**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #1) residents reviewed for quality of care. The facility did not ensure Resident #1 was assessed by a nurse after a fall. Resident #1 was improperly transferred to her bed by CNA G and CNA H without first being assessed by the nurse, LVN E. The noncompliance was identified as PNC. The IJ began on 1/30/24 and ended on 2/2/24. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of serious harm, and not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the undated face sheet revealed Resident #1 was an [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 7/30/24 revealed Resident #1 had diagnoses that included: Alzheimer's Disease (a type of dementia that was progressive leading to loss of ability to carry on a conversation), chronic pain (long lasting or constantly recurring pain), Type 2 Diabetes (the body cannot control sugar), Osteoarthritis (flexible tissue at the ends of bones wears down), and Generalized Anxiety Disorder (severe, ongoing anxiety that interferes with daily activities), and hypertension (force of blood against the artery walls is too high). The physician's orders revealed she was on hospice services due to Alzheimer's disease at admit (9/11/23). Record review of the quarterly MDS revealed Resident #1 had no speech, rarely understood others and was sometimes understood by others. She had a BIMS score of 5 indicating severe cognitive impairment. Resident #1 required substantial/maximum assistance (staff did more than half the work) for her to go from a sitting to standing position and for her to walk 10 feet. She used a manual wheelchair. Record review of the care plan dated 10/6/23 revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes. She was at risk for falls with interventions including: Anticipate and meet the resident's needs, provide a safe environment, and needs activities that minimize the potential for falls with diversion and distraction. Resident #1 was receiving hospice services due to a terminal illness. A care plan revision on 2/2/24 indicated she had a right hip fracture (break) and was totally dependent on staff for turning and repositioning in bed. Record review of an incident report dated 1/30/24 at 5:07 AM revealed Resident #1 was sitting on the couch in the common area and got up to walk, and fell onto her buttocks. Resident #1 was unable to give a description of what had happened. She was assessed with no bruises, scratches or skin tears, range of motion unchanged, voided and no complaints of pain or tenderness. Resident #1 was not taken to the hospital. The incident report indicated there were no injuries observed at the time of incident. Record review of the PIR dated 1/30/24 revealed: LVN A reported at 9:23 AM, Resident #1 was complaining of pain to her right hip/thigh area and was unable to bear weight on it. Right leg appeared to rotate outward. Resident #1 administered pain medication per PRN order. Call placed to hospice and MD with new order for x-ray of right hip/thigh with 2 views. Portable x-ray came out to perform an x-ray and the report was back at 7:16 PM indicating, There is an acute fracture of the proximal femur noted. There is not soft tissue swelling or foreign body identified. Record review of an undated, unsigned portion of the PIR indicated: Record review of a Neurological Assessment indicated Resident #1 had neurological assessments beginning 1/30/24 through 2/1/24 with no abnormal indications. Resident #1 was complaining of pain and refusing to bear weight on the morning of 1/20/24. LVN A performed an assessment and noticed possible external rotation to her right leg. LVN A notified the DON of her assessment and that the resident had a fall on the previous shift. LVN A notified the MD who gave an order for an x-ray and she administered pain medication. Resident #1 was kept in bed and monitored for the effectiveness of pain medication. The family was notified of Resident #1's status and the order for mobile x-ray, to which she agreed, rather than sending Resident #1 out to the ER due to her Alzheimer's diagnosis. X-ray results were received by LVN A around 6:00 PM on 1/30/24 confirming right femur fracture. ADM was notified of the X-ray results on 1/30/24 around 7:30 PM. Documentation was reviewed to determine how the fracture possibly occurred. Resident #1 had a fall on 1/30/24 during the early morning hours. The incident report was marked as witnessed; however, witness statements were unable to be located. LVN E, who was the charge nurse on duty at the time of the incident was interviewed to determine how the fall occurred and who witnessed the fall. LVN E stated that on 1/30/24 around 5:00 AM she was told by CNA's G and H that Resident #1 was sitting on the couch, stood up, then fell down. When she went to assess Resident #1, she was lying in bed toward her right side, she had her eyes closed with no signs or symptoms of pain or distress. LVN E pulled Resident #1's covers back and assessed her lying on her back, she noted no bruising or skin tears. She asked Resident #1 if she was hurting and her answer was no. On 1/31/24 CNA G stated that she saw Resident #1 going back into her room. She looked away for a second and when she looked back, Resident #1 kind of tripped on her foot and she went down slowly. As far as hearing anything Resident #1 didn't really make a sound. They transferred Resident #1 to her bed with CNA G holding her feet and CNA H holding her arms underneath. When they informed LVN E of the fall and what they did, it was round 4:40 AM or 4:50 AM. On 1/31/24 CNA G stated that Resident #1 was walking by herself towards her room, and she just collapsed to the ground. She was looking down at first and about 5 minutes later she looked up and heard like a thump and saw Resident #1 was on the floor. They transferred Resident #1 to bed with CNA H holding her top part and CNA G holding her feet. They got her off the floor because they didn't want to leave her there. CNA G and CNA explained to LVN E, that they didn't see her at first, so they proceeded to put her to bed together to get her off the floor. More than likely the fracture occurred from her falling to her right side. We were unable to determine when the fracture actually occurred. Therefore, the injury of unknown origin has been marked as inconclusive. Resident #1's pain will be managed. On 1/30/24 oxycodone 5 mg, 1 tab po every 4 hours PRN was added, and her codeine-acetaminophen 30 mg/300 mg 1 tab po was increased from every 6 hours to every 4 hours PRN. On 2/1/24 a new order was given for oxycodone 5 mg 1 tab every 8 hours routine. On 2/2/24 a wedge (cushion to aide in positioning for comfort) was obtained to help with the healing process and comfort. Resident #1 was placed on a low air loss mattress on 2/2/24 and received a foley catheter for comfort to help decrease the amount of time when will have to be moved for care. Record review of an Incident Statement from CNA H dated 1/31/24 indicated: Resident #1 was wearing a purple shirt, black shoes, and unsure on the pants. It was a clear area, nothing was round her (Resident #1). She was walking by herself towards her room and she just collapsed to the ground. I was looking down and at first and about 5 minutes later I looked up and heard a thump and seen Resident #1 was on the floor. Previously, before the incident she was up the majority of the night which was not normal for her. She would keep walking around and her leg was swollen. I reported to the nurse around 8-9:00 PM about Resident #1's leg being swollen when she walked into the unit. It was between 9-9:30 PM when Resident #1 was constantly keep getting up on her own, restless. Falling asleep and kept moving around and me and the other aide kept putting her in bed to give her feet some rest. CNA G seen the actual fall and I had just looked up when I heard a thump and seen Resident #1 on the ground. First when I seen her she was on the floor and me and CNA G around 2:30 AM or 3:00 AM went to the nurse station and I noticed Resident #1 wasn't there. So, me and CNA G got on both ends with CNA G holding her feet and me holding her top part we transferred Resident #1 onto the bed. We got her off the floor because we didn't want to leave her there. Resident #1 wasn't getting fussy until we had to get her in bed. We continued to do our checking through the unit and [illegible] waited on the nurse to come back. We started our actual round at 4:00 AM- 4:20 AM and did our normal routine going through residents. CNA G went in room on last round to check on Resident #1 and change her and that's when CNA G came out and notified me that Resident #1 was fussing about her side hurt. I was already getting ready to go out to B-wing to finish up my round and that's when I seen the nurse and notified what was going on. Nurse spoke and said thank you for letting me know and said she was going to go check in. Me and CNA G even explained to her and said we didn't see you at first and so me and CNA G proceeded to let her know we put her in bed together to get her off the floor. Nurse replied with thank you again. When talking to the nurse, when I seen her, it was about 4:40 AM. Record review of an Incident Statement dated 1/31/24 from CNA G indicated: Resident #1 was wearing black shoes, shirt, and pants. The area was well lit and the only thing that was round was the cart. There was no spills on the floor nor was there clutter. I saw Resident #1 going back into her room, I looked away for a second and I looked back. She kind of tripped on her foot and she went down slowly. She did not really make a sound. When we (CNA G and CNA H) transferred Resident #1 I had her feet and the other CNA had her arms underneath and we both picked her up and laid her in the bed. When informed the nurse that was working that night I let her know that while I was changing Resident #1 she was screaming in pain and she was fighting me which is not normal for her. I also informed the nurse that I did check for bruises or scars, red areas and I told the nurse I didn't see any. The nurse reply was 'Okay, that's fine and thank you for checking for bruises.' From the best of my knowledge the falfl happened around 2:00 AM and when we went to report the fall to the nurse she wasn't there but when I informed the nurse on my side of the story and I told her what I did it was around 4:40 AM or 4:50 AM . Record review of an Incident Statement dated 1/30/24 from LVN E indicated: 4:51 AM, CNA opened nurse station door and reported Resident #1 had fallen, that is all she said then left to go to B-wing to do a round. I went to assess Resident #1. Resident #1 was wearing black and white pajamas and tennis shoes. When I responded Resident #1 was in her bed. She was quiet and resting comfortably. I entered room, Resident #1 was resting, eyes closed, no signs or symptoms of pain or distress. I assessed her lying on her back. I noted no bruising or skin tears. I asked Resident #1 if she was hurting and she answered no. Record review of an Employee Disciplinary Report dated 1/30/24 indicated LVN E will be placed on an investigatory suspension pending an investigation into allegations of failure to report. The report indicated she would be suspended pending the investigation. CNA reported resident had fallen-nothing about pain, did not say they moved her to bed. Record review of an Employee Disciplinary Report dated 1/30/24 indicated LVN E will be placed on an investigatory suspension pending an investigation into allegations of delay to assess in a proper manner. Record review of an Employee Disciplinary Report indicated CNA G was suspended 1/30/24, terminated 2/7/24, and her last day to work was 1/30/24. Record review of an Employee Disciplinary Report indicated CNA H was suspended 1/30/24, terminated 2/7/24, and her last day to work was 1/30/24. Record review of an undated statement from the DON indicated: I [name], DON reviewed surveillance with the ADM after an event. A resident in the unit had a fall and it was reported that it was witnessed in the common area. I witnessed the aides transferring our resident inappropriately prior to being assessed by the nurse. The nurse was not notified until approximately 1 hour later. Record review of a statement from the ADM dated 2/6/24 indicated: I [name], ADM, reviewed surveillance with the DON after a fracture that allegedly occurred from a fall. The fall was around 3:53 AM. I witnessed CNA G and CNA H immediately take Resident #1 under her arms and drag her to her room. They notified the nurse at 4:51 AM. Record review of a Patient Report dated 1/30/24 indicated Resident #1 had a right radiologic examination, femur and the findings revealed: Acute fracture of the proximal femur notes .Acute commminuted fracture of the proximal femur is seen. During an interview on 7/29/24 at 4:16 PM, Family Member Y said Resident #1 had been on hospice since August of 2023. She said when Resident #1 fell on 1/30/24, 2 CNA's picked her up inappropriately, one by her feet and one under her arms before she was assessed by a nurse. She said the nurse, was checking in medications and did not know Resident #1 fell. She said the nurse did not know she fell until later. She said the CNA's did not follow protocol. She said Resident #1 was on a lot of narcotics but her pain was controlled. She said the staff fed her. She said Resident #1 was bed bound after the fall because she was not a candidate for surgery. She said Resident #1 passed away 5/20/24. During an interview on 7/30/24 at 12:30 PM, LVN D said she took care of Resident #1 sometimes after she came out of the secure unit. She said Resident #1 had fallen and broken her hip but she did not remember the date. She said she was bed bound after that. She said she was able feed herself until the very end and they provided cueing. She said she did not think the hip fracture led to her death, because she had a lot of comorbidities. She said Resident #1's pain was controlled with medication. She said she did not have a lot of pain meds, but she was on hospice and had scheduled pain medications. She said she did not seem groggy, and was easy to wake up if asleep. She said after the hip fracture Resident #1 could not get out of bed anymore. LVN D said when she cared for Resident #1 she was happy, talking, thriving, but she had declined mentally. She said mobility wise Resident #1 seemed happy. During an interview on 7/30/24 at 1:06 PM, the ADM said Resident #1 fell in the middle of the hall. She had been having snacks and she was coloring but not really engaging in the activity. The ADM said the CNA's moved her from the floor and should not have moved her. She said the CNA's got her back in bed and then told the nurse she had fallen. The ADM said she saw the video (no longer available-due to being recorded over). The video showed one CNA got her from behind and under the arms and the other CNA stood by. She said the CNA backed/dragged Resident #1 into her room and she did not know how they got her in the bed. She said she did not remember if Resident #1's feet were moving (as if stepping) or if dragging. She said when she saw the video she did not see anyone grab her by her feet but the video was in the hallway, not the bedroom. She said her bed was 10 feet from her fall. She said CNA's G and H were fired and both admitted they did not get the nurse (LVN E) before moving Resident #1. She said the video showed CNA G and CNA H coming out of the room after putting Resident #1 in bed. The ADM said the CNA's went to look for the nurse then when they did not see her they continued to do their rounds. As soon as the CNA's saw the nurse, in less than one hour, then they told her nurse about the fall. Resident #1 was asleep when LVN E went to assess her. When LVN E assessed Resident #1 she did not see anything [NAME]. She said LVN E reported to LVN A (the oncoming day nurse). The ADM said she thought the morning routine started then LVN A thought Resident #1 was in pain or the Resident #1 complained about pain. She said Resident #1 had multiple falls. ADM said she the CNA was behind her and got her to bed by holding her from under the arms and pulling backwards. During an interview on 7/30/24 at 1:35 PM, LVN A said she came on shift 1/30/24. She said she went to get Resident #1 up for some reason, maybe breakfast and her leg had an internal rotation. She said Resident #1 was complaining of pain when she tried to use her leg. She said she medicated her for pain and contacted the physician. She said she had an x-ray to the best of her knowledge but could not remember if they sent her out for the x-ray or if it was in-house, but the results showed a hip fracture. She said Resident #1 moved to A-wing shortly after (non-secure unit). She said they did not do surgery as she remembered. She said LVN E told her the aides had already transferred Resident #1 to the bed when she saw her, and the aides had done it wrong. She said she thought she had a femur or hip fracture. LVN A said Resident #1's hip could have broken then she fell, or fell and it caused the break, she said there was no way to know. She said prior to the fall Resident #1 needed help to walk and staff assisted her. She said she also used a wheelchair. She said she was not with it mentally, but could carry on a conversation and the subject changed repeatedly. She stated she could tell you if she was in pain. However, she was not reliable to tell you what had happened. During an interview on 7/30/24 at 3:16 PM, LVN F said she was not in the facility when Resident #1 fell and she did not work on the unit. She said after she left the secure unit she cared for her. She said after the fall Resident #1 got scheduled pain medications. She said she did not appear to be out of it and would try to get out of bed. She said she was not sedated. She said her scheduled pain medication put her in a good place. She said Resident #1 would yell sometimes from anxiety and she thought she had medication for that. She said she did not think the fall/fracture contributed to her death, because she was on hospice and lived for several months after the fall. She said CNA's cannot get residents up if they fall or are on the floor. A nurse had to assess the resident before they were moved. She said she believed all the CNA's knew that because they always went to get her to assess if a resident was found in the floor. During an attempted phone interview on 7/30/34 at 3:40 PM, called CNA G. She did not answer, and this surveyor left a message requesting a return call. During a phone interview on 7/30/34 at 3:51 PM, Resident #1's Hospice nurse said she had followed the natural progression of the Alzheimer's Disease process and did not believe the fall/fracture contributed to her death due to the time frame. After the fall her pain was well managed. She said the family and the Hospice Medical Director decided she was not a surgical candidate, so they kept her as comfortable as possible. She said Resident #1 was not groggy, had lots of visits with family and was able to hold her new grandbaby. She said her decline was natural. She said they gave her scheduled oxycodone and did a wedge (a type of pillow for positioning for comfort) positioner for her fracture. She said hospice made multiple medication changes to meet her needs regarding pain and comfort. During an interview on 7/30/24 at 6:23 PM, LVN E said CNA G and CNA H told her Resident #1 had fallen, and the CNA's had already put her back in bed. She said she told them they were not supposed to do that and did not remember their reaction. She said she was not sure how long it was from the time Resident #1 fell until she was told about it and assessed her. She said it was only a few minutes, not hours. She said the CNA's said they knew they were not supposed to transfer her until a nurse had assessed her. She did not know why they had done that. She said both CNA G and CNA H were fired. She said before the CNA's left to do their rounds on B hall they let her know that Resident #1 had fallen, and they had put her back into bed. LVN E said she went to assess Resident #1 as soon as the CNA's told her she had fallen. She said she did not take her clothes off and could not remember what she was wearing but said she could see her legs and nothing looked out of the ordinary. She said she had heavy thighs and had lost weight so she had some lose skin and she could have missed something because of that. She asked Resident #1 if she was in pain and said she denied any pain. She had no skin tears or bruising. She said she raised her top/shirt and did not see any injuries but did not remove the clothing from her bottom half and could not remember what she had on. She said either she turned Resident #1 to check her back or Resident #1 turned for her and she did not yell or appear to be in pain. She did not cry out when she turned. She said she checked leg length and bent both her legs and saw nothing out of the ordinary. She said when checking her legs and bending them Resident #1 did not appear to be in pain and did not complain of pain. During an interview on 7/31/24 at 8:14 AM, the DON said she assessed Resident #1 after LVN A. She asked her if she was having any pain and she said no, it only hurt when she moved her leg. She said she did not attempt to move her leg or her. She said she did not see a deformity of her leg. The DON said she did not remember what she was wearing or how she was able to see her legs. LVN A told her she had ordered an x-ray. She said it was hard to remember details, because it was in January. She said she did not do anything because the x-ray had been ordered. She said she did not document this assessment but was sure she made sure LVN A had given her pain medication. She said she did not have a good answer as to why she did not document her assessment. During an interview on 7/31/24 at 11:05 AM, LVN J said if a resident fell, she would assess, start neuros if unwitnessed, notify the MD, DON, family, and the ADM as soon as possible. She said she had been in-serviced on falls, X-ray's and numerous things regarding falls. She said a CNA should never transfer a resident after a fall, the nurse had to be notified to assess the resident. She said if a stat X-ray could not be done within 2 hours she would call the NP or the MD to see about sending the resident to the hospital. She said if a resident could not safely get off the floor after the nursing assessment, she would call the MD and EMS. She said if a resident was not in pain and she did not suspect a fracture, she could wait 4 hours on the X-ray. During an interview on 7/31/24 at 11:11 AM, RN B if a resident fell she would assess, do vitals, let the ADON, DON, and the nurse know. Notify the MD quickly, within 10-15 minutes. Call EMS if warranted (bleeding). She said she has been at the facility 2 weeks. She had in-services on fall prevention, X-rays, notification of MD, and numerous others. She said if a resident had a possible fracture, and the stat X-ray was not done within an hour she would call the MD to send the resident to the hospital. She said a CNA was never to transfer a resident that had fallen because they had to get the nurse to assess. She would call EMS if a resident could not safely be gotten up. During an interview on 7/31/24 at 11:12 AM, LVN T said if a resident fell she would assess the resident, take vital signs, and make sure they could move their limbs. She said a CNA would assist the nurse to move them back to bed. She said she would medicate the resident if needed, notify the doctor, family, the ADM, the ADON, and the DON. LVN T said she would do neurological assessments if the fall was unwitnessed. She said she would do a risk management Kardex and a fall note. If a fracture was suspected she would not move the resident, she would contact the MD and notify of a suspected fracture, call EMS and send the resident to the ER. Send to ER. She said she would notify the resident's family, and offer pain medication to the resident. She said for a STAT x-ray she would notify the doctor if they had not done the x-ray after a couple of hours. During an interview on 7/31/24 at 11:18 AM, LVN L said if a resident fell, she would assess the resident, then notify the the ADON, the DON, and the MD. She said she would get the resident off the floor and to their bed if fracture was not suspected. She said if a fracture was suspected she would call EMS and sent the resident to the hospital. She said she would notify all administration staff. LVN L said she would expect a STAT X-ray in 2-4 hours and if the resident did not get their x-ray timely she would notify MD to see if he wanted the resident to be sent to ER. During an interview on 7/31/24 at 11:21 AM, CNA K said if she found a resident in the floor, she would have someone stay with the resident while she found the nurse. She said if there was no one to stay with the resident she would turn the call light on and look out the door for someone to go get the nurse. She said you never ever transfer a resident that had fallen or was in the floor, no matter how long it took the nurse to get there. CNA K said you could hurt the resident worse than they were by transferring them. She said pulling a resident up by their arms or feet was improper and could hurt them and she stated staff had to use a gait belt, unless the resident required a hoyer lift then 2 staff were required. She said she had numerous in-services on resident's falling, notifying the nurse, fall prevention, etc. She said if she saw another CNA attempting to get a resident off the floor before a nurse assessment she would tell them to stop, the nurse had to assess for the safety of the resident. During an interview on 7/31/24 at 11:22AM, LVN V said if a resident fell he would do a total assessment in the location where he found the resident, check vital signs, assess for pain and medicate, check for wounds, and initiate neuros if necessary. LVN V said he would notify the DON, the ADM, family, and the MD. If a fracture was suspected, he would call 911. He said he would not wait on the X-ray company to arrive and if it was a STAT X-ray and they were not at the facility within an hour he would call the MD and send the resident to the hospital if necessary. During an interview on 7/31/24 at 11:27 AM, LVN L said if a resident fell she would assess the resident, then if no injury she would assist them to get back in bed. She said if there was an injury she would not move the resident and would call 911 for transport to the hospital. LVN L said she would notify the the MD, the DON, the ADM, and family immediately. She said 1-2 hours was too long for notification. She said 30 min-1 hour is reasonable time to give notification because you had to take care of the resident. She had in-services on fall prevention, ANE, x-rays, notification, SBAR, and many other in-services. She said 4 hours was reasonable if the resident had no suspected injury. If a resident was in pain, she felt 1 hour was reasonable. She said if a resident was in pain, and she suspected a fracture she would just send them out. She said if a resident fell or was found in the floor, a CNA had to get the nurse to assess the resident prior to moving the resident to prevent harm. During an interview on 7/31/24 at 11:48 AM, CNA W said if a resident fell she was going to get the charge nurse. She said she would stay with the resident and yell for a nurse if necessary. She said she would call someone on her phone, stick her head out the door and yell if she needed to because she could not leave the resident. If a long time passed, then they she would call EMS. Do not move the resident no matter what because you do not want to make an injury or fracture worse. It was important for the nurse to be notified so they could do a thorough assessment and ensure there were no injuries. She said she had many in-services on not moving a resident and getting the nurse as soon as possible. During an interview on 7/31/24 at 11:49 AM, CNA M said if a resident fell she would get a nurse. She said she would watch the resident and yell until she got a nurse to come. She said she could stick her head out the door and look for someone, call someone on her cell phone, but she would not leave them. She said if a nurse had not gotten there in 10 minutes she would call EMS. She said she would not move the resident no matter what. She said moving a resident before a nurse saw them could make their injury worse. The nurse had to see the resident to make sure nothing was broken or no internal injuries. She said she had numerous in-services on falls, notifying the nurse, and change in condition. No matter what the injury on the resident, or no injury, she had to get the nurse immediately. During an interview on 7/31/24 at 11:54 AM, CNA R said if a resident fell, she would notify the nurse and stay with the resident. She would attempt to find a nurse by yelling for one or using her phone to call the nurse. She would call EMS if necessary. She said the nurse had to be notified so the resident could be assessed and receive further treatment if needed. She would not move the resident. She said she had been in- serviced on residents falling and notifying the nurse. During an interview on 7/31/24 at 12:01, CNA N said she had many in-services regarding falls, change of condition, notifying the nurse, and abuse and neglect etc. She said if she found a resident in the floor, she would never move him/her or try to get them up. She said she had to get a nurse to assess the resident before touching the resident. She said she would make sure the resident was safe then stick her head out the door and holler for a nurse, call a nurse on the her phone, or have someone get a nurse. She said if the resident was screaming in pain and the nurse did not get there quickly, she would call 911. During an interview on 7/31/24 at 1:02 PM, LVN E said the night CNA's (CNA G and CNA H) never told her that Resident #1 was hurting or in pain after her fall. She said if they had, she would have reassessed her and sent her to the ER. During an interview on 7/31/24 at 1:43 PM, the ADON said the transfer with Resident #1 was an improper and dangerous transfer. She said the CNA's should not have done that. She said the risk could have been serious bodily injury. She said Resident #1 got a serious bodily injury that day, but it was unclear how. She said all staff had extensive in-services for an extended period of time and were trained and re-trained. All CNA's know that they should not ever move a resident prior to a nurse assessing them. During an interview on 7/31/24 at 1:51 PM, the DON said the CNA G and CNA H transferred Resident #1 improperly. She said that had the potential to result in serious bodily injury. She said Resident #1 had a femur fracture but it could not be determined if it occurred before the fall, after the fall, or the improper transfer. The CNA's were suspended pending investigation and then terminated after the investigation. She said LVN E was also suspended pending investigation. The DON said all staff had been in-serviced extensively regarding x-ray time expectations, reporting, change of condition, what to do in the event of a fall or a resident found in the floor, proper assessment, notifying the MD & family, all notifications, abuse and neglect, SBAR and several others. She said they did in-services for each department, some for nursing, some for CNA's and some for other departments. She said Resident #1's fracture could have possibly been prevented if the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14) in that: Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit, Resident #13, and Resident #14. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 10/4/23 at 6:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems These failures could cause emotional and physical harm and could lead to additional pain and suffering. Finding included: 1.Record review of Resident #12's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia (impairment of memory) with other behavioral disturbances, psychotic disorder (a mental problem that causes people to perceive or interpret things differently from those around them), with delusions, cognitive communication deficit, and major depression. Record review of Resident #12's quarterly MDS dated [DATE] indicated her cognitive status was severely impaired. Record review of Resident #12's Care Plan dated 9/7/22 indicated a focus area of impaired cognition due to dementia or impaired thought processes. Some of the interventions were, use the residents preferred name, identify self at each interaction, face resident, and make eye contact when speaking and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about 27 years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. 2.Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F600 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. Resident #1 was assessed for pain by the charge nurse on 10/3/23. Resident #1 was offered a shower by the charge nurse on 10/3/23. Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and Resident #1 care plans were reviewed and updated. Social Worker assessed Resident #13 and other African American Male on the Unit on 10/04/23 and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. The medical director was notified of the immediate jeopardy situation on 10/3/23.?? An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Resident #'s 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling services. Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any pain. Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify the nurse of all behaviors. The staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them, they would report to the Abuse Coordinator the Administrator. During an interview on 10/4/23 at 7:05 p.m., the Administrator said she was in serviced on the abuse neglect policy. She said as the Abuse Coordinator it was her responsibility to identify and act on any allegation of abuse or neglect. She said she would suspend immediately the individual, follow policy, and follow the policy. She said with LVN C she did not feel that Resident #12 was abused because Resident #12 said she loved LVN C and LVN C was usually the only one that can get her to take her medications. The Administrator said she received in service on ADLs. She said as the administrator her part was to monitor the system they have that tracks ADLs. She said they conducted morning meeting have assignments discussed. They also conducted Champion Rounds (where each department head had a section of the facility, they questions residents about their care). They would ask the residents how they were treated, if they got showers, beds made, and if they were getting t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement written polices and procedures to prohibit abuse by ensuring residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14). Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. The LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. The Administrator did not follow the abuse policy when she unfounded the abuse when the LVN admitted she had abused the resident. LVN C was suspended for part of her shift and returned to work the following day. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit Resident #13 and Resident #14. The facility did not follow their abuse policy and continued to allow Resident #12 with a history of abusive behaviors to continue to abuse residents. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 10/4/23 at 6:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could caused emotional and physical harm and could lead to additional pain and suffering. Finding included: Record review of the facility's Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility will be responsible to identify, correct, and intervene in situations of possible abuse or neglect. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1.Record review of Resident #12's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia (impairment of memory) with other behavioral disturbances, psychotic disorder (a mental problem that causes people to perceive or interpret things differently from those around them), with delusions, cognitive communication deficit, and major depression. Record review of Resident #12's quarterly MDS dated [DATE] indicated her cognitive status was severely impaired. Record review of Resident #12's Care Plan dated 9/7/22 indicated a focus area of impaired cognition due to dementia or impaired thought processes. Some of the interventions were, use the residents preferred name, identify self at each interaction, face resident, and make eye contact when speaking and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about 27 years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. 2. Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F607 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. Resident #1 was assessed for pain by the charge nurse on 10/3/23. Resident #1 was offered a shower by the charge nurse on 10/3/23. Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and resident #1 care plans were reviewed and updated. Social Worker assessed on 10/4/23 residents #13 and other African American Male on the Unit, and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. The medical director was notified of the immediate jeopardy situation on 10/3/23.?? An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Residents 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling services. Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any pain. Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to immediately consult with the resident's primary care physician and/or resident's hospice provider/physician following a fall resulting in a hip fracture for 1 of 6 residents (Resident #1) reviewed for resident rights. The facility failed to inform the attending physician, NP, hospice physician and hospice provider for Resident #1 following a fall with injury on 07/06/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (the body does not make enough insulin or cannot use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. Resident #1 was on the secured dementia unit until 07/11/2023. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on revised on 02/19/2023. Record review of Resident #1's incident and accident report dated 07/06/2023 by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident was complaining of pain on right wrist, lump has presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported, Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuros within normal limits at this time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to right side of her forehead and small abrasion to left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with (Family Member) but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's nurse notes revealed, no nurse notes were recorded from 07/07/2023 until 07/09/2023. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward right side, tramadol was administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this a.m. to report patient was 'very different' today. She would not stand up 'at all' today. She reported (the resident) was in wheelchair during her visit today and staff had her up in dining area for a meal. RN G asked (Hospice Aide H) if Tramadol had been given, she reported she was not aware, but wanted RN G to know of change since last Friday 07/07/2023. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in am and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. Resident 'acted like' she was having increased pain with position changes. Facility CNAs also reported this was noted since they 'returned to work' yesterday. There was no documentation over the weekend of her mobility status form facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient (Resident #1) was seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give her (Resident #1) as staff had just informed LVN E, she was 'whimpering and acting like she was uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today r/t pain. (2) Tramadol 50mg 1 po q 6 hours routinely. (3) D/C routine fingerstick blood sugar checks. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of Resident #1's July 2023 MARS indicated, Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discontinue the morphine Resident #1 had been taking and started her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated she was never notified Resident #1 had a fall that a.m. RN G stated Resident #1 was asleep in the bed when she was there. RN G stated she was notified about the change in condition of Resident #1 by hospice CNA H on 07/10/2023. RN G stated she was called by CNA H during the afternoon of 07/10/2023 and was told Resident #1 was in a wheelchair and was unable to bear weight when transferring from the wheelchair to the shower chair. CNA H observed new bruising to right leg and right arm on 07/10/2023. RN G stated she came to the facility the next morning (07/11/2023) to assess Resident #1 and found the resident in pain. RN G contacted the MD, and he ordered her to x ray both hips. RN G stated she asked the facility nurses about any falls, and they (the facility nurses) stated she fell on [DATE] but no injuries were reported on the incident report. RN G stated x rays were obtained on 07/11/2023, and it was noted that she had a right hip fracture. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an interview on 08/09/2023 at 2:20 p.m., MD I stated he could not recall being contacted about the fall for Resident #1 on 07/06/2023. MD I stated he would have remembered being called at 4:00 a.m. MD I stated had he been contacted with the information of right wrist pain, a lump on the right forehead and an abrasion to her left arm, he would have ordered to send her to the ER (emergency room) if the family wished for her to go. If the family had not wanted her to go, or he would have ordered in house x rays. MD I stated Resident #1 was on anticoagulant medications that can cause bleeding on the brain that can lead to death. MD I stated anyone on anticoagulant therapy would be sent to the ER if they hit their heads. MD I stated anyone that complained of bone pain after a fall would get an x ray either at the facility or at the hospital. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:45 p.m., the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2:50 p.m.,The Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 2:40 p.m., NP J stated she was not called about the fall for Resident #1. NP J stated she should not have been called about her because she did not follow hospice residents. During an interview on 08/09/2023 at 3:00 p.m., MD F stated he was not notified about the fall for Resident #1 by the facility or by the hospice company. Record review of the facility policy titled Notifying the Physician in a Change of Status, dated 03/11/2013 indicated the physician is notified promptly of any significant change in resident status. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: Plan of Removal F580 o All residents in the facility were assessed for any change of condition by the DON and Charge Nurses as of 8/9/23. No additional issues were found. o All charge nurses were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires and PRN. Staff not in-serviced by 8/9/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment will be performed by the charge nurse on all residents who present with a change in condition. In-services were initiated for all nursing staff on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced on 8/9/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain and decreased mobility. MD I, Medical Director, was notified by the DON on 8/9/23 at 5:15p.m. about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the EHR dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the EHR dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 8/10/23 and will continue x 4 weeks. * Resident #1 had completed pain assessments that showed no pain on 08/09/2023, 08/10/2023 and 08/11/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training dated 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment was performed by the charge nurse on all residents who present with a change in condition. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed CNA J, K, L, N. S, U, W, X Y and Z all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting changes in condition by using a Stop and Watch form and giving a copy to the charge nurse, and DON. Interviews revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits and doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received care and services in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for quality of care. -The facility failed to treat Resident#1 after a fall with injury and reports of pain. -The facility failed to have prescribed pain medication available for Resident #1. -The facility failed to notify the MD of the fall with injury and Resident #1 was diagnosed with a fractured right hip on 07/11/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (the body does not make enough insulin or cannot use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. No indicators of pain were noted on the MDS. Resident #1 lived on the dementia unit until 07/11/2023. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on 02/19/2023. No pain care plan was noted. Record review of Resident #1's physician orders for July 2023 revealed an order with a start date of 05/23/2023 for Morphine sulfate 20mg/ml give 0.25ml every 4 hours as needed for pain. This order for Morphine sulfate was discontinued on 07/06/2023 and restarted on 07/13/2023. An order dated 05/09/2023 for acetaminophen 325 mg give two tablets every 6 hours as needed for pain. An order for Eliquis (anticoagulant) 2.5mg twice daily was ordered 01/23/2023. Record review of Resident #1's incident and accident report dated 07/06/2023 at by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident is c/o pain on right wrist, lump presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Harbor hospice was called at 4:09 a.m., and fall was reported, Message sent to DON and Admin. Contact attempted with husband but was unsuccessful. Neuros within normal limits at the time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to R side of her forehead and small abrasion to left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's notes indicated, no nurse notes from 07/07/2023 until 07/09/2023. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward right side, tramadol was administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this am to report patient was 'very different' today. She would not stand up 'at all' today. She reported she was in wheelchair during her visit and staff had her up in dining area for meal. RN G asked Hospice Aide H if Tramadol had been given, she reported she was not aware, but wanted RN to know of change since last Friday. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in a.m. and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. She 'acted like' she was having increased pain with position changes. Facility CNA's also report this was noted since they 'returned to work' yesterday- there was no documentation over the weekend of her mobility status from facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient is seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give Resident #1 as staff had just informed LVN E, she was 'whimpering and acting like she is uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today related to pain. (2) Tramadol 50mg 1 orally every 6 hours routinely. (3) Discontinue routine fingerstick blood sugar checks. Husband present and aware of all new orders. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of Resident #1's July 2023 MARS indicated, Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated the resident had been out of the prn morphine for 3 or 4 days and she contacted hospice herself several times for refills. RN D stated the hospice RN had not wanted the morphine given unless Resident #1 was actively dying. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice to replace the morphine Resident #1 previously had ordered. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discharge the morphine Resident #1 had been taking and start her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated she was never notified Resident #1 had a fall that a.m. RN G stated Resident #1 was asleep in the bed when she was there. RN G stated she was notified about the fall by hospice CNA H on 07/10/2023. RN G stated she was called by CNA H during the afternoon of 07/10/2023 and was told Resident #1 was in a wheelchair and was unable to bear weight when transferring from the wheelchair to the shower chair. CNA H observed new bruising to right leg and right arm. RN G stated she came to the facility the next morning (07/11/2022) to assess Resident #1 and found the resident in pain. RN G contacted the MD, and he ordered a x ray of both hips. RN G stated she asked the nurses about any falls, and they stated she fell on [DATE] but no injuries were reported on the incident report. RN G stated x rays were obtained, and it was noted that she had a right hip fracture. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an interview on 08/09/2023 at 2:20 p.m., MD I stated he could not recall being contacted about the fall for Resident #1 on 07/06/2023. MD I stated he would have remembered being called at 4:00 a.m. MD I stated had he been contacted with the information of right wrist pain, a lump on the right forehead and an abrasion to her left arm, he would have ordered to send her to the ER ( emergency room) if the family wished for her to go. If the family had not wanted her to go he would have ordered in house x rays. MD I stated Resident #1 was on anticoagulant medications that can cause bleeding on the brain that can lead to death. MD I stated anyone on anticoagulant therapy would be sent to the ER if they hit their heads. MD I stated anyone that complained of bone pain after a fall would get an x ray either at the facility or at the hospital. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:40 p.m., NP J stated she was not called about the fall for Resident #1. NP J stated she should not have been called about her because she did not follow hospice residents. During an interview on 08/09/2023 at 2:45 p.m. the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2: 50 p.m., the Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 3:00 p.m., MD F stated he was not notified about the fall for Resident #1 by the facility or by the hospice company. During an interview on 08/09/2023 at 3:20 p.m., the Administrator stated she was unaware that RN D had not contacted the MD to report Resident #1's fall and her injuries. The Administrator stated it was the job of the charge nurse to assess residents, treat their pain, contact the physicians for intervention related to injury during falls. The Administrator stated contacting the physician was required even if the resident was on hospice services for acute issues such as falls with injuries. Record review of the facility policy titled Notifying the Physician in a Change of Status, dated 03/11/2013 indicated the physician is notified promptly of any significant change in resident status. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: -The facility failed to notify the physician of a fall with injury that occurred on 7/6/23. -The facility failed to notify the hospice agency and hospice physician. -The facility failed to treat Resident #1's pain due to not having her prescribed pain medication available. -The facility failed to send resident #1 to the hospital or get x-rays after the resident fell and sustained a lump to the right side of her forehead, complained of right wrist pain, and an abrasion to her left elbow. -The facility failed to follow their policy on notifying physician of change condition. Interventions: o As of 8/9/23 resident # 1 was assessed for change of condition and increased pain without any new findings. Attending Physician and hospice services notified of fall, fracture, and pain. Orders received as of 8/9/23 for scheduled and PRN pain meds. o As of 8/10/23, 100% audit was completed on all resident pain medications to ensure medications are available in the facility. o All residents in the facility were assessed for any increased pain and change of condition by the DON and Charge Nurses as of 8/9/23. No additional issues were found. In-services: o In-services were initiated for charge nurses on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All nurses including agency staff, new hires and PRN staff not in-serviced by 8am on 8/10/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including falls, fractures, increased pain, decreased mobility, or a change in eating habits. The Charge Nurse will follow physician's orders on transferring resident to hospital as ordered. Notification of the change of conditions to the hospice service for Residents on hospice. Implementation of physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. Reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in PCC under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. All residents on hospice services who have a fall or change in condition the Charge Nurse will notify the attending physician and hospice nurse. In-services were initiated for all nursing staff were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced by 8am on 8/10/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility using the Stop and Watch. Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) Medical Director was notified by the DON on 8/9/23 at 5:15pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident with falls or change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring will begin 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring will begin 8/10/23 and will continue x 4 weeks. The DON/designee made daily rounds on all residents. The DON/designee asked 4 nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition X 4 weeks. The DON/ADON audited all pain medication weekly to ensure medications are received x 4 weeks. * Resident #1 had completed pain assessments that showed no pain on 08/08/2023, 08/09/2023 and 08/10/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training on 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. Head-to-toe assessment were performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. And doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. The nurses were aware of the process of notification of the change of conditions to the hospice service for Residents on hospice. They were aware to implement physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. They were aware they are responsible for completing a head-to-toe assessment on all residents who complain of increased pain. The nurses were educated on reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in PCC under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. The nurses know all residents on hospice services who have a fall or change in condition the Charge Nurse will notify the attending physician and hospice nurse. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident reviewed for pain management. (Resident #1) The facility failed to ensure Resident #1 had effective pain management by failing to have pain medication available and failing to administer pain medication with complaints of pain. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place resident at risk for increased pain causing undo suffering. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (your body doesn't make enough insulin or can't use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. No indicators of pain were noted on the MDS. Resident #1 lived on the secured unit until 07/11/2023, she was then moved off the secured unit because she no longer ambulated independently. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on 02/19/2023. No pain care plan was noted. Record review of Resident #1's physician orders for July 2023 revealed: An order with a start date of 05/23/2023 for Morphine sulfate 20mg/ml give 0.5ml every 1 hour as needed for pain or shortness of breath. The order for Morphine sulfate was discontinued on 07/06/2023. An order for Morphine sulfate 20mg/ml administer 0.25ml every 4 hours for pain or shortness of breath as needed was started on 07/13/2023 An order dated 05/09/2023 for acetaminophen 325 mg give two tablets every 6 hours as needed for pain. An order for Tramadol 50 mg administer one every 8 hours as needed for pain beginning on 07/06/2023 and discontinued on 07/11/2023 An order for Tramadol 50mg administer one every 6 hours routinely was began on 07/11/2023 and was discontinued on 07/13/2023. An order for Norco 5-325mg administer one every 6 hours routinely beginning on 07/13/2023. An order for Norco 5-325mg administer one every 4 hours as needed for breath through pain. Record review of Resident #1's incident and accident report dated 07/06/2023 at by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident is c/o pain on right wrist, lump presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m., and fall was reported, Message sent to DON and Admin. Contact attempted with husband but was unsuccessful. Neuros within normal limits at the time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to right side of her forehead and small abrasion to left elbow. Resident is assessed and transferred to a wheelchair for continued observation. The hospice company was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's nurse notes indicated, no nurse notes from 07/07/2023 until 07/09/2023. No documented assessments of pain noted. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward R side, tramadol is administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this am to report patient was 'very different' today. She would not stand up 'at all' today. She reported she was in wheelchair during her visit and staff had her up in dining area for meal. RN G asked Hospice Aide H if Tramadol had been given, she reported she was not aware, but wanted RN to know of change since last Friday. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in am and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. She 'acted like' she was having increased pain with position changes. Facility CNA's also report this was noted since they 'returned to work' yesterday- there was no documentation over the weekend of her mobility status from facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient is seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give Resident #1 as staff had just informed LVN E, she was 'whimpering and acting like she is uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today related to pain. (2) Tramadol 50mg 1 orally every 6 hours routinely. (3) Discontinue routine fingerstick blood sugar checks. Husband present and aware of all new orders. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of the July 2023 MAR for Resident #1 revealed no pain medication was administered from the time she fell and complained of wrist pain at a 5 on a scale of 1-10, at 4:00 a.m. on 07/06/2023 until 07/07/2023 at 11:33 a.m. Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated the resident had been out of the prn morphine for 3 or 4 days and she contacted hospice herself several times for refills. RN D stated the hospice RN had not wanted the morphine given unless Resident #1 was actively dying. RN D stated she thought Resident #1 had an order for Tylenol but she was unsure. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice to replace the morphine Resident #1 previously had ordered. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discontinue the morphine Resident #1 had been taking and start her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated MD I wanted morphine to be given as an end-of-life medication to ease the transition when a resident was actively dying. RN G stated Resident #1 was not dying, so when the morphine ran out, she advised the nurses to use acetaminophen and call if they needed something stronger for Resident #1. RN G stated Resident #1 never presented with pain before she was notified of the pain Resident #1 was experiencing on 07/10/2023 by Hospice CNA H. RN G stated no one from the facility reported pain or the fall to the hospice company. RN G stated Resident #1 was now on routine Norco and prn tramadol for breakthrough pain, and it seemed to be effective. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:45 p.m., the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2:50 p.m., the Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 2:20 p.m., MD I stated Morphine sulfate was an end-of-life drug and in collaboration with the hospice nurse it was decided to discontinue the Morphine sulfate for Resident #1 based on the information at the time that she was not actively dying and was not presenting with pain. MD I stated it was decided the facility would start with acetaminophen to treat pain and if that was ineffective to let hospice know and we would consider other medications. During an interview on 08/09/2023 at 3:20 p.m., the Administrator stated she was unaware that RN G had discontinued the Morphine sulfate for Resident #1. The Administrator stated the last time she talked with RN G she said she was putting the morphine on hold until Resident #1's pain was assessed, and the correct pain medication was prescribed for Resident #1. The Administrator stated it was important to have pain medication available for the residents and the facility to be communicated with about the residents' care. Record review of the policy on Pain Management dated 08/10/2021 indicated the community recognizes that a resident's response to pain is subjective and individual. The community will treat the resident under the premise that pain is present whenever the resident says that it is. The physician will order appropriate pain medications intervention both routine and PRN to address the individual's pain. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: -The facility failed to provide Resident #1 with pain medication following a fall with complaints of pain -The facility failed to ensure ordered pain medications was available to dispense for complaints of pain for Resident #1. -The facility failed to follow their pain policy. Interventions: o As of 8/9/23 resident # 1 was assessed for pain. Orders received as of 8/9/23 for scheduled and PRN pain meds. o As of 8/9/23, 100% audit was completed on all resident pain medications to ensure medications are available in the facility. Audit completed by DON 8/10/23 at 300am. o All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 8/9/23. No additional issues were found. In-services: In-services were initiated for charge nurses on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All nurses including agency staff, new hires, and PRN staff not in-serviced by 8am on 8/10/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. Implementation of physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. A head-to-toe assessment will be performed every time by the charge nurse on all residents who complain of increased pain. Effectiveness of pain medication administrated i=for increased pain will be charted on the EMAR. A licensed nurse will complete a follow up assessment for effectiveness of pain. In-services were initiated for all nursing staff were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced by 8am on 8/10/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse, immediately including falls, injuries, increased pain and decreased mobility. Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) Medical Director was notified by the DON on 8/9/23 at 5:15 pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring will begin 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring will begin 8/10/23 and will continue x 4 weeks. The DON/designee will make daily rounds on all residents. The DON/designee will ask 4 nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition X 4 weeks. The DON/ADON/Designee will audit all resident pain medications twice per week to ensure a 4-to-7-day supply of medications are present and maintained. * Resident #1 had completed pain assessments that showed no pain on 08/08/2023, 08/09/2023 and 08/10/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training on 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment was performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. And doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. The nurses were educated on reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in EHR (electronic health record) under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.