**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was an accident involving the resident which resulted in injury and required physician intervention for 1 (Resident #1) of 4 residents reviewed for notification of changes. LVN-A failed to notify Resident #1's physician for 24 hours when she complained of pain after a witnessed fall on 06-23-25 which resulted in an acute fracture of the left humerus (the long bone in the upper arm) and soft tissue swelling. The noncompliance was identified as Past Non-Compliance IJ. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. This failure placed dependent residents at risk of not receiving proper care, a decline in health, and pain.Findings included: Record Review of Resident #1's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Primary insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep), lack of coordination (impaired balance or coordination), muscle weakness (decreased strength in the muscles), Hyperlipidemia (abnormally high levels of lipids in the blood), Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and Unspecified Osteoarthritis (a type of arthritis where the specific location is not identified in the medical record). Record review of Resident #1's significant change in status MDS assessment dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment). Record Review of Resident #1's Care Plan dated 06/25/25 revealed she was at risk for falls due to unsteady gait, poor awareness with visual deficit, altered cognition and poor safety awareness. She was a one person assist with her ADL. Observation of Resident #1 on 07/01/2025 at 12:50 p.m. revealed she resided in the facility's locked unit. Resident #1 was in bed with her left arm in a splint to keep it immobilized. Her bed was in the lowest position (the bed frame was adjusted to be as close to the floor as possible), fall mats were in place and her call light was in reach. Record Review of Resident# 1's progress note dated 06/23/25 reflected that the following note was written by LVN A: Nurse witnessed resident on floor in front of room [ROOM NUMBER], laying on her left side, assessment/observation completed with no verbal c/o pain or discomfort, no acute changes at the time of fall, resident assisted up into w/c via nurse and CNA, VS obtained 128/72, 97.0, 97% RA, 18, 67 stable, supplement given, resident up and walking from sitting in w/c, nurse redirected and assisted resident back to w/c, continued with no signs/symptoms of pain during observation, resident assisted to bed via CNA with no complaints of uncontrolled pain. Record Review of CNA-A's witness statement dated 06/30/2025 reflected that CNA-A stated that Resident #1's fall on 06/23/2025 was caused when Resident #1 was getting up from her seat and she accidentally bumped into a resident that CNA-A was assisting. Record review of Resident #1 shower sheet dated 06/24/25 reflected that she refused her shower on 06/24/25. Shower sheet was signed by CNA-GG. Record review of Resident#1 skin assessment dated [DATE] reflected that there wasn't any alterations in skin integrity noted. The Assessment was conducted by LVN-BB. Record review of Resident #1's progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325 mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Resident #1 Physician's order dated 08/14/23 reflected that 2 tablets be given by mouth every 8 hours as needed for Pain. Record review of Resident #1 MAR dated 06/25/25 reflected that she was given 2 tabs of Tylenol 325 mg. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture across the left humerus neck (broken arm)with subtle displacement of bony edges, overlying soft tissue swelling as noted. Record review of Resident #1's progress note dated 06/30/25 reflected that she had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. In an Interview on 07/02/25 at 10:30 am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall Head-to-Toe assessment must be done, the NP, the ADON or DON needs to be notified, and the results of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. Therefore, due her not following policy, LVN-A was terminated. On 07/02/25 at 11:00 am, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 07/02/25 at 3:30 PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident #1 according to the result of the assessment. In an interview on 08/04/25 at 4:20 pm with LVN BB, she stated that on 06/24/25 she was notified by CNA-GG that Resident #1 was complaining of pain to her left arm. LVN-BB stated that she assessed Resident #1's left arm by pulling up Resident#1 sleeve and observed that her arm did not have any redness nor any swelling. LVN BB said that she also conducted a range of motion assessment on Resident#1's arm and Resident#1 did not complain of any pain. However, on 06/25/25, LVN-BB stated that CNA-GG went to get Resident#1 up out of bed, and she complained of pain to her left arm. LVN-BB stated that she assessed Resident#1, and Resident#1 stated that her arm was hurting. LVN-BB said that she notified the NP, and an order was given to have an X-ray performed on Resisdent#1's arm. LVN-BB stated she ordered the X-ray, and she gave Resident#1 two 325 mg Tylenol for pain. On 08/04/25 at 5:35pm, an unsuccessful attempt was made to contact LVN-A and CNA-A, but both parties did not answer their phone. In an interview on 08/04/25 at 6:11pm with CNA-GG, she stated that on 06/24/25 she was trying to get Resident#1 ready for her shower when Resident#1 complained of pain to her left arm. CNA-GG stated that she reported to LVN-BB that Resident#1 was complaining of pain to her left arm. In an interview on 08/04/25 at 6:33pm with CNA-HH, she stated that on 06/23/25, she came to work and Resident#1 was already in bed asleep. In an interview on 08/05/25 at 11:20am with the ADON, he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm. The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse, she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she started showing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP, and get an order for an X-ray. The Wound Care Nurse stated that when the results of the x-ray came back that Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling, as noted, she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that she if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. Record review of the facility's policy regarding to Accidents and Incidents date 03/2025 revealed in part, All accidents and incidents involving residents, employed, visitors, vendors , etc., occurring on our premises shall be investigated and reported to the administrator The following information also has to be documented in the report , the time the physician was notified and the instructions of the physician, and the date and time the resident's family were notified, the condition of the injured person, including his/her vital signs, the disposition of the injured (i.e., transferred to hospital, or put to bed. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctors orders promptly. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on Topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions: 1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that assured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility's resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment had been terminated. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse, all stated that when a resident had a fall that a Head-to-Toe assessment must be done, the NP must be notified, the ADON, or DON needs to be notified. And the result of the assessment must be documented. They stated that LVN A did not complete a Head-to-Toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the residents RP if the resident isn't their own RP. LVN-B also stated that and SBAR must be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head, an SBAR must be done, and all the information must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in service pertained to conducting a head-to-toe assessment when a resident has a fall, call the medical staff, RP, if necessary, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the residents RP if necessary and perform and SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA, her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist, his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall, then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure LVN-A adequately assessed, monitored, provided appropriate interventions, and contact the physician immediately when Resident #1 complained of pain after a fall which resulted in an acute fracture of her left humerus (the long bone in the upper arm). The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. This failure placed residents who experience falls with injury at risk of not receiving adequate treatment in a timely manner, further injury, and pain.Findings included: Record Review of Resident #1's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Primary insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep), lack of coordination (impaired balance or coordination), muscle weakness (decreased strength in the muscles), Hyperlipidemia (abnormally high levels of lipids in the blood), Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and Unspecified Osteoarthritis (a type of arthritis where the specific location is not identified in the medical record). Record review of Resident #1's significant change in status MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment). Record Review of Resident #1's Care Plan dated 06/25/25 revealed she was at risk for falls due to unsteady gait, poor awareness with visual deficit, altered cognition and poor safety awareness. Interventions included: Anticipate and meet the resident's needs; Be sure the call light is within reach and encourage the resident to use it for assistance as needed; Ensure resident wears appropriate footwear when ambulating or mobilizing in wheelchair; Keep needed items in reach; and Physical Therapy evaluate and treat as ordered or as needed. Observation of Resident #1 on 07/01/2025 at 12:50 p.m. revealed she resided in the facility's locked unit. Resident #1 was in bed. Resident #1 was in bed with her left arm in a splint to keep it immobilized. Her bed was in the lowest position (the bed frame was adjusted to be as close to the floor as possible), fall mats were in place and her call light was in reach. Record Review of Resident #1's progress note dated 06/23/25 reflected that the following note was written by LVN A: Nurse witnessed the resident on floor in front of room [ROOM NUMBER], lying on her left side. An assessment/observation were completed with no verbal c/o pain or discomfort. The resident was assisted to bed with no complaints of uncontrolled pain. Record review Resident#1 progress note dated 06/25/25 reflected that she had mild swelling and warmth to touch to her left arm. The NP was notified, and X-ray was ordered, Tylenol 325mg 2 tabs was given., vitals recorded and was within range. Rp was notified and care was continued. Record review of Resident#1 progress note dated 06/30/25 reflected that she has had one fall in the past three months. Date, time, and how the fall occurred was not documented in the progress note. Record Review of Resident #1's X-Ray report dated 06/25/25 reflected that she had sustained an Acute fracture (a sudden and complete break in a bone) across the left humerus neck (upper arm) with subtle displacement (broken bone fragments are slightly out of alignment) of bony edges, overlying soft tissue swelling as noted. In an interview on 07/02/25 at 10:00am with the DON, Administrator, and Regional Nurse revealed they all stated that when a resident had a fall that a head-to-toe assessment must be done, the NP must be notified, the ADON, or DON needed to be notified. And the result of the assessment must be documented. They stated that LVN A did not complete a head-to-toe assessment, she failed to notify the facility medical staff, and she also failed to notify the DON. In an interview on 07/02/25 at 3:30PM, the NP stated that she did not receive a call from the facility notifying her that Resident #1 had a fall. She said that if she had been given a call, she would have given an order for Resident#1 according to the result of the assessment. In an interview on 08/11/25 at 11:30am with Resident#1 RP he stated that he was not notified of Resident#1 fall on the 23rd of June until the 25th of June when the facility was getting ready to send her to the hospital. In an interview on 08/05/25 at 11:20am with the ADON he stated that LVN-BB reported to him on 06/25/25 that Resident#1 was experiencing pain in her left arm, The ADON stated that he told LVN-BB to call the NP for an order for an X-ray. The ADON stated that the X-ray was performed and as result of the X-ray Resident#1 was sent to the Hospital. The ADON stated that 06/25/25 was the first time it was reported to him that Resident#1 was having pain. In an interview on 08/05/25 at 11:35am with the Wound Care Nurse she stated that LVN-BB called her on 06/25/25 to come to station for 4 because Resident#1 was complaining of pain. The Wound Care Nurse stated that she and the ADON both witnessed CNA-GG attempting to put a shirt on Resident#1 when she starting sowing signs of pain. The Wound Care Nurse stated that LVN-BB was told to call the NP and get an order for an X-ray. The Wound Care Nurse stated that when the results of the x-ray came back as Resident#1 had an Acute fracture across left humerus neck with subtle displacement of bony edges, overlying soft tissue swelling as noted she was sent to the hospital. The Wound Care Nurse stated that 06/25/25 was the first time it was reported to her that Resident#1 was having pain. Record review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting revised on 03/27/25 revealed, Policy Statement. All accidents or incidents involving residents, employees, visitors, and vendors occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Record Review of facility's internal investigation documentation dated 06/24/2025 regarding the incident of Resident #1 having a broken arm reflected that the facility interviewed staff beginning on 06/24/2025. Staffed interviewed were staff LVN-A, B, C, D. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON regarding falls management and changes in resident conditions. Record Review of an In-service Training Report dated 06/25/2025 revealed 10pm-6am facility staff were educated by the DON/ADON regarding Abuse & Neglect/Exploitation, and Who is the Abuse coordinator. Record Review of an In-service Training Report dated 06/26/2025 revealed facility administrative staff were educated by the Regional [NAME] President of Operations regarding Reporting Guidelines HHSC Provider Letter #2024-14. Record Review of In-service Training Report dated 06/27/2025 revealed 6am-2pm and 2pm-10pm facility staff were educated by the administrator/ DON regarding resident's rights. Record Review of an In-service Training Report dated 06/27/2025 revealed facility 6am-2pm staff were educated by DON/ADON on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of ‘In-service Training Report dated 06/28/2025 revealed all staff and all shifts were educated by RN Weekend Supervisor on Timely reporting of any changes of condition, to Nurse management, MD, and timely intervention. Record Review of an In-service Training Report dated 06/28/2025 revealed facility all staff and all shifts were educated by RN Weekend Supervisor Fall and incident Protocol. The protocol call being License Nurse assesses resident, notify the MD/NP, RP if needed, DON, Neuro Checks, and implement Doctor's orders promptly. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 06/30/2025 revealed facility 6am-2pm, 2pm-10pm and 10pm-6pm staff were educated by DON/ADON Topics of Fall protocol, witnessed falls, do not move residents until assessed by Licensed Nurse. Notify all parties, NP, DON, RP, document in progress notes. Record Review of an In-service Training Report dated 07/01/2025 revealed facility leadership staff were educated by Director of Regulatory Compliance on the topic of Abuse & Neglect. Record Review of facility resident interviews-safe review dated 06/27/2025 reflected Residents #2, #3, #4, #5, and #6 were interviewed to ensure that they were feeling safe while living at the facility. Residents were asked the following questions:1.Do you feel safe here? 2. If you have a concern or compliant, do you feel comfortable reporting It?3. Are you afraid of anyone here?4.When the staff come to your room, do they knock, tell you their name and why they are there? Residents #2, #3, #4, #5, and #6 answered the questions in a manner that ensured facility staff that they all felt safe and that they had no concerns with staff or other residents at the facility. Record Review of facility resident audits for recent falls dated 06/28/2025, and 07/01/2025 reflected Residents #7, #8, #9, & #10 were properly assessed, notifications were made, progress notes were written, SBAR, changes in condition were documented if needed. Record Review of CNA-A witness statement dated 06/30/2025 reflected that CNA-A stated that Resident #1's fall on o6/23/2025 was caused when Resident #1 was getting up from her seat and she accidentally bumped into a resident that CNA-A was assisting. Record Review of a facility email dated 07/01/2025 reflected the Administrator placed a phone call to LVN-A at 4:52pm on 07/01/2025 informing her that her employment has been terminated. LVN-A was terminated because she failed to follow facility policy regarding a resident's fall. Record Review of facility emailed dated 07/01/2025 reflected the Administrator called CNA-A on 07/01/2025 informing her employment has been terminated. CNA-A was terminated for failing to follow policy regarding a resident's fall. In an interview on 07/02/25 at 3:40pm with LVN-B, she stated that she was in-serviced on 06/26/25 regarding resident falls. She stated that she was told to complete a head-to-toe assessment, call the facility medical staff, call the ADON, or DON, and the resident's RP if the resident wasn't their own RP. LVN-B also stated that a SBAR had to be performed, and that the assessment must be documented in the resident's progress notes. In an interview on 07/02/25 at 3:45pm with LVN-C, he stated that he was in-serviced on 06/26/25 regarding resident falls. He stated that he must perform a head-to-toe assessment on the resident, call the NP, call the ADON, or DON, and the RP if necessary. He also stated that neuro checks must be conducted if the resident hit their head. And a SBAR was to be done, and all the information had to be documented in the resident's progress notes. In an interview on 07/02/25 at 3:55pm with LVN-D, she stated she was in-serviced on 06/26/25 regarding resident falls. She said the in- service pertained to conducting a head-to-toe assessment when a resident has a fall, call the RP if necessary, call the facility medical staff, call the ADON, or DON and let them know that there was a fall. Also document the assessment, and SBAR in the resident's progress notes. In an interview on 07/02/25 at 4:05pm with LVN-E, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated the in-service taught her to conduct a head-to-toe assessment, call the facility medical staff, call the ADON, DON, and the resident's RP if necessary; and perform a SBAR and document the finding in the resident's progress notes. In an interview on 07/02/25 at 4:15pm with CNA-A, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:20pm with CNA-B, she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that as a CNA her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:25pm with the Receptionist, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that as a receptionist his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:35pm with the Director of Therapy she stated she was in-serviced on 06/26/25 regarding resident falls. She stated that if she witnessed a resident fall then her job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:40pm with the Director of EVS, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. In an interview on 07/02/25 at 4:45pm with the Director of Maintenance, he stated he was in-serviced on 06/26/25 regarding resident falls. He stated that if he witnessed a resident fall then his job is to notify the nurse, and that the resident cannot be moved until the nurse has completed their assessments. Observation of the facility's secure unit on 07/01/2025 from 12:50 p.m. until 1:05 p.m. revealed there were always six staff members inside the locked memory care unit. Observation also revealed that Resident #1 was in her bed, her bed was in the lowest position, fall mats were in place and her call light was in reach. The noncompliance was identified as Past Non-Compliance. The IJ began on 06/23/25 and ended on 06/26/25. The facility corrected the noncompliance before the survey began. On 07/03/25 at 4:35 p.m. the facility's Administrator and DON were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 07/03/25 at 4:35 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed ensure that residents requiring respiratory care are provided with necessary services consistent with their care plans for one of three residents reviewed for the use of oxygen. The facility failed to ensure that CR #1's portable oxygen was fully charged before leaving the facility for a clinic appointment. This failure could place residents at risk of not receiving needed services in an emergency. The noncompliance was identified as PNC IJ began on 0328/25 and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of being neglected by not providing necessary care and services. Findings include: Record review of CR #1's admission record face sheet, dated [DATE], revealed a-[AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Chronic obstructive pulmonary disease, (primary) (a progressive lung disease that limit air flow to the lungs) essential hypertension (High blood pressure), obstructive sleep apnea (a condition that prevent air flow to the lungs), type 2 diabetes mellitus (a condition that affect how the body uses blood sugar), post-traumatic stress disorder, depression, anxiety disorder, heart failure and acute kidney failure. Record review of CR#1's progress note, dated [DATE] at 6:50AM, revealed the resident's RP is here to take resident to a local clinic for Doctor's appointment, pt left awake and alert, no SOB /distress noted, left with portable oxygen, no complaint of pain, scheduled morning meds given. Resident left with his walker via a private vehicle. Record review of CR #1'sprogress note did not specify if CR #1 had oxygen on or not, the level of the oxygen concentrator nor how much oxygen CR #1 was receiving at the time of departure. Record review of CR #1's comprehensive care plan, dated [DATE], with a revision date of [DATE], indicated CR #1 was care planed -for Congestive Heart Failure . CR #1 has a Heart Monitor, a small patch, placed on the left side of the chest wall.Goal: Resident will verbalize less difficulty breathing (Dyspnea) and be more comfortable through the review date.-CR #1 had oxygen therapy r/t COPD Date Initiated: [DATE] Revision on: [DATE]Goal- CR #1 will have no s/s of poor oxygen absorption through the review date. Date Initiated: [DATE] Revision on: [DATE] Record review of CR #1's MDS assessment indicated CR #1 had a BIMS score of 14 out of 15, which indicated he was cognitively intact. In an interview with CR #1's RP on [DATE] at 2:00 PM, the RP said she picked up CR #1 for an appointment at about 6:30AM to a local hospital for eye appointment. She said when she got to the clinic, CR #1 requested to have his oxygen but there was no tube to administer the oxygen. She said she asked the nurse at the clinic for an oxygen tube. She said CR#1 said he could not breath and fell before the nurse could place the tube on him. CR #1's RP said the nurse started working on CR # 1 until he was transported to the hospital section of the facility. She said it did not take long before the oxygen tube was brought to CR#1. She said CR #1 did not leave the facility with his oxygen on. She said CR #1 had just finish his treatment when they left the facility. She said she did not remember leaving the facility with tubing, but she had the portable oxygen concentrator in her car. She said she did not know what happened to the oxygen tube. She said she could not recall if the tube was given to her or not. She said one thing she knew was that CR#1 did not have his oxygen prior to leaving the facility. During an interview on [DATE] at 10:30 AM, LVN C said before sending any resident out of the facility, the nurse in charge must complete the assessment complete the form and had it witness by a second nurse before leaving regardless of means of transportation. She said there were serval in-services on assessments, documentation and ensuring that the form was filled out correctly and witnessed by two nurses. She explained that the forms were in a binder at the nurse's station and scanned into the resident's clinical records as soon as possible. During an interview with RN D on [DATE] at 11:50AM, he said before sending any resident out of the facility, he would have a charge nurse with him to assess the resident and document any special treatment and who was responsible for transportation and ensure that the RP know what to do in an emergency. He said he would document time date and what the resident left the with if on any special treatment He would make sure the RP knows what to do. He said if resident was on oxygen, he would make sure that the RP knows how to monitor the oxygen by education the RP. He said Resident on oxygen are always transported out of the facility by EMS. He said there was a form that must be completed by both nurses the are present during the transfer. He said the forms must be signed and scan to resident clinical record. In an interview with facility's DON, and Administrator on [DATE] at 12:00 PM, the DON said the resident's RP called to let the facility know that CR #1was admitted to the hospital. The Administrator said the local Hospital called to inform the facility that CR # 1 died a few days ago. She did not remember but would check her e-mails for the exact time and date. She said as soon as the local hospital explained what happened, herself and the DON started an investigation, called the State Survey Agency and started in-services. The DON said the facility started their own investigation and an in-service on abuse, neglect and exploitation. The DON said training included residents' assessment and proper documentation before transporting residents out to an appointment and outing as well as assessing all residents on Oxygen and on any special treatment. The DON and Administrator said LVN A was immediately suspended awaiting the result of the investigation. The DON said all residents on oxygen or special treatment were usually transported by ambulance to their appointment or by the facility van on regular appointments if there was no special treatment. The DON said in case of CR #1's RP chose to take him to the clinic because that was what she did before admission to the nursing home and did not allow the facility to transport CR #1 to his appointment. During a phone interview on [DATE] at 3:00 PM, CR#1's charge nurse, (LVN #A) said she sent CR #1 to the appointment on [DATE] at about 6:30 AM with his oxygen concentrator and told CR #1's RP to ensure the concentrator was plugged in as soon as they get got to the appointment office, because the concentrator was not fully charged. She said she believed what was left would be enough to get to the Clinic. She said she knew the concentrator was not charged because it was supposed to be charged overnight but CR #1's RP did not return the charger to the facility to charge the concentrator overnight. LVN A said she thought whatever was left on the concentrator would be enough for the trip since the trip was only 30 minutes from the facility. She said she did not know how fully charged the oxygen concentrator was and did not answer to how may liters of oxygen CR #1 was on at the time of departure. She said she did not recall. LVN A said she was suspended for 3 days and had training on abuse, neglect and exploitation, assessment and documentation prior to sending any resident out of the facility regardless of means of transportation. She said all transfers must be assessed, documented, and signed by two nurses. She said there were forms to be completed by both nurses before leaving the facility. During an interview with RN A (local clinic\hospital nurse) on 07/ 23/25 at 9:15 AM, she said the RP brought CR #1 to the clinic between the hour of 7:15 AM to 7:30 AM. and immediately requested for oxygen and stated CR #1 was out of breath. RN A said CR # 1's RP said she needed an oxygen tube for CR #1. RN A said the clinic nurse immediately brought the oxygen tubes and before the nurse could start the oxygen, CR #1 collapsed. RN A said there were always supplies at the clinic and oxygen tubes were readily available and provided to CR #1. RN A said CR #1 was intubated and transported to ICU where he later died. RN A said the administration started an internal investigation. She said she had to look at the records and find out from Medical Records before providing further information. RN A did not get back prior to exit on [DATE]. During an interview with CR#1's physician on [DATE] at 3:00 PM, he said CR #1 was one of his residents at the facility, but his medical treatment was mostly done at the local Hospital and clinic. He said CR #1 had multiple medical conditions which included COPD; and a heart condition. He said he could not speculate the course of death other than he had multiple medical conditions. The facility implemented the following to remove the noncompliance:Interview with LVN B on [DATE] at 3:00PM, he said there was a form in a binder at all nurse's station that must be filled out after assessing the resident being transported out of the facility. He said complete assessment includes all vital signs, and condition. He said the form had specific information such as oxygen, How many liters of oxygen the resident was on at the time of departure, type of portable, if the order is continuous or as needed, educate the RP on the type of equipment with a returned demonstration; if equipment uses batteries or need an electric charger and to ensure all equipment are functioning well before leaving the facility. Record Reviews of in-services and training completed by the facility, which started [DATE]- and ended on [DATE], reflected. training and in-service on Abuse, neglect and exploitation, checklist with the following requirement that must be completed by charge nurse and verified by a manager before a resident could be transported out of the facility:Resident assessment and documentation before leaving the facility. The forms revealed the following process--Do we have the necessary accessories to go with a portable oxygen yes/no-Indicate whether oxygen order is continuous or as needed-continuous/PRN.-Will this resident need a portable concentrator for hospital appointment or day pass-yes/no-Oxygen portable oxygen functional and full- yes/no-Is resident and caregiver education regarding portable oxygen use completed- Yes/No-Is resident owned equipment charged and ready to use-Yes/no.-Can giver demonstrate competency of portable Oxygen Usage-Yes/no.Last in-service was dated [DATE]- Administration of oxygen therapy:-How to read oxygen on oxygen concentrator-How to connect properly with different oxygen devices. -If a resident goes out on appointment or with family: make sure resident has sufficient oxygen in cylinders, make sure oxygen cylinder is secured properly.-If a resident uses home personal portable oxygen concentrator, then make sure battery is full and adapter is attached. Record review of facility's, undated, policy on Abuse, Neglect and Exploitation undated revealed Neglect' the failure of the facility, its employee or service providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for one (Resident#122) of 24 sampled residents reviewed for behavioral heath. The facility failed to ensure that Resident #122 had individualized behavioral health needs addressed through a person-centered care plan. The facility failed to ensure that Resident #122's suicidal ideation was addressed and followed up on. An Immediate Jeopardy (IJ) was identified on 02/16/24 at 6:30 PM. While the IJ was removed on 02/18/24 at 5:15PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of not receiving care and services to address their mental health condition such as PTSD. Finding included Record review of Resident #122's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original admission date of 8/1/23. He had diagnoses of facial weakness after a stroke, dysphagia (trouble swallowing), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, PTSD, and hemiplegia and hemiparesis (weakness and paralysis) after a stroke affecting the dominant side. Record review of Resident #122's admission MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. The admission MDS revealed he was diagnosed with PTSD. Record review of Resident #122's care plan dated 9/12/23 read in part- Behavior Management (Initiated: 8/30/23). *Focus: Resident #122 has depression r/t admission (Initiated: 8/3/23, Revised: 8/3/23). *Goal: Resident #122 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). Resident #122 will remain free of s/sx of distress, symptoms of depression, anxiety, or sad mood by/through review date (Initiated: 8/3/23, Revised: 1/30/24, Target: 3/6/24). *Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness (Initiated: 8/3/23). The care plan did not mention anything about his PTSD Record review of Resident #122's medical records from the hospital on 8/29/23 revealed he presented to the hospital for dysuria (trouble urinating) and SI. He also had suicidal ideation at his nursing home with plan to hang himself with call bell. He only had these ideas because he wanted to get out of nursing home. He currently denies suicide ideation here. Record review of Resident #122's psychiatric note from 12/27/23 revealed he stopped the Psychiatrist in the dining room to tell him he was having nightmares of war combat mostly when he heard other residents yelling out of help. In an interview with Psychiatric Nurse Practitioner on 2/15/24 at 1:45 pm, she stated seeing Resident #122 every month and evaluates him. She knew he had PTSD and had talked to staff about it and what to do if he was in crisis. She said he told her in the hall in August that he thought about wrapping the call light cord around his neck, but he never did since he did not know how to do it. He told her then he felt trapped and did not want to be here. He wanted to live with his [family member]. She said she immediately recommended to send him to VA for further evaluation because of suicidal thoughts. She said he had never said anything about symptoms or suicidal thoughts since that one time, and she asked him about it at every visit and evaluation., and he had no thoughts of suicide. She said she put him on a low dose of Melatonin in December since he told her he was having nightmares, but on further visits, he said he was not having nightmares anymore. She said she always talked to staff about Trauma Informed Care and to be aware of resident's conditions and be there if they are in crisis because of past events. Record review of Resident #122's medical record revealed a Trauma Informed Care Assessment-PTSD on 1/18/24 given by the Social Worker, that was scored a 5 out of 5 of probable PTSD. The assessment indicated he had PTSD. Record review of Resident #122's progress notes written by the the Social Worker on 1/18/24 stated, Resident approached SW to discuss his increased depression. Per [Resident] he is unable to sleep at night due to continuous noises. Per [Resident] the noise reminds him of his time in the Vietnam War. Per [Resident] the noise triggers his PTSD badly. He is requesting discharge home since his [family member] circumstances have changed. SW and resident called [family member]and she plans on moving to a larger house and will be working in [local] vs [out of town]. SW to send email request to VA to request discharge orders. In an interview with the Social Worker on 2/1/24 at 1:03pm, she said she did not care plan suicidal ideations unless the resident was actively suicidal. She said she checked Resident #122 daily to see how he was and performed a Trauma Screen on him. Observation and interview with Resident #122 on 2/15/24 at 11:25 am the resident was in his room in bed, watching TV bringing his lunch. Resident #122 told me he does not want to be here, he would rather be at home with his family member. He said he was living with his family member, but he had a stroke and had to go to the hospital, then came here. He said one time after he came here in the summer, he felt trapped and did not like being here, he thought about wrapping the call light cord around his neck, but he did not do it since he could not figure out how. He said he does not want to do that anymore but he still wants to go live with his family member. In an interview with Social Worker on 2/15/24 at 12:05 pm, she said she looks out for Resident #122 because of his PTSD, and she sees him every week, often every day. She said she can re-direct him if he is feeling anxious, and sometimes he will come to her office to talk if something is bothering him. She said he is being seen by an NP with Team Health that is part of Deer Oaks, and VA has quarterly meetings with him, as well as SW and RN from VA every month. She said she has talked to the nurses and aides about his PTSD and triggers that might agitate him, and interventions such as re-direct, talking, distractions from the triggers. She said she updates the progress notes with her visits with him. She said he is in a VA NH to Home program where the VA helps him with the transition, and his daughter is moving back to Houston and will buy a house so he can live with her. She said she asks him every time she sees him about any suicidal thoughts, and he says no. Observation on 02/16/24 at 5:00PM, revealed Resident #122 was in bed sleeping. He was clean and dry. His face was covered with his sheet. During an interview with LVN K at 5:15PM, he said Resident #122 usually go to bed after dinner and he sleeps through the night. He said not to disturb him because noise irritate him. LVN K said Resident #122 was a post war veteran and gets irritated when he hears noises. LVN K said he had an in-serviced on 02/15/24 to reduce noise at the nurse's station during shift change. He said he had not observed resident #122 with any sign of behavior. During an interview with the DON on 02/16/24 at 6:00PM, he said Resident #122 had not shown any sign of suicidal ideation since he came back from the hospital around August. He said all active staff were in-serviced on suicidal precaution sometime in August. He said he had initiated an in-service on 02/15/24 when the issue of suicide was brought to his attention. Observation and interview on 02/17/23 at 12:30PM, revealed Resident #122 in his wheelchair in the dining room socializing with other residents. During an interview he said he was waiting for his lunch. Observation revealed no sign of depression. Observation on 02/17/24 from 1:30 to 3:00PM, revealed no concerns. Observation revealed there were two staff nurses on each station (2,3, & 4). Observation and interview on 02/17/24 at 4:30 PM revealed Resident #122 in bed and said he was doing fine. He said he was looking forward to going home as soon as he gets better. He said he was not ready to go home until he was strong enough to transfer himself from his wheelchair to bed. He said he was receiving therapy and working on being strong. He said the only thing he hated was the noise that remind him of the war. He said all he heard during the war were people crying for help and in pain. He said noise brought bad memories to him. He said that was one of the reasons why he had to sleep with his head covered. He denied suicidal ideation. Record review of facility policy on Suicidal Threats (undated) stated: If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Observation on 02/18/24 at 12:30PM revealed Resident #122 was in church activities in the dining room. He was clean and dry. No concern on observation. Observation at 1:30PM revealed he was observed in his room with his call light on. During an interview, he said he needed to be changed and assisted back to bed. CNA G. Administrator was notified an Immediate Jeopardy situation was identified on 2/16/24at 6:36 pm a template was provided. Facility's Plan of removal was accepted on 02/18/24 at 2:00PM and included: [facility] - Plan of Removal F 740 Resident #122's Care Plan and behavioral health concerns and needs were reviewed again on 02/16/2024 by the Interdisciplinary Care Team. The Director of Nursing initiated Safety Rounds for Resident #122 at 7:00 p.m. on 02/16/2024. Resident #122 was interviewed and assessed by the Director of Nursing at 7:15 p.m. and found to have no suicidal ideations and no active suicidal behaviors. Resident #122 was found to be stable and in good mood. A Clinical Chart review of Resident #122 was conducted by the Interdisciplinary Care Team. The Interdisciplinary Care Team updated Resident #122's to add specificity to individualizing the Care Plan to state resident's name instead of using the word resident, added Monitor for Safety, Monitor for Target Behaviors, Behavior Management of PTSD and monitoring Target Behaviors, Monitor for mood due to PTSD, risk for Visual Impairment due history of CVA, ADL Self Care deficit due to history of CVA Completion Date: 02/16/2024 Resident #122's Care Plan was reviewed again on 02/16/2024. Review of Resident #122's Care Plan confirmed that the Care Plan was updated on 09/12/2023 and 02/15/2024 to identify history of PTSD and suicidal ideations. The trauma informed care assessments that were completed 08/03/2023, 01/18/2024 and 02/17/2024 were used to update Resident #122's Care Plan. The facility did determine how to lessen the likelihood of Resident #122's triggers by relocating him closer to the nursing station for safety, closer observation and decreased environmental noise. Information was added to the Resident's Care Plan to address how to lessen the likelihood of triggers on 02/15/2024. Completion Date 02/17/2024 Head to Toe Assessment of Resident #122 - Completed 02/16/2024. Psychiatric Nurse Practitioner was contacted and notified by Director of Nursing concerning Immediate Jeopardy F 740 regarding Resident #122's needs and assessment. Completion Date: 2/16/2024 and 02/17/2024. Resident's attending physician and the Medical Director were notified of the Immediate Jeopardy related to F740 regarding Resident #122. Completion Date: 02/16/2026 and 02/17/2024 QAPI Meeting - A Called Ad Hoc QAPI Meeting was held on the evening of 2/16/2024 to review and address the Immediate Jeopardy citation. Completion Date: 02/16/2024 In-services - The Director of Nursing re-educated and in serviced all staff on Managing Residents with Behaviors, Suicide Ideations, Dementia, and other Behaviors. The Objective of the In-Services is to educate staff on (1) Reporting residents who express Suicide Ideations to the licensed charge nurse, Director of Nursing, one of the Assistant Director of Nursing, Weekend Supervisor, Administrator, or other management staff immediately. (2) Educating staff on understanding persons with Dementia, (3) Understanding post-traumatic stress disorder (PTSD), (4) Understanding the importance of keeping residents calm when exhibiting behaviors, (5) The need to provide trauma informed care and culturally sensitive care. Direct care staff will not allowed to provide direct resident care until they have completed Inservice Training on the aforementioned topics. Completion 02/17/2024 Staff were Inservice on using the individualized plan of care to assist with person-centered intervention for each resident. Staff will not be able to provide direct resident care until they have completed Inservice training on using the individualized plan of care to assist with person-centered interventions for each resident. Trauma Informed Care Assessment has been completed on Resident #122. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Facility Plan to Ensure Compliance All Residents were reviewed for Diagnosis of PTSD. Four (4) of 125 Residents were identified to have diagnosis of PTSD. The four residents identified Care Plans were reviewed and updated to ensure they are individualized to identify and meet the needs of each resident. The Care Plans of all four residents with a history of PTSD were updated and individualized to add behavior management / risk for behaviors related to PTSD. No other residents were identified with a history of SI. Completion Date: 02/17/2024 Social Worker and/or Registered Nurse completed updated PHQ-9 Assessments on all four (4) Residents with diagnosis of PTSD. (Residents were in bed asleep on 02/16/2024). Social Worker completes a Resident Mood Interview, also known as PH Q-9, on all residents quarterly or as per MDS schedule. The PHQ-9 is a psychological assessment tool to measure depression. No other residents with a history of SI were identified. Completion Date: 02/17/2024 Administrator will inform and Inservice Interdisciplinary Team regarding Care Plan Policy including residents with diagnosis of PTSD and updating residents' Care Plans to identify and address the individualized behavioral health needs and person-centered concerns and interventions for all residents. Administrator and Director of Nursing reviewed the Care Plan policy and confirmed that it includes that review of residents who are readmitting from the hospital and includes that person-centered care plans include care planning for physical, mental, and psychosocial well-being of each resident. Care plans are revised relating to behavioral and mental health based on initial assessments, quarterly and as information about the resident and the residents' condition change. Completion: 02/17/2024 Director of Nursing will continue to Inservice all facility staff on Managing Residents with Dementia, PTSD, Suicide Ideation and Other Behaviors. Resident Care Plans are archived in Point Click Care, and all nursing staff have access to Point Click Care. Completion Date: 02/17/2024 Trauma Informed Care Assessment has been completed on all residents identified to have a diagnosis of PTSD. The Trauma Informed Care Assessment looks for psychological symptoms or triggers that prompt recall of a previous traumatic event. The primary purpose is to address the needs of trauma survivors by minimizing triggers or re-traumatization. Completed 02/17/2024 Administrator shall create a Monitoring Tool to monitor Care Plans for residents with diagnosis of PTSD and Suicide Ideations to confirm they have been updated. Completion 02/17/2024 The surveyor confirmed the plan of removal had been implemented sufficiently from 02/17/24 to 02/18/24 by During an interview with facility Administrator and the DON on 02/17/23 at 1:00PM, the Facility Administrator said the facility had initiated training and in-services since the incident was brought to the attention of the facility. She said the DON had in-services with all available staff and will continue to provide in-services till all staff are trained to implement resident's behavior on care plan and the attention of staff during morning meetings. The DON said some of the residents are post war veterans. He said the facility had identified 4 out of 17 residents with the diagnoses of PTSD. He said the facility had gone through all care plans, reviewed and revised their care plan to reflect their diagnoses. The DON said he would continue to provide in service and training to minimize noise during shift change. During an interview with LVN E on 02/17/24 at 5:00PM, she said she had just had an in-services on documentation, answering call lights and paying attention to resident's verbalized concerns. During an interview with CNA G on 02/18/24 at 1:45PM, CNA G said she had an in-service communication with residents and ensuring that their needs are being met and paying attention to their verbal communication. She said she would stay with any resident with suicidal ideation and find out if they have a plan on how. She said she would remain with the residents and notify the nurse in charge and the DON. She said she would the conversation on the resident chart. Record review on 02/17/24 revealed Resident #118, #122, #209, and 314's clinical record care plan had been updated to include their diagnoses of PTSD. Interview on 02/18/24 at 3:34PM RN H said he worked at the facility double on weekend 6AM-10PM shift and was in serviced on suicidal ideation and threats to take the following steps: place the resident on 1 on 1 supervision never leaving the resident, remove any objects in the resident room that the resident could use to try and harm themselves, call the RP, doctor, and Administration. To ensure that all communication with the resident were documented on the resident's clinical record and followed up on. Interview on 02/18/24 at 3:45PM, RN M said he worked the weekends and as needed 6AM-10PM shift. He said he was in-serviced on suicide precautions on 02/17/24 that if a resident expressed suicide ideation to not leave the resident alone, place the resident on to one supervision, remove any objects that resident could use to harm himself, notify the family, doctor, and Administrator. RN K said resident had to remain on one-to-one supervision until sent out for psychiatric evaluation\further notice. Interview on 02/18/24 at 3:50PM CNA F said she was a fulltime staff and had been at the facility for almost a year. She said she remember having an in-service on suicidal threats if a resident expressed harm to themselves. She said that was long time ago when she first started and had just had one yesterday 02/17/24. She said to stay with the resident do not leave them alone, inform the charged nurse, and continue to monitor the residents. She said she would tell the charge nurse, the administrator and continue conversation with the resident till further action is taken. Interview on 02/18/24 at 4:00 PM CNA I said she worked regular full time she said she had been in-serviced on suicidal attempts. CNA I said that if a resident expressed that they wanted to harm themselves she was not to leave the resident alone, have someone to go and inform the nurse, make sure that she removed any objects from the resident room to prevent the resident from harming themselves. She would make sure that she engages the resident in conversation through her shift. She said she had been working at the facility for over a year and had not witness any resident talked about hurting themselves. Interview on 02/18/24 at 4:15 PM LVN T said he worked the 2:00 PM-10:00 PM shift full time. LVN T said she received in-serve on suicidal precautions to never to leave the resident alone and to remove any objects that the resident might use to harm themselves, and to send for the DON and ask a CNA to remain with the resident. She said the last in-services she had was on 02/18/24 this morning to keep noise down during shift change and to pay attention to resident's call light. All resident identified with PTSD diagnoses were observed from 12:00PM to 5:00pm observation revealed no sign of distress. Records review revealed all were updated to reflect monitoring, reporting and documentation. On 2/18/24 at 5:30PM, the Administrator was informed that the Immediate Jeopardy (IJ) was removed, however, the facility remained out of compliant at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm , the facility was continuing to monitor the implementation and effectiveness of their plan of removal.