/31/24 and discharge date [DATE]. It reflected Resident #1 had diagnoses to include alcohol abuse with intoxication delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly) and alcohol dependence with alcohol-induced persisting amnestic disorder (a disturbance in memory). Record review of Resident #1's BIMS assessment, dated 09/04/24, reflected a score of 10 out of 15, indicating moderate impairment. Record review of Resident #1's Baseline Care Plan assessment, dated 08/30/24 and created by ADON B, reflected no answers for sections 3. Health Conditions . B. Level of Consciousness/Cognition . H. Safety Risks . 9. Is the resident an elopement risk?, mental health needs, and behavioral concerns. Record review of Resident #1's Elopement Risk Assessment, dated 08/31/24, reflected Resident #1 was Moderately impaired-decisions poor; cues/supervision required with One or more times [previous attempts to leave residence/facility] in the last week. It further revealed Resident #1 did not recognize stop lights and signs, did not know precautions when crossing streets, did not know location of current residence, did not know location of current residence, and did not recognize physical needs. The assessment further revealed he was at high risk for elopement and Wanderguard appropriate at this time-initiate wanderguard interventions. Record review of Resident #1's September 2024 MAR, dated 01/15/25, reflected: VISUAL CHECK EVERY 2 HOURS . for elopement risk with a start date of 08/31/2024. WANDER GUARD CHECK PLACEMENT EVERY SHIFT . with a start date of 09/04/24 and D/C Date of 09/10/24. Record review of Resident #1's hospital documents, dated 08/30/24, revealed Resident #1 was admitted to the hospital on [DATE]. The hospital documents reflected Resident #1 comes into the ED today from the local jail for altered mental status . He was going through alcohol detox and thought related to his detox but he complete(d) the program today and still was not in a normal mental status. [Resident #1] is disoriented and can give his name but not his date of birth , the current year, where he is. Record review of Resident #1's Nurse's Note, authored by LVN C, dated 08/31/24 at 01:28PM, reflected Resident has attempted to get out of the back doors to the facility several times this shift. He states that he wants to go home . Obtained new order from PCP for medications to assist with anxiety and added 2 hour location checks to charting. Resident continues to insist that he has to leave. Record review of Resident #1's progress notes in PCC reflected no mention of Resident #1 leaving the facility on 09/04/24. Record review of a statement provided by the DON AK, authored by the DON AK, undated, reflected, I was notified by [ADON B] that [Resident #1] was no longer in the facility, facility was searched and head count was done to ensure other residents were all accounted for. Every resident with the exception of [Resident #1] was accounted for. Sign out book was checked, resident had not signed out. When facility and property was checked, it was noted that pillows and personal effects were placed on an employee's car. Family, administration and authorities were notified. [Received] notification from authorities that resident was pulled over in a vehicle (that did not belong to him) and taken to (another town) for further detainment. [Administrator G] went to pick up resident and brought him back to facility. Full body assessment done per [DON AK]. No injuries or discolorations noted at this time. No s/s of distress. Resident was apologetic for leaving without notifying anyone. [Resident #1] was alert and oriented and knew what he was doing was wrong but continued to leave the facility [without] signing out. Resident suffers from alcoholism which causes some disorganized thinking processes. Resident was able to explain what roads he took to get to where he was at and that he took a car without permission. Resident was safely brought back to facility via [Administrator G] and was encouraged to enter a detox center. Resident agreed and was ultimately safely discharged to another facility that specializes in detox from substance abuse. During an interview on 01/15/25 at 12:45 PM, Resident #1's RP revealed Resident #1 was confused but she did not know how confused or how bad his condition was after his hospital stay, several weeks before admission. She revealed the facility should have Resident #1's hospital documentation to reflect his mental status. She revealed she did not want to get the facility in trouble because it was her fault that she didn't realize what his new baseline mental status was. She revealed she would think the facility would have assessed Resident #1 to know how to care for resident and should have kept eyes on Resident #1 to prevent him from leaving the facility as she found out that his mental status was poor, after Resident #1 left the building. Resident #1's RP did not reveal any details about where the resident was found but the administrator had to drive to pick up Resident #1 from another location. During an interview on 01/15/25 at 01:17PM, RN A revealed she did not do the 4 AM check on 09/04/24 , which was a part of the doctor's orders to check on Resident #1 every 2 hours. RN A revealed when the morning shift was coming into the facility, they saw clothes that had Resident #1's name on them. RN A went to Resident #1's room and he was gone. During an interview on 01/15/25 at 02:45PM, LVN F revealed she knew Resident #1 was an elopement risk due to his behavior from the previous day. She revealed the nursing staff found Resident #1 was not in his room when the 6AM staff came in for their shift. The nursing staff searched inside and outside of the facility and found Resident #1 was no longer on the premises. LVN F revealed she called Administrator G and another nurse (unidentified) called the DON. She revealed Administrator G instructed her to call the local police department to report a missing person. LVN F could not identify what staff member called the local police department. She revealed Administrator G found out Resident #1 was in another town about an hour's drive away from the facility went to pick him up, brought Resident #1 back to the facility, and worked on placing Resident #1 in a different facility this same day. LVN F revealed she felt this incident was considered an elopement, however, LVN F was corrected by Administrator G this was not an elopement because Resident #1 could explain what and why he left the facility. LVN F further revealed she recalled Resident #1 did not have a wander guard bracelet on because there were not enough wander guard bracelets available at this time. LVN F revealed she was not trained on elopements or wandering after this incident . LVN F knew what to do for residents who wandered or were at risk for elopement. During an interview on 01/16/25 at 06:35 AM, the CDM revealed after the incident involving Resident #1, the dietary department was trained on elopement and signed a sheet someone from the nursing department handed them. She further revealed her whole department signed a sheet to prove they got trained. (This sign-in sheet was not able to be produced by the facility.) During an interview on 01/16/25 at 08:13 AM, the DON revealed Resident #1 did not elope but left AMA because he had intact cognition but presented with disorganized thinking due to his alcoholism. She revealed she was told by nursing staff that Resident #1 was not in his room during a visual check. She revealed Resident #1 was on visual checks because she thought it was good protocol to have him on visual checks because he had disorganized thinking. She further revealed Resident #1 did not sign out on pass and he had doctor's orders to go out on therapeutic pass. The DON revealed she did not know if Resident #1 was capable of driving a car. She revealed she did not know if Resident #1 was an elopement risk but an elopement risk assessment would let the staff know. She revealed when Resident #1 was not in his room, they did a head count, and they couldn't find him on the premises. The DON revealed at this point, he was considered missing and they called the authorities, PCP, RP, and Administrator. When they called the authorities, they found him at another town'spolice department. She revealed the family who owned the car Resident #1 took from the nursing home parking lot did not decide to press charges against Resident #1. The DON revealed she started working at the facility in May 2024. She revealed staff were trained on wandering and elopement before this incident. She revealed Administrator G stated corporate risk management team did not consider this an elopement and the facility was advised not to report this incident to HHSC. She further revealed Administrator G said risk management advised the facility not to document in PCC and to do a soft file (physical copy) of this incident to include assessments of Resident #1. The DON revealed she trained everyone face to face, but she did not have a staff roster when training her clinical staff to train all of these staff members. The DON revealed if she did not get to train nursing staff, she left it in the binder where nurses signed in for their shift. She further revealed the nursing staff know to read what she puts in the binder and sign off that they read the pertinent documents. The DON revealed she only trained her department and no other departments. She further revealed she did not train the office staff. During an interview on 01/16/25 at 01:40PM, Confidential Staff N revealed they heard no one was going to report when Resident #1 eloped and was found in a different city about an hour away. They further revealed ADM G picked Resident #1 and brought him back to the facility but was not aware of anything else. They revealed they were told not to report this incident to HHSC because the facility was going to handle this incident a different way. During an interview on 01/16/25 at 02:37PM, ADM G revealed Resident #1 had alcohol induced dementia. ADM G revealed Resident #1 told him he looked out the window one night and thought he saw his wife's car and it was time to go home. ADM G revealed he remembered the facility staff called him, the police were involved, they tracked his phone, and the authorities had pulled him over in another town about an hour away. ADM G revealed he drove to the town to pick Resident #1 up from the police station. He revealed Resident #1 did not know where he was going. He revealed they had a conversation with the facility's ownership immediately about this incident. ADM G further revealed he thought this incident was reportable. ADM G revealed the COO gave them direction to not report this incident to HHSC. ADM G revealed Resident #1 did not have a wander guard bracelet. He revealed the front doors going outside did not lock overnight. He revealed he remembered knowing this was an issue, figuring out how to prevent residents from leaving the facility overnight. ADM G after he picked up Resident #1 he filled out a self-report form, in-serviced some staff about ANE and elopement and was still working on this. He revealed he started the paperwork as soon as he came into the building because he knew he was on the clock to complete in order to report to HHSC. During an interview on 01/16/25 at 04:16PM, the Medical Director revealed Resident #1 was at risk for elopement and he requested for everything to be done before Resident #1 left the building on 09/04/24. He further revealed he was contacted after this incident and the expectation was to ensure Resident #1 did not leave the facility for the resident's safety. 2. Record review of Resident #2's admission record, dated 01/15/25, reflected an [AGE] year-old male with admission date 08/13/24 and discharge date [DATE]. It reflected Resident #2 had diagnoses to include dehydration, altered mental status, muscle weakness, abnormalities of gait or mobility, lack of coordination, dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and depression. Record review of Resident #2's Care Plan, close date 09/09/24, reflected focus The resident is an elopement risk/wanderer r/t impaired safety awareness, initiated 08/15/24 with interventions to include WANDER ALERT bracelet check placement and functioning q shift. Record review of Resident #2's August 2024 MAR, dated 01/15/25, reflected: WANDER GUARD CHECK FOR FUNCTION EVERYDAY. with a start date of 08/14/24 and D/C Date 09/03/24, filled out appropriately for day and night shifts. VISUAL CHECK EVERY 2 HOURS with a start date of 08/14/24 and D/C Date 09/03/24, filled out appropriately. Record review of Resident #2's Elopement Risk Assessment, dated 08/14/24, reflected Resident #2 was Moderately impaired-decisions poor; cues/supervision required with One or more times [previous attempts to leave residence/facility] in the last week. It further revealed Resident #2 did not recognize stop lights and signs, did not know precautions when crossing streets, did not know location of current residence, did not know location of current residence, and did not recognize physical needs. The assessment further revealed he was at high risk for elopement and Wanderguard appropriate at this time-initiate wanderguard interventions. Record review of Alert Note, authored by AD, dated 08/22/24 at 12:06PM, reflected, AD finished exercise group in main dining room and on the way back to AD office alarm in activities room was going off. AD looked out the outside door to make sure no one had gone out. Upon looking down the sidewalk resident was spotted going down looking (sic) at cars. She thought her son was out there. AD approached and redirected resident back to building and inside. AD and resident went to find the charge nurse to let her know about the adventure. [DON] was at the nurse's station as well, so she is (sic) aware of the incident. Record review of Resident #2's progress notes and assessments reflected no skin assessments were done after Resident #2 was found outside of the facility on 08/22/24 around 12:06PM. During an interview on 01/15/25 at 12:15 PM, LVN E revealed if a resident left the building and there were no eyes on the resident, she would complete a skin assessment on resident. After reading the alert note on 08/22/24 at 12:06PM, LVN E revealed she would have done a skin assessment on Resident #2 because Resident #2 exited the building and it appeared there was some time where a staff member wasn't with Resident #2. During an interview on 01/16/25 at 08:13 AM, the DON revealed Resident #2 was found on the facility sidewalk by the AD. She revealed Resident #2 was still on property and this incident was not reported because Resident #2 was on the premises. During an interview on 01/16/25 at 01:05PM, the AD revealed she had heard the door next to her office sound, so she went to check to see if a resident had left the building. She revealed Resident #2 was observed walking on the sidewalk between the nursing home parking lot (on her left) and the facility building/yard (on her right). The AD revealed Resident #2 was able to walk past 3 trees on the right side of her before she laid eyes on Resident #2. The AD revealed she was able to go outside and redirect Resident #2 to come back into the facility. The AD revealed she was trained on elopement this morning and had already been trained prior to this morning. During interview on 01/16/25 at 10:57 AM, the DON revealed there were no skin assessments done for Resident #2 on or after 08/22/24. 3. Record review of Resident #3's admission record, dated 01/15/25, reflected a [AGE] year-old female with admission date 02/07/24 and discharge date [DATE]. It reflected Resident #3 had diagnoses to include abnormalities of gait and mobility, repeated falls, lack of coordination, muscle weakness, hypertension (high blood pressure), and dementia. Record review of Resident #3's Care Plan, close date 03/20/24, reflected focus The resident is an elopement risk/wanderer r/t impaired cognition Dementia wandering about in wc not easily redirected . 3/17/24 eloped from facility, located and easily redirected back to facility . 3/13/24 eloped out front doors to sidewalk easily redirected back into facility, initiated 02/07/24, with interventions to include WANDER ALERT bracelet applied check placement and function q shift, initiated 02/13/24, careplan meeting pending for alternated placement for secure unit for safety, initiated 03/14/24, 1:1 initiated, still attempting to assist family to find a suitable secured unit for her safety, initiated 03/18/24. Record review of Resident #3's March 2024 MAR, dated 01/15/25, reflected: WANDER GUARD CHECK PLACEMENT EVERY SHIFT, with a start date 02/12/24 and D/C date 03/25/24, filled out appropriately for day and night shifts. WANDER GUARD CHECK FOR FUNCTION EVERYDAY, every shift with a start date 02/12/24 and D/C Date 03/25/24, filled out appropriately for day and night shifts. Record review of Resident #3's Elopement Risk Evaluation V 2.0, dated 03/13/24, reflected Resident #3 was at risk for elopement. Record review of Resident #3's admission MDS assessment, dated 02/12/24, reflected Resident #3 had a BIMS score of 05 out of 15, indicating severely impaired cognition. Record Review of written statement in intake 491104's investigation provided by the facility, undated, by COTA J reflected I was alerted by [Unidentified resident] that [Resident #3] was outside. [unidentified resident] stated that she saw her walking down a road opposite direction of our building from her window. I immediately found [LVN F] to alert her of [Resident #3] being outside. We both left the building to look in the direction of where [unidentified resident] last saw her go. [LVN F] was able to quickly locate [Resident #3] and guide her back to the building. Record review of written statement in intake 491104's investigation provided by the facility, dated 03/17/24, by DON K reflected .[Resident #3] continues on [every 15 minute] checks that were initiated Friday, 3/15/24 . [LVN F] reports wanderguard device has been alarming appropriately but they did not hear any door alarm with her last exit from the [building]. She is unsure why there was no alarm sounding when she went to retrieve her through the front door exit. During an interview 01/15/25 02:02 PM, the Business Office Manager was not aware if she was trained on elopements. She revealed she would contact the Administrator or the DON if she saw a resident leaving the facility. She revealed she would try to redirect the resident and try to stop the resident from leaving the facility. She would try to get help, even calling someone while trying to help resident. During an interview on 01/15/25 at 03:14 PM, RN H revealed she had received an in-service on wander guards and what to do for residents who wandered but had not been trained on elopements. She revealed it would be a good idea to be trained on elopements because she was not aware of how to help her coworkers if an elopement occurred. RN H stated rhetorical questions (questions to make a point rather than to get an answer) like Do we notify the doctor or RP?. She revealed she was present when Resident #1 eloped and stated she was not asked for a witness statement, which she felt would be the procedure for this incident to figure out how this resident left the building. Observation 01/16/25 at 04:32AM revealed the facility's front door was locked from the outside. However, it was revealed the doors were not locked going from the inside of the facility to the outside of the facility. During an interview and observation on 01/16/25 at 04:38AM with ADON B, ADON B revealed there were 2 doors to open before accessing the outside, in the front of the building. The first door had a machine attached to the door that should lock the doors if a resident with a wander guard bracelet approached the door. She further revealed if a resident had a wander guard the first door should lock itself to prevent these residents from walking outside, however, if the 1st door was held open for 15 seconds, then the resident could walk out but the alarm will continue to sound. She revealed when the alarm sounded, the staff would look to see what exit was alarming to investigate if a resident left the building or not. She further revealed the second and last door that goes to the outside did not have an alarm. ADON B revealed residents without wander guards could open both doors to exit the front of the building without any alarms sounding. ADON B further revealed if a resident was allowed to go out on pass and wanted to leave, they would have to sign out with staff. She revealed there were no current residents that sign out on pass during the overnight shift. During an interview on 01/16/25 at 05:27AM, the current administrator (Administrator I) revealed if there was a confirmed elopement or abuse, neglect, exploitation, he would print the current staff roster and train 100% of all facility staff members. He revealed he would be important for all staff to know what to do in the case of these situations. During a combined interview on 01/16/25 at 05:51AM, RN A and CNA D revealed they did not recall being trained about topics that included elopement or residents who wander after the incident where Resident #1 left the facility. RN A revealed she did know a little bit of what to do if a resident eloped and she would check all the rooms and outside of the facility if the door alarmed. CNA D revealed those residents with wander guards would alarm the door if they opened the door to exit the facility. RN A revealed she knew what residents were at risk for elopement because it popped up on her point of care screen. CNA D revealed she knew residents were at risk for elopement if they were wearing a wander guard, but it did not show her on her point of care screen. During an interview on 01/16/25 at 01:54PM, OT AQ revealed since February 2024, she had not received any training to include elopement and Abuse, Neglect, and Exploitation. She was educated on Elopement this morning to include pay attention to exit seeking behaviors. During an interview on 01/16/25 at 04:09PM, COTA J revealed Resident #3 left the building and walked down the road and about 1 to 2 blocks away from the facility before an unidentified resident told her they saw Resident #3 outside. She revealed she did not recall how Resident #3 got out and that the door alarms did not sound when resident left the building. She revealed she was trained on elopement before this incident and refreshers after . Record review of in-service about policy Wandering and Elopements, dated 03/17/24, reflected 20 staff were in-serviced. Requested staff roster for 03/17/24 on 01/15/25 at 09:50AM and no staff roster was able to be provided. Record review of in-service, undated, titled Elopement Risk Residents/Q2hr checks, reflected 8 nurses were in-serviced. The summary of this in-service reflected, As nurses, we need to make sure we are constantly laying eyes on our residents especially our elopement risk residents. Rounds must be made at the very least, 2hrs, if not sooner. It is our responsibility to keep our residents safe. It is of the upmost importance that we are correctly documenting our 2hr checks on these resident and appropriately documenting exit seeking behaviors. This is not an option. An Immediate Jeopardy (IJ) was identified and presented to Administrator I on 01/16/25 at 05:45 PM. A Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 01/17/25 at 06:19 PM. 1) Resident #1, Resident #2 and Resident #3 no longer reside in facility. 2) DON Inserviced all staff on elopement policy, 1/16/2025 those who cannot be reached by telephone will be in-serviced when they return to work before taking the floor, by DON. This will be ongoing process and new hire employees will be in-serviced on elopement policy during hire process. 3) Maintenance to verify all wanderguards in use in facility are functional 1/16/25. This was completed 01/16/25. Verified by administrator. Maintenance will make these checks daily Monday thru Friday and nursing staff makes the checks on weekends. These daily wanderguard checks are documented in Point Click Care Nurse Medical Administration Record. 4) Maintenance to verify all doors with wanderguards or alarms are functional this was completed 1/16/25 verified by the administrator. Door locks are checked Monday through Friday by Maintenance. Maintenance documents on his written log. Doors with wanderguard alarms alert and locks the door when resident with wanderguard approaches. Doors with wanderguard system do not alert if staff or visitors open door. Doors with other exit alarms alert when staff, residents or visitors open door. The front door also has the receptionist observing during business hours. When the receptionist leaves the doors are unlocked for staff and visitors but lock automatically with approach of resident with wanderguard. The facility monitors doors after hours by staff responding to alarms. A visitor exiting and a resident behind them with a wanderguard still sets off the alarm as witnessed by Surveyor. Staff responds to door alarms to ensure the safety of residents who wander. Front double door doors will be locked with keypad. Staff will unlock for visitors to enter or exit. 5) Updated elopement assessment on all current residents 1/16/25. Completed by DON, ADON, and MDS nurse. Residents with wanderguards are identified for staff in the front of the elopement binder, on the home dashboard of Point Click Care and the Kardex. Residents may be at high risk for elopement but not actively exit seeking. Until we see exit seeking behavior, they would not be deemed appropriate for an actual wander guard. At the bottom of the elopement risk assessment, it asks if a wanderguard is indicated. If the answer is yes then we would apply a wanderguard. Nurses in-serviced on 1/17/2025 by Administrator to ensure that checks ordered by physician are completed and documented timely. Nurses not in facility today will be in-serviced before they begin their next shift in the facility, this will include new hires. Interdisciplinary team will review elopement assessments that trigger for high risk to determine if a wander guard is warranted. 6) Residents with wanderguards have current orders, careplan and elopement assessment. Completed by ADON on 1/16/25 7) Elopement binders equipped with all high risk for elopement resident facesheets at the front, and all other residents facesheets behind the tab were placed at the nurses station and at the receptionist desk by the DON/Administrator. 8) Staff were inserviced by BOM regarding the elopement binders, where they are located, and how to use them on 01/16/2025. 9) The administrator inserviced on 1/16/2025 the DON and ADON to update the facesheets in the elopement binder with any new admission, or change in elopement risk from low risk to high risk. All nursing staff were inserviced on the elopement policy, including all assessments and notifications to RP and provider that are required, by the DON on 01/16/2025. All nursing staff will receive the inservice prior to starting their next shift. 10) All residents at high risk for elopement will be identified on the C NA Kardex. This inservice will be delivered by the DON to all staff on 01/16/2025. All staff will receive this inservice prior to starting their next shift. 11) All residents who are at high risk for elopement will be added to the home dashboard on the EMR by the DON on 01/16/2025. An inservice will be provided by the DON on 01/16/2025. All nursing staff will receive this inservice prior to beginning their next shift. 12) Facility completed internal investigations on the three elopement incidents. 13) Medical Director informed of IJ on 1/16/2025 by Administrator 14) Ad Hoc QAPI, 1/16/2025 reviewed the IJ, What occurred and what the facility has in place to prevent it from recurring. POR verification was as follows: Record review of facility's discharge list, dated 01/17/25, reflected Residents #1, 2, and 3 were discharged . Resident #3 discharged home on 3/18/24; Resident #1 discharged home on 9/4/24; and Resident #2 discharged to an ALF on 9/3/24. Record review of facility's in-service sheets dated 01/16/25 at 5:45 PM to 01/17/25 at 5:30 PM reflected: 41 staff working had been in-serviced on elopement (100% training rate). Total paid staff was 65. Record review of Logbook Documentation, dated 01/16/25-01/18/25, reflected all doors passed for magnetic door locks(100 hall, 200 hall, 300 hall, 300 hall service door, 400 hall, family room, front door, main dining room, small dining room, therapy rehab gym) and resident monitoring system (400 hall, therapy rehab gym, front door, and Residents #4-10). Record review of the home dashboard of Point Click Care, posted 01/16/25, reflected: Residents at High Risk for Elopement: Resident #4 Resident #5 Resident #6 Resident #7 Resident #25 Resident #24 Resident #23 Resident #22 Resident #21 Resident #20 Resident #19 Resident #18 Resident #9 Resident #10 Resident #26 Resident #16 Resident #15 Resident #13 Resi[TRUNCATED]

Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: The facility failed to implement their policy to report and investigate Resident #21's 11/21/23 fall with a serious injury, per [state agency] guideline. The Administrator, DON, and LVN D did not report Resident #21's fall with a fracture to the state agency. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment, contributing to further serious injuries. The findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admission date of 11/11/23 with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Record review of Resident #21's Nurse's Note, authored by LVN D, on 11/21/2023 at 01:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. There were no other notes pertaining to an investigation of the 11/21/2023 incident. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed the DON and LVN D did not report Resident #21's fall on 11/21/23 fall that resulted in a fracture. Record Review of Resident #21's incident reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. Record Review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. There was no record of a Provider Investigation Report of the 11/21/2023 fall with serious injury. Record review of the facility's Change in a Resident's Condition or Status, revised February 2021, revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):1. Accident or incident involving the resident. Record review of the facility's Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents . 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administer receives a copy of the Report of Incident/Accident form for each occurrence. 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record Review of Long-Term Care Regulation Provider Letter, revised 01/19/23, revealed A provider must report reportable incidents to [state agency] Complain and Incident Intake In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. On 1/17/2024 at 11:11 AM, there was a request for the Abuse, Neglect, Exploitation policy from the Administrator. No policy was provided. This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on nterview and record review the facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #21 had an unwitnessed fall with a serious injury on 11/21/23, per [state agency] guideline. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment, contributing to further serious injuries. The findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admission date of 11/11/23 with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Record review of Resident #21's Nurse's Note, authored by LVN D, on 11/21/2023 at 01:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. There were no other notes pertaining to an investigation of the 11/21/2023 incident. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed the DON and LVN D did not report Resident #21's fall on 11/21/23 fall that resulted in a fracture. Record Review of Resident #21's incident reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. Record Review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. There was no record of a Provider Investigation Report of the 11/21/2023 fall with serious injury. Record review of the facility's Change in a Resident's Condition or Status, revised February 2021, revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):1. Accident or incident involving the resident. Record review of the facility's Accidents and Incidents-Investigating and Reporting, revised July 2017, revealed, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . 3. The facility is in compliance with current rules and regulations governing accidents and/or incidents . 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administer receives a copy of the Report of Incident/Accident form for each occurrence. 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Record Review of Long-Term Care Regulation Provider Letter, revised 01/19/23, revealed A provider must report reportable incidents to [state agency] Complain and Incident Intake In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. On 1/17/2024 at 11:11 AM, there was a request for the Abuse, Neglect, Exploitation policy from the Administrator. No policy was provided. This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of residents, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 24 residents (Resident #21) reviewed for quality of care, in that: The facility failed to ensure Resident #21 received appropriate assessments and interventions due to being at high risk for falls. The facility failed to develop Resident #21's care plan to address interventions for risk of falls. Resident #21 had a fall on 11/21/2023 which resulted in an emergency hospitalization for a hip fracture and was admitted to the facility without any interventions for Resident #21's high fall risk. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of not receiving the necessary medical assessments and treatments and contribute to a decline in health status. These findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admission date of 11/11/23 and re-admission date of 11/25/23 with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23, revealed Resident #21 had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #21 was assessed with a need for help with self-care and functional cognition. Resident #21 used a walker and a wheelchair in the past 7 days. Resident #21's admission performance was substantial/maximal assistance for the following: toileting hygiene, putting on/taking off footwear, and lower body dressing. Resident #21 had a fall in the last month prior to admission. Resident #21 also had 91 minutes of individual occupational therapy in the last 7 days and 59 minutes of individual physical therapy in the last 7 days. The Care Area Assessment Summary for falls revealed the care area for falls was triggered, For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. Record review of Resident #21's MDS assessment, dated 11/28/23, revealed Resident #21 had the following declines, when compared to her 11/14/23 MDS admission assessment: Instead of needing substantial/maximal assistance, Resident #21 was dependent for putting on/taking off footwear. Instead of partial/moderate assistance, Resident #21 needed substantial/maximal assistance for toilet transfer. Resident #21 had a new active diagnosis of hip fracture. Resident #21 had a fall in the last month, in the last 2-6 months, and had a fracture related to a fall in the last 6 months. Resident #21 had a new health condition of Hip Replacement. Resident #21 had a new skin condition of a surgical wound. fall in the last month prior to admission. Resident #21 also had 82 minutes of individual occupational therapy in the last 7 days and 67 minutes of individual physical therapy in the last 7 days. There was no Care Area Assessment Summary for this assessment. Record review of Resident #21's care plan revealed Resident #21 had the following: Problem: Transfers, initiated 11/13/23, with an intervention of 1 person assist .Problem: Ambulation/Mobility, initiated 11/13/23, with an intervention of 1 Person Assist and Uses [NAME] .Problem: The resident has limited physical mobility, initiated 11/13/23, with an intervention of The resident uses a walker for walking .Problem: The resident has impaired cognitive function/dementia or impaired thought processes, initiated 11/13/23, with an intervention of Cue, reorient and supervise as needed. Problem: The resident has an alteration in musculoskeletal status LEFT HIP FX .initiated 12/29/23, with interventions Anticipate and meet needs . Problem: The resident has impaired visual function, initiated 11/13/23, with an intervention of Ensure appropriate visual aids glasses are available to support resident's participation in activities . Record review of Resident #21's care plan revealed no documentation of Resident #21 being at risk for falls after admission on [DATE] and re-admission on [DATE]. Record Review of a Nurse's note, authored by LVN B, on 11/11/23 at 01:05 PM revealed, [Resident #21] arrived via [van] for a fall. ***FULL CODE*** No know[n] allergies. A&0 x 3 with confusion. Skin intact Record review of Resident #21 ' s Nurse's Note, authored by LVN D, on 11/21/2023 at 1:42 PM revealed, It was reported to this nurse that [Resident #21] had fallen in her room during independent transfer. It was noted [Resident #21] was unable to move left hip after the fall during assessment. [Resident #21] c/o pain to left hip which was new pain for her. EMS called to send resident to ER for evaluation and treat due to above information. [Resident #21] left facility via EMS at 1342 [01:42 PM]. Record Review of Resident #21's hospital visit, dated 11/21/23, revealed chief complaint of hip fracture with diagnosis that included fracture of .part of neck of left femur (thigh bone) and fracture of part of her left arm [bone] and discharge recommendations for physical therapy and occupational therapy at a Skilled Nursing Facility. During an interview on 01/12/24 at 01:47 PM, MDS nurse C revealed there had been an issue of completing eINTERACT Change in Condition assessments. There was training on completing change in condition assessments. MDS nurse C stated Change in Condition assessments were completed after an injury and after falls. MDS nurse C stated after a resident falls, progress notes and incident reports were to be completed. MDS nurse C further revealed if a resident was a fall risk, it should be documented in the resident's care plan. MDS nurse C revealed that she thought every resident in the facility should be considered at risk for falls. MDS nurse C revealed that a resident's initial care plan came after the IDT admission assessment and Resident #21's care plan was missing Resident #21 she was at risk for falls. MDS nurse C noted that Resident #21's Fall Risk Assessment showed that Resident #21 was a high fall risk. After Resident #21 admission on [DATE], after being sent to the hospital for her 11/11/23 fall, the MDS nurse C admitted to not updating Resident #21's care plan to reflect that Resident #21 was at risk for falls. During an interview on 01/12/24 at 03:23 PM, ADON A revealed Resident #21 came back to the facility on [DATE]. ADON A revealed there was not an incident report for the 11/21/23 fall, because Resident #21 went to the hospital and the incident report should have been done when Resident #21 came back. ADON A read aloud the 11/21/2023, Resident #21's nurse progress note, authored by LVN D, to provide information about this incident. ADON A stated that EMS was called and LVN D wrote Resident #21 had left hip pain. ADON A could not give further details about this incident. ADON A further revealed that nursing staff was trained on making incident reports but it would be good to re-train the nursing staff. During an interview on 01/12/24 at 04:33 PM, LVN D revealed that she was not aware of Resident #21 had a fall on 11/11/23. During an interview on 01/12/2024 at 06:04 PM, ADON A revealed there could be an education for when to fill out an incident report and training on falls. ADON A revealed the baseline care plan included falls. ADON A revealed the MDS nurse was to ensure that at risk for falls was added to resident care plans for interventions. During an interview on 01/13/24 at 01:07 PM, the Medical Director revealed there was a high turnover of staff and visiting nurses who did not know specific care for the residents. She further revealed they may not be familiar with the facility's policies. The Medical Director revealed most residents should be identified as high fall risks, making sure there were interventions in place like call lights working. The Medical Director stated since Resident #21 fell before that it would be a given to include being at risk for falls in her care plan. She stated residents with no interventions for those at risk for falls could have recurrent falls. During an interview on 01/13/24 at 01:47 PM, CNA I (who worked on 11/21/23 from 6 AM to 2 PM with Resident #21) revealed she did not recall a fall that occurred on this day. During an interview on 01/13/24 at 01:59 PM, NP Y, who worked for Resident #21's doctor and has worked with Resident #21 to her admission to the facility revealed he recounted care for Resident #21 as follows: Prior to being admitted to this facility, Resident #21 fell, went to the hospital, and then went back to her Assisted Living Facility. She was prescribed medication for pain and became increasingly confused. She had to go back to the Emergency Room. She was treated and assessed at the hospital, and it was determined that she needed to go to a nursing facility for some rehab. NP Y revealed Resident #21 had dementia and it could have contributed to her fall. NP Y revealed after her 11/21/23 fall, Resident #21 sustained a fracture to her shoulder and her hip. He revealed Resident #21 came back to the nursing home facility to continue rehab. NP Y further revealed his expectation was for the facility to have interventions to prevent falls because Resident #21 was a high fall risk. He recommended that Resident #21 should have been monitored every 2 hours and have her call bell within reach, at the very least. NP Y also mentioned Resident #21 had a UTI, which could have also contributed to her 11/21/23 fall. During an interview on 01/13/24 at 02:08 PM, the DON revealed that all nursing management staff were out, with covid the week of 11/21/23 when the fall occurred. The COVID outbreak date was 11/15/23. The DON revealed that the baseline care plan [NAME] for the CNAs was created after the Interdisciplinary team (IDT) assessment. The DON revealed, if a resident had a fall, a risk assessment report would trigger a fall risk assessment to be completed and an action plan would be triggered as well. The DON revealed MDS nurse C was responsible for completing baseline care plans. The DON revealed that LVN D would be able to give more details about Resident #21 ' s 11/21/2023 fall. During an interview on 01/13/24 at 03:26 PM, the Administrator revealed Resident #21 was identified as a high risk for falls due to a fall risk assessment. The Administrator revealed the facility ' s electronic medical record system did not automatically add Resident #21 was at risk for falls on her care plan. The Administrator revealed that they now know how to make sure residents who are assessed as at risk for falls get added to resident care plans. The Administrator revealed that this was important for residents to prevent injuries and for their overall safety. The Administrator further revealed that the care plan should be a story of the Resident and their time in the facility. The Administrator also revealed after Resident #21 ' s 11/21/23 fall, the family and physician were not notified. Resident #21 was discharged on 01/12/24 and unavailable for observation. The phone number listed on Resident #21's admission record was called without an answer and a message was left on 01/13/24 at 12:06 PM and 05:50 PM, There was no response back. This was the phone number for Resident #21 and Resident #21's Responsibly Party (RP). Record review of the facility's 2023 in-service training records revealed there were no staff trainings completed after Resident #21 ' s 11/21/2023 fall with a serious injury incident. Record Review of Resident #21's Assessments from November to December 2023, revealed that the facility failed to complete an eINTERACT Change in Condition Evaluation V4.2. Record Review of Resident #21's Assessments revealed that the facility completed NSG: FALL RISK EVALUATION V2 assessments, 11/11/2023 (for Admission) and 11/25/2023 (for Reentry), which reflected Resident #21 was at High Risk for falls. Record review of the facility's admission Assessment and Follow Up: Role of the Nurse policy, revised September 2012, revealed the following: .7. Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission . 9. Conduct supplemental assessments (following facility forms and protocol) including: c. Fall risk assessment Record Review of the facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the following: .1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .3. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .11. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change .12. The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay Record review of the facility's Fall Risk Assessment policy, revised March 2018, revealed .1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time Record review of the facility's Falls and Fall Risk, Managing policy, revised March 2018, revealed the following: 1. Resident-Centered Approaches to Managing Falls and Fall Risk .1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .7. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling 2. Monitoring Subsequent Falls and Fall Risk .1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified Record review of the facility's Change in a Resident's Condition or Status policy, revised February 2021, revealed the following: .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status Record Review of the facility's Charting and Documentation policy, revised July 2017, revealed the following: .2. The following information is to be documented in the resident medical record: a. objective observations; c. Treatments or services performed; d. Changes in resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate This was determined to be an Immediate Jeopardy on 01/12/2024. The Administrator was notified and provided the IJ template on 01/12/2024 at 07:14 PM. The following Plan of Removal submitted by the facility was accepted on 01/13/2024 at 06:25 PM. Plan of Removal Immediate Jeopardy On 01/12/2024 during annual survey at [facility] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that an event occurred at the facility constituting an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: the facility failed to develop and implement a base line care plan to support Resident #21( ' s) needs for safety related to the assessed high fall risk and experienced a fall with a serious injury. 11/11/23 Resident was assessed by admitting nurse LVN B as high fall risk with a history of falls. (see Action Item #1) MDS nurse C assessed Resident #21 as not a fall risk without a history of falls. (see Action Item #2) Record reviews of Resident #21's incidents reports revealed no incident report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #3) Record review of TULIP from 11/21/2023 to 01/12/2024 revealed no serious injury report for Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #4) Record reviews of Resident #21's nursing assessments revealed no record of change in condition related to Resident #21's 11/21/2023 fall with a serious injury. (see Action Item #5) During an interview on 01/12/2024 with MDS C nurse revealed after Resident #21's 11/25/2023 admission post hospitalization for evaluation and treatment of a hip fracture, she did not update Resident #21's care plan. (see Action Item #2) A record review of the facility's nursing staff in-services from January 2023 through December 2023 revealed no staff training for falls completed after the incident on 11/21/2023. (see Action Item #6) Action #1: Facility Assistant Directors of Nursing (ADONs) completed a Fall Risk Assessment on current residents within the facility on 1-12-2024. Census was 71 and 71 residents had a new Fall Risk Assessment completed. Monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: ADONs, Director of Nursing and Administrator to review completion. Action #2: DON and Administrator inserviced the MDS Nurse on review of fall risk assessments of residents and to reflect on the MDS when completing the MDS for accuracy. MDS nurse also educated on updating the plan of care after review of incident reports for falls and when any resident fall has been identified. Monitoring will continue for new admission review by the clinical leadership (DON,ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: MDS Nurse, Director of Nursing and Administrator to review completion. Action #3: DON and Administrator inserviced the Licensed Nurses on completion of incident reports as required for resident falls and falls with injury timely after the event occurrence. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator to review completion. Action #4: DON and Administrator will review Tulip reporting guidelines and will follow required reporting serious injury reporting. Administrator and DON inserviced by Chief Clinical Officer on incident reporting process. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing and Administrator Action #5: DON and ADON's inserviced the Licensed Nurses on change of condition and assessment and documentation for any resident with an identified change in condition. Any licensed nurse not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for licensed nursing to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Action #6: DON and ADONs inserviced the Nursing staff on fall management including identification of risk, baseline care plan, care plan interventions, monitoring for falls. Any nursing staff member not present during this inservice will be inserviced prior to the start of their next scheduled shift. The DON, ADONs will monitor staff schedules for nursing staff to ensure education has been completed, this will continue until team members scheduled through the next week have been inserviced. DON, ADONs will add this process review to be included in new hire orientation for nursing staff. Start Date: 1/12/2024 Completion Date: 1/12/2024 Responsible: Director of Nursing, ADONs and Administrator to review completion. Administrator [Facility] 1/12/2024 POR Verification Evidence Action #1: Record review of the facility fall risk assessments revealed a census of 71 residents assessed as a fall risk. All 71 residents were revised for care plans with fall risk interventions. A record review of the facility's New admission IDT Care Plan Checklist dated 01/13/2024 revealed monitoring will continue for new admissions review by the clinical leadership (dons, ADON's) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Further record review revealed the monitoring included Resident identifiers, diagnoses, fall risk assessments, IDT post admission plan of care completed, care plan updated, and a quality of life manager review. During an interview on 01/13/2024 at 02:45 PM the Administrator stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. During an interview on 1/13/2024 at 03:25 PM the DON stated each POR action plan from 1 through 6 were completed by the DON, ADON's, CCO. Further interview revealed monitoring will continue for new admission review by the clinical leadership (DON, ADONs) ongoing, audits will be conducted weekly x 4 and shared with the facility QAPI team to monitor sustained compliance. Action #2: Record review of the facility's in-services revealed the MDS nurse C received an in-service dated 01/12/2023, fall risk assessment and fall risk managing. Action #3: A record review of the facility's nursing staff roster dated 01/13/2024 revealed 78 Nursing staff to include 25 Licensed nurses and 53 CNA's. A record review of the facility's staffing schedule dated 01/13/2024 revealed 6 Licensed nurses worked the 06:00 AM to 06:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 Licensed nurses worked the 06:00 PM to 06:00 AM shift. A record review of the facility's Accident and Incidents in-service records dated 01/12/2024 through 01/13/2024, revealed 12 nurses were in-serviced. Action #4: During an interview on 01/13/204 at 02:45 PM revealed the Chief Clinical Officer in-serviced the Administrator and the DON on TULIP reporting. A record review of the facility's TULIP reporting in-service, dated 01/13/2024 revealed, DON and Administrator will review TULIP reporting Guidelines and will follow required reporting serious injuries. Action #5: A record review of the facility's Change of Condition in-service dated 01/13/2024 revealed 13 nurses were in-serviced. Action #6: Licensed Nurses work 12 hour shifts-6a-6p,6p-6a; C.N.A. staff work 8 hour shifts (6-2,2-10,10-6) A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 19 CNA's received the training. A record review of the facility Care Plan, and Fall risk Assessment, in-service records revealed 12 nurses received the training. A record review of the facility's staffing schedule dated 01/13/2024 revealed 10 CNA's worked the 06:00 AM to 02:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 8 CNA's worked the 02:00 PM to 10:00 PM shift. A record review of the facility's staffing schedule dated 01/13/2024 revealed 4 CNA's worked the 02:00 PM to 06:00 AM shift. A record review of the facility's nursing roster revealed a nursing staff of 78, including 53 CNAs and 25 Nurses. 32 staff members were interviewed and a sample of the 18 from all 3 shifts were documented as follows: During an interview on 1/13/2024 at 12:31 PM, ADON A and ADON E revealed that they received four in-services that included: falls, baseline care plans, incident reporting, and change of conditions. CNA 06:00 AM to 02:00 PM shift: During an interview on 1/13/2024 from 01:31 PM- 01:36 PM, CNA G, CNA H, CNA I, CNA L revealed that they received recent training to include care plans and policy for falls. Licensed nurse 06:00 AM to 06:00 PM shift: During an interview on 01/13/2024 from 01:31 PM- 01:36 PM, LVN F, LVN J, LVN K, CMA M revealed that they received recent training to include care plans, when to report an incident, and policy for falls. CNA 02:00 PM to 10:00 PM shift: During an interview on 1/13/2024 at 3:50 PM, CNA O, CNA V, CNA W revealed that they were trained on the policy for falls and care plans. During an interview on 1/13/2024 at 4:20 PM, CNA P revealed that she was trained on knowing care plans, knowing her residents, reporting to nurses, and recognizing change in conditions. CNA 10:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:59 PM, CNA N revealed that she was trained on fall protocol, change of conditions, and documenting to include incident reporting, care plans. During an interview on 1/13/2024 at 4:15 PM, CNA Q revealed that they were trained on care plans and falls. Licensed Nursing 06:00 PM to 06:00 AM shift: During an interview on 1/13/2024 at 3:54 PM, LVN R revealed that she had been a nurse for a while and was trained on care plans, falls, change in conditions, and reporting incidents. During an interview on 1/13/2024 at 4:15 PM, LVN U revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. During an interview on 1/13/2024 at 4:18 PM, LVN S revealed that he received training to include falls, reporting incidents, care plans, and change in conditions. During an interview on 1/13/2024 at 4:23 PM, LVN T revealed that she was trained on care plans, the fall policy, reporting incidents, and change in conditions. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . The facility remained out of compliance at severity of no actual harm with a potential for more than minimal harm. Based on interviews and record reviews, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #1) reviewed for receiving nursing services in that: 1. The nurses did not report Resident #1's weight gain to the physician as ordered. 2. The nurses did not follow physician orders to weigh Resident #1 daily. 3. The nurses did not report to the physician Resident #1 was not weighed daily per orders. 4. The nurses were unable to contact Resident #1's physician when the resident had a change of condition on 12/29/2022 which required emergency services and a transfer to the emergency room. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 01/17/2023 at 4:50 p.m. While the IJ was removed on 01/20/2023, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its corrective systems. These failures could place residents at risk for health status decline and deny the physician opportunities to intervene on behalf of the resident(s). The findings included: A record review of Resident #1's admission Record, dated 01/01/2023, revealed an admission date of 11/25/2022, with diagnoses of a head laceration (cut), heart failure, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart which causes the heart to work harder to pump blood into the lungs), and a cardiac pacemaker (medical device implanted under the skin to assist the heart with beating). The admission Record indicated Resident #1's primary physician was Physician A. Further review of the admission Record under Miscellaneous Information revealed Resident #1 was discharged from the facility on 12/30/2022 to another nursing home. A record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female diagnosed with heart failure and her cognitive skills for daily decision making were intact with a BIMS (Brief Interview of Mental Status) score of 13 out of 15, and required assistance of 1 person with locomotion. A record review of Resident #1's Care Plan dated 01/01/2023, revealed Resident #1 had a need for monitoring and support for her heart failure and a cardiac pacemaker. The interventions were monitor, document, report, any signs, and symptoms of coronary artery disease .dependent edema [swelling]. A record review of Resident #1's Physician's Order Summary dated 01/01/2022, revealed an order dated 11/26/2022, for nurses to weigh Resident #1 daily and report to Physician B (Resident #1's cardiologist [heart doctor]) any weight gain of 3 pounds or more in 1 day and/or a 5-pound weight gain over 3 days. A record review of Resident #1's Daily Weight Record revealed a weight gain of 3.4 pounds from 116 pounds on 11/29/2022 to 119.4 pounds on 11/30/2022. Further review revealed Resident # 1 was not weighed on 12/04/2022, 12/23/2022, 12/25/2022, and 12/26/2022. A record review of Resident #1's Nursing Progress Notes dated 12/19/2022, authored by the Registered Dietician (RD) indicated the resident's weight was 123.2 pounds on 12/08/2022, 126.2 pounds on 12/14/2022, and was 126.4 pounds on 12/19/2022 which was a significant weight gain of 10.2 pounds, an 8.8% increase in 21 days. A record review of Resident #1's Nursing Progress Notes dated 12/23/2022, authored by LVN C documented the reason why Resident #1 was not weighed daily was due to Resident on contact isolation. A record review of Resident #1's Nursing Progress Notes dated 12/26/2022 revealed a note authored by LVN D documented the reason why Resident #1 was not weighed daily was due to on isolation for COVID-19. A record review of Resident #1's Nursing Progress Notes dated 12/27/2022, authored by LVN D documented the reason why Resident #1 was not weighed daily was due to on isolation and can-not leave room. Record review of Resident #1's emergency room Nursing Home Transfer form dated 12/29/22, located in the resident's electronic clinical record under the Miscellaneous tab, revealed Resident #1 was admitted to the emergency room at 13:51 (01:51 p.m.). The report revealed Resident #1's Physician B (her cardiologist) was contacted who recommended Resident #1's Lasix (diuretic medication to release fluid from the body) be increased to 40 mg twice a day, then 40 mg once a day. The Nursing Home Transfer form revealed Resident #1 received Lasix 40 mg IV (intravenous) at the hospital for peripheral edema (swelling to the hands or feet), was provided with new orders for Lasix 40 mg BID (twice a day) for 2 days and was discharged at 16:36 (04:36 p.m.) on 12/29/22 back to the facility. Record reviews of Resident #1's Medical Record on 01/01/2023 failed to reveal any documents (nurses notes or assessments) related to Resident #1's change of condition on 12/29/2022 which required emergency services and a transfer to the emergency room. During an interview on 01/01/2023 at 1:10 p.m., Resident #1 stated on 12/29/2022 she was taken to the emergency room at the hospital. Resident #1 stated her primary care physician (Physician A) informed the emergency room doctor he had not received any messages from the nursing home concerning her weight gain and swelling. Resident #1 stated her body was swollen from 13 pounds of excess fluid and the emergency room nurse had to cut off her wedding ring before administering intravenous medications. Resident #1 stated the emergency room doctor reported the amount of excess fluid was extremely serious due to her heart condition and may have contributed with problems getting her head wound to close. Resident #1 stated LVN A and RN B cared for her on 12/29/2022 and discovered her left arm and left side of her body were swollen to the point her clothes were not fitting her and she was losing circulation to her left hand and feet. Resident #1 stated she requested the nurses call her physician to which they replied, we cannot it is Christmas holidays, and the doctor is not available. Resident #1 stated she was eventually transported to the hospital where she received care. Resident #1 stated she was not weighed daily and was told we do not have a scale. Resident #1 stated the facility did have a scale, I was weighed on a wheelchair scale and a 'stand on scale', but when they moved me to the COVID-19 isolation room they did not weigh me daily. During an interview on 01/01/2023 at 5:20 p.m., LVN A stated she and RN B assessed Resident #1 on 12/29/2022 with a swollen left body side, which included her arm and hand. LVN A stated she and RN B called Resident #1's physician (Physician A), reached the physician's office, and left a message for the physician to return their call. LVN A stated the physician did not call back and after 2 more attempts to reach the physician failed, she and RN B arranged for the facility's van driver to transport Resident #1 to the emergency room. LVN A stated she was not aware of Resident #1's gradual weight gain over the month. LVN A stated she had not documented any findings surrounding the events of Resident #1's weight gain, swelling, change of condition, attempts to reach the physician, details surrounding the transport of Resident #1 to the hospital, I have no excuse .I thought RN B was going to write the notes. During an interview on 01/01/2023 at 5:37 p.m. RN B stated she and LVN A assessed Resident #1 on 12/29/2022 and discovered Resident #1 with pain and swelling to her left side of her body which included her left hand, I was concerned for the lack of circulation and swelling to her left ring finger. RN B stated she and LVN B attempted to call Resident #1's physician more than 3 times without success, RN B stated each time over the course of 2 hours they left messages with Resident #1's physician office (Physician A) for an urgent call back, with no call back from the physician. RN B stated the situation grew to a stressful situation where she did not believe the situation called for a 911 call but was serious enough to warrant LVN A and herself to arrange for the facility's van driver to transport Resident #1 to the hospital's emergency room. RN B stated she was not aware of Resident #1's gradual weight gain over the month. RN B stated she had not documented any findings surrounding the events of Resident #1's weight gain, swelling, change of condition, attempts to reach the physician, details surrounding the transport of Resident #1 to the hospital, I know I should have documented . I did not .I thought LVN B documented. RN B stated the failure to document could place residents at risk for harm by inaccurate medical records. Further interview on 01/14/2023 at 4:15 p.m. RN B stated she did not contact the medical director when she and LVN A were unable to contact Physician A about Resident #1's change of condition. In a telephone interview on 01/14/2023 at 11:30 a.m., Physician A stated she honestly could not remember if the facility had contacted her about Resident #1's weight gain, stated it would have been Resident #1's cardiologist (Physician B) who would have been notified about the weight change since he had prescribed her diuretics. Physician A stated she was not notified Resident #1's weights were not obtained daily as ordered. Physician A stated her office nurse did notify her Resident #1 had been sent to the ER. On 01/14/2023 at 1:24 p.m., the surveyor called Physician B (Resident #1's cardiologist) without success of contacting him by the time the surveyor exited the facility. During an interview on 01/01/2023 at 6:10 p.m. the Administrator and the DON stated the events surrounding Resident #1's 12/29/2022 need for emergency services were not handled as best as could be. Resident #1 could have and should have been weighed daily even in the COVID-19 isolation unit. The DON stated the facility had scales the staff could have used to assess Resident #1 for weight gain. The DON stated the nursing staff could and should have reported to him and the physician the lack of a daily weights for Resident #1. The DON stated the inability to give Resident #1's physician a report was a serious problem the Administrator and himself would investigate. The Administrator concurred. The Administrator and the DON stated the failure could have placed Resident(s) at risk for serious harm for health status decline and inaccurate records. Further interview on 01/14/2023 at 10:44 a.m., the DON stated he was not aware Resident #1's weights were not obtained daily as ordered. The DON stated, I know there was a difficulty in reaching a response from some of the physicians and Physician A was one of the ones that are difficult to get a hold of. The DON stated we have changed physician groups since then to Physician Group C who started providing services to residents. The DON stated on 01/16/2023 the facility would approach the residents and their responsible parties who reside on 100 Hall to ask them if they want to switch their primary physician to the physician with Physician Group C. Then residents on the other halls would also be approached to slowly phase out the local physicians that are difficult to reach. The DON stated newly admitted residents had the option of receiving services from Physician Group C and several newly admitted residents had chosen Physician Group C for their primary physician. The DON stated the physician with Physician Group C had given the DON his cell phone number, does not mind being called 24-hours a day and was prompt in returning calls from the facility. In an interview on 01/14/2023 at 11:43 a.m., the Administrator stated the facility had started to use the services from Physician Group C. The Administrator stated they did not have a contract with Physician Group C as the physician with that group was not their medical director. The Administrator stated he did have emails with Physician Group C he could provide to the surveyor. Record review of email correspondence from Physician Group C to the Administrator, dated 1/2/2023, revealed Physician Group A provided the facility with an onboarding form. Record review of email correspondence from the DON to Physician Group C, dated 01/10/2023, revealed the DON had requested information of the groups medical personnel to set up their electronic medical records access. In an interview on 01/14/2023 at 1:45 p.m., RN A stated she had called Physician Group C yesterday (01/13/2023), left a message and received a call back in about 20 minutes. In an interview on 01/14/2023 at 2:00 p.m. LVN E stated she has not had a change in a resident's condition that needed an immediate response from the physician. LVN E stated the response times from the local physicians would vary and often they would not get back to the facility until the next day for non-urgent issues. LVN E stated the facility recently started working with Physician Group C; she had worked with Physician Group C before, and it was nice having a group (of physicians) who answers right away. In an interview on 01/14/2023 at 11:57 a.m. with the DON, he revealed the facility had not done any in-services since 12/27/2022 which was about abuse and neglect. In an interview on 01/14/2023 at 4:47 p.m., the DON stated the facility did not have a policy directing staff who they should contact when the resident's physician could not be notified. The DON stated the policy on a resident's change of condition mentioned contacting the resident's physician. Record review of the Change in a Resident's Condition or Status policy, revised February 2021, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition; .g. need to transfer the resident to a hospital/treatment center; .2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); . Record review of facility's Abuse/Neglect/Misappropriation Prevention Program dated April 2021 read: .Protect residents from abuse, neglect .develop and implement policies and protocols to prevent and identify .neglect of residents . The Administrator was notified by phone on 01/17/2023 at 4:50 p.m. that an Immediate Jeopardy was identified due to the above failures and the IJ template was provided via email. The facility's plan of removal (POR) was accepted on 01/18/2023 at 4:30 p.m. and included: Abatement plan for IJ called 01/17/2023 around 5 p.m. today at Windcrest Nursing and Rehab, 210 W Windcrest Street, Fredericksburg, Texas 78624. Summary of details which lead to outcomes: IJ called relating to facility not ensuring licensed nurses were assessing residents and reporting abnormal findings to the physician according to physician orders, that could likely result in serious harm to this 1 resident, that was identified during the investigation. The following plan of action outlines immediate interventions employed by the facility to abate any further concerns surrounding the above issue. 1. On 01/01/2023, the two licensed nurses were educated by the DON on facility protocols for assessing and reporting abnormal findings physician orders. This included education on the protocols for assessing a resident with change of condition, reporting process to physicians for change of condition, documenting in clinical record, and following physician orders. DON/designee, will continue to monitor, daily, in morning meeting, the assessments and change of conditions for the past 24 hours, and following of physician orders to reporting changes to be documented in the clinical record. 2. DON/designee educated facility licensed nurses on using the current process from 01/01/23, change of condition, daily weights. This process has been effective since 01/01/2023 going forward, with no concerns identified by DON/designee for any of the above. DON/designee continue to review 24-hour report daily regarding assessment of residents, changes of condition, notification to physicians and documentation in the clinical record. 3. Morning clinical stand up has identified no other concerns since 01/01/2023 going forward. 4. DON/designee will continue to monitor daily, for assessments, complying with physician orders, change of condition for any potential issues that might occur and will address when identified. 5. All licensed nurses will be educated by DON/designee, on the facility protocols regarding changes of condition, notifications associated with and documentation of incident identified on an ongoing basis as needed. Chart review will be conducted by DON/designee utilizing 24-hour report, for follow-up on appropriate assessments, change of condition, reporting to physician, and documenting the event in the clinical. 6. During daily morning clinical meeting, documentation from the past 24 hours will be reviewed by the DON/designee to ensure assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Since the identified concern noted on 01/01/2023, this process has been in place and no identified issues or concerns were identified per guidance. Any concern found will be addressed at the time identified. DON/designee will continue to review clinical documentation daily on an ongoing basis to ensure nursing assessments, change of condition, reporting and documenting is completed. On 01/18/2023 through 01/20/2023, the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: During an observation and interview on 01/18/2023 at 3:43 p.m., Resident #2 was in her room in bed watching TV, receiving continuous oxygen at 3.5 liters per minute; w/c and walker were present. Call light was within reach. The resident revealed: the care she received was pretty good. She was given the assistance she needed for ADLs. She revealed that interventions for her CHF included medications, monitoring, and taking of vital signs. She stated that daily I am weighed for fluid retention .right now I am not retaining fluids . She stated that she knew the signs of fluid retention which included swelling of the legs. She felt that the facility and MD were monitoring her weight and fluid retention. She had no complaints about her care and did not feel neglected. During an observation and interview on 01/18/2023 at 4 p.m., Resident #4 was in his room sitting on a w/c, cleaned and groomed, call light was within reach, no skin tears or bruises present. The resident revealed his care was good and his needs were met. The resident stated that he was weighed every day and sometimes twice in the month of December and January 2023. Observation and interview on 01/18/2023 at 5 p.m. of Hot Zone (Hall 300) revealed: a sitting weight chair was present in the Hot Zone. Observation of Resident #3 revealed she was sitting on a coach watching TV, alert and oriented, receiving continuous oxygen at 2 liters per minute. The resident revealed she had been weighed two times since she was moved to the Hot Zone. The resident stated that weights were taken as an indicator of any fluid retention for her CHF. The resident described her care as excellent and her needs were met. The resident denied any neglect around treatments and interventions for her multiple diagnoses. During an interview on 01/18/2023 at 5:15 p.m., LVN F revealed: Resident #3 was weighed the two days she was in the Hot Zone; and the resident was being monitored for any change of condition. LVN F would notify the MD if there was a change of condition. LVN F stated she attended training on assessing a resident for change of condition, reporting to the physician, and following physician orders. During an interview on 01/19/2023 at 9:22 a.m., the DON revealed: the DON provided in-service on change of condition and notification of physician on 01/01/2023 to LVN A and RN B. Also, the training involved monitoring a resident in the COVID-19 unit and documenting a weighing a resident in the COVID-19 unit. Documentation of education for the latter nursing staff was placed in the employee files.[ Surveyor interviewed LVN A and RN B on the training received from the DON] During an interview on 01/19/2023 at 9:28 a.m., RN B (day shift) revealed: she received in-service on 01/01/2023 on change of condition, following MD orders, and contacting MD. The highlight that stood out from the training was to contact the facility's physician when you cannot contact the primary. Also, the MD orders need to be followed and documented even if the resident was in the Hot Zone. RN B stated the system failure was not contacting the MD to address the fluid retention in the resident's arm. Likewise, RN B had received training on abuse and neglect. During an interview on 01/19/2023 at 9:37 a.m., LVN A (day shift) revealed: she received in-service training on 01/01/2023 on the topics of change for condition, contacting the MD, and following MD orders. The highlights of the training were to contact the MD or the facility MD to address a change of condition, and to follow MD orders. LVN A stated the system failure was lack of communications from the MD's office; the resident's arm was swelling and the whole left side of the body was swelling; resident was on the COVID-19 for 10 days. Also, LVN A had received training on abuse/neglect in the past. During an interview on 01/19/2023 at 10:05 a.m., LVN E (day shift) revealed: she received training on change of condition and the highlight was to call the MD and if nurse could not find the primary MD to call the facility MD. Also, nursing staff needed to follow MD orders even if the resident was in the COVID-19. She also received training on abuse/neglect. During an interview on 01/19/2023 at 10:12 a.m., LVN G (day shift) revealed she attended in-service on change of condition and MD notification. She recalled the highlights were to contact the facility MD if no contact was made with primary MD. Also, follow MD orders regardless of the location of the resident. Also, contact RP and MD immediately when there is a change of condition. During an interview on 01/19/2023 at 10:18 a.m., Med Aide H (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, Med Aide H received abuse/neglect training in the past. The highlights of the training were: concerns need to be voiced involving a change of command as soon as possible to the charge nurse. During an interview on 01/19/2023 at 10:31 a.m., CNA I (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA I received abuse/neglect training in the past. The highlights of the training were: contact nursing staff when there was a change of condition. CNA I stated there was a weight scale in the Hot Zone to weigh residents. During an interview on 01/19/2023 at 10:40 a.m., CNA J (morning shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA J received abuse/neglect training in the past. The highlights of the training were: to contact the charge nurse if there was a change of condition and to closely monitor a resident. CNA J stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 10:58 a.m., LVN L stated: he attended morning meetings this week (01/16/2023 to 01/19/2023) and the meetings discussed assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Also, meetings emphasized to follow through on any change of condition or assessments of new admissions. Regarding new admissions, residents would be put in the warm zone regarding their vaccination history and signs and symptoms of COVID-19. LVN L stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 10:53 a.m., CNA K (night shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, CNA K received abuse/neglect training in the past. The highlights of the training were: to report any change of condition to the charge nurse. CNA K stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During an interview on 01/19/2023 at 11 a.m., LVN L (night shift) revealed: education was provided on change of condition, contacting the MD, and documentation. Likewise, LVN L received abuse/neglect training in the past. The highlights of the training were: document change of condition, notifying the MD in timely manner and follow-up with any new orders given. As a nurse, to monitor, document, and report findings whether the resident is improving or declining. LVN L stated that training revealed there was a weight scale in the Hot Zone for weighing residents. During a joint interview on 01/19/2023 at 11:10 a.m., the Administrator stated morning reports are held at 9 a.m. to discuss assessments, change of conditions, reporting to physicians, and documentation of events are in the clinical record. Since 01/01/2023 to 01/19/2023, there have been 13 new admissions and the assessments and MD follow-up were discussed at the morning meetings. The DON added that the focus of the morning meetings was the discussion of the 24-hour report. The clinical part of the meeting's attendees were: Administrator, DON, 2 ADON, MDS nurse and Director of Rehab and charge nurses. Immediacy per the DON for Resident #1 was removed when the resident was sent to the hospital on [DATE] and a weight was placed in the COVID-19 unit. During an interview on 01/19/2023 at 7:28 p.m., CNA M (evening shift) stated: education was provided on change of condition, contacting the MD, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: to report a change of condition if a changed occurred to the nurse; follow orders on daily weights. If working in the COVID unit there was a scale present; just sit the resident on a chair, get a reading to tell the nurse. During an interview on 01/19/2023 at 7:33 p.m., CNA N (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: inform the charge nurse if there was a change of condition in the resident; and follow MD orders on weights. In the Hot Zone there was a chair that takes weights and once weights are taken give the result to the charge nurse. During an interview on 01/19/2023 at 7:37 p.m., Med Aide O (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: observe for reactions to medications and adverse effects to medications and inform the charge nurse; follow MD orders regardless of time; in the Hot Zone there was a weight chair; and sanitize after every use. During an interview on 01/19/2023 at 7:43 p.m., Student Nurse Aide P (evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: monitor resident's change of condition and report changes to the nurse. As for weight assessment, we should take weights before breakfast .in the Hot Zone there is a wheel scale chair for weights. During an interview on 01/19/2023 at 7:47 p.m., LVN Q (night shift) revealed: education was provided on change of condition, contacting the MD, weight assessments, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: report and document change of condition and notify the MD if no call the facility MD and call the DON and send resident to ER. The main highlight on weight assessments was to follow MD orders and document. In the Hot Zone there was a permanent weight chair for weighing residents. Care and service should continue in the Hot Zone LVN Q stated, because the residents are people. During an interview on 01/19/2023 at 7:55 p.m., LVN R (night shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: document a change of condition and if you cannot find the primary MD call the facility MD and last option is to send resident to ER. As for weight assessment document and if there was a discrepancy re-weigh the resident. LVN R added, In the Hot Zone you can weigh a resident by the use of the weighing chair. During an interview on 01/19/2023 at 8:03 p.m., CNA S (evening and night shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: report any change of condition to the charge nurse; document and take weights per MD orders. In the Hot Zone there was a weight chair. During an interview on 01/20/2023 at 9:59 a.m., RN T (Nurse Consultant) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: change of condition needs to be reported immediately to the MD; if one cannot locate the on-call MD; if no contact with an MD; send to the ER. The highlight on weight assessment was to follow the order; and document. There was weight scale chair in the COVID-19 unit was placed permanently on 01/01/2023. During an interview on 01/20/2023 at 10:32 a.m., Med Aide U (day shift) revealed: education was provided on change of condition, contacting the MD, weight assessment, and documentation. Likewise, the staff member received abuse/neglect training in the past. The highlights of the training were: if change of condition occurred notified the charge nurse immediately. Regarding weight assessment, if resident is in the COVID-19 unit there was a scale to measure the resident; and follow MD orders on weights. During an interview on 01/20/2023 at 10:35 AM, LVN F (day and evening shift) revealed: education was provided on change of condition, contacting the MD, weight assessment and documentation. Likewise, the staff member received [TRUNCATED]