**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of seven residents (Resident #2) reviewed for accidents and supervision . The facility failed to ensure Resident #2 was transferred by two staff, which resulted in a fall with fracture of her distal left Femur (a distal femur is a fracture of the thighbone that occurs just above the knee joint) on 01/19/24 . The noncompliance was identified as PNC. The IJ began on 01/19/24 and ended on 01/22/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury due to unsafe transfers. Findings included: Review of the admission Record for Resident #2. A discharged resident, dated 03/06/24 reflected a [AGE] year-old female who was admitted to facility on 10/15/20. Her diagnoses included unspecified dementia, Senile degeneration of the brain, glaucoma (a vision problem), lack of coordination, muscle weakness, cognitive communication deficit (difficulty with thinking in regard to language use), unsteadiness on feet, neuropathy (nerve pain), need for assistance with personal care, repeated falls and high blood pressure. Review of Resident #2's annual MDS assessment, dated 12/02/23, reflected Resident #2 had a BIMs score of 2, which indicated severe cognitive impairment, and showed no behavioral issues or psychosis. Resident #2 was dependent on staff for movement in bed, and for transfers from chair to bed/ bed to chair. Dependent defined in the MDS assessment was Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The document reflected Resident #2 had no prior falls. Review of Resident #2's care plan undated due to discharge status printed on 03/06/24 reflected Focus: The resident has had an actual fall with no injury on 2/17/2021, 6/7/21, 7/31/21, Fall with injury (pain) at a later date 1/20/24, Goal: The resident will resume usual activities without further incident through the review date, Interventions: Anti-skid mat placed on W/C [wheel chair] o Bed in low position o Call for assistance before you fall LVN o Continue interventions on the at-risk plan.o Fracture left femur sent to Hospital The Care Plan further reflected Focus: The resident has an ADL Self Care Performance Deficit r/t Activity Intolerance, Fatigue. Goal: The resident will maintain current level of function in Transfers, Eating, Dressing, Toilet Use through the review date. Interventions/tasks o Hoyer Lift for transfers, o Toilet Use: The resident requires assistance to adjust clothing, transfer onto toilet, transfer off toilet. o Transfer: Two-person Hoyer post fall 1/19/24. o Encourage the resident to participate to the fullest extent possible with each interaction. o Encourage the resident to use bell to call for assistance. o Bathing: The resident requires (1) staff participation with bathing. o Dressing: Assist the resident to choose simple comfortable clothing that maximizes the president's ability to dress self. o Dressing: The resident requires (1) staff participation to dress. CNAo Eating: The resident is able to feed self . Review of Resident #2's Transfer/Discharge, dated 03/06/24, reflected Resident #1 was discharged to an acute care hospital on [DATE]. Review of Resident #2's progress notes, dated 01/19/24 at 9:05 PM by LVN B, reflected CNA A called him to report Resident #1 had an assisted fall while transferring from the Geri chair to bed. LVN B said Resident #1 was alert and confused to base line, Blood Pressure 121/62, Heart rate 65, Temperature 97.7, Oxygen saturation 94 %, Respiration Rate 17. He wrote skin was intact. Hospice, daughter and DON were notified. Review of the ambulance run sheet, dated 01/20/2024, reflected Resident #2 was transported to a nearby hospital due to pain in her lower extremity caused by a fall from the bed, and her level of distress was mild. Review of Resident #1's emergency room admission documentation, dated 01/21/2024, reflected she was admitted on [DATE] for a fractured left femur in a nursing home. It reflected [AGE] year-old female with a history of hypertension, hypothyroidism, colon cancer, dementia, CVA with left sided weakness presenting to the ED via EMS from her facility for a fall that happened 2 days ago. Per EMS, patient reportedly had an x-ray at the facility which showed a left nondisplaced fracture which prompted them to send her to the ER. History obtained from prior record reviews. Patient has a history of dementia and there is no family member at bedside. Patient was tender to palpation over the left female close to the knee. No active bleeding, no obvious dislocation noted. Was given 75 mcg fentanyl IV x 1 for her pain Control. The document reflected Pertinent imaging interpreted ( .) X-ray of the left femur shows periprosthetic (fractures that occur in association with an implant) fracture involving the distal femoral metadiaphysis (wide portion of a long bone). No abnormalities noted on the anterolateral (outside front) pelvis. Medications ordered the ED: 75 mcg IV fentanyl x 1. The document included a Supervising Physician note, which reflected [AGE] year-old female history of dementia advanced requires help with all ADLs here with the left knee pain found to have left periprosthetic fracture occurred during transfer from chair to bed; Had a long discuss ion with orthopedics given age and current baseline status low likely to improve quality of Iife surgery agree posterior long leg and can outpatient follow up. Review of the radiology report included in the emergency room documentation for Resident #2, dated 01/21/2024, reflected Radiology - [NAME] Femur Min 2 Views Lt 01/21 1258 * * * Report Impress Ion - Status: Signed Entered: 01/21/2024 1355 (1:55 PM) Im Pression: Left total knee arthroplasty in place with a nondisplaced periprosthetic fracture involving the distal femoral metadiaphysis . Adjacent soft tissue swelling and knee joint effusion. Review of Resident #2's Hospice Combined Disciplinary Comprehensive Assessment, dated 01/09/2024, reflected Musculo/ Skeletal- Nurse; Mobility Score:3 on a scale of 10 (Full range of activity) to 0 (Immobile); Ambulation: Mainly sit/lie; Uses device; Two person assist; Strength: Weak; Grips: Weak; Conditions: Joint stiffness; Foot drop left; Foot drop right Needs assistance with: Bathing; Ambulation; Dressing; Continence; Transfer Interview with LVN B on 03/06/24 at 4:08 PM revealed CNA A was transferring Resident #2 by herself from the Geri chair to bed around 8 or 9 PM. He said CNA A reported to him Resident #2 began to fall and CNA A assisted her to the floor in a seated position. LVN B said when he entered Resident #2's room, the resident was sitting on the floor with one of her arms holding onto the bed rail. LVN B said CNA A did not ask him for help during transfer. He said he did a full assessment of Resident #2. After Resident #2 denied pain, CNA A and LVN B lifted Resident #2 into her bed. LVN B said he monitored Resident #2 and asked her roommate if anything had changed. LVN B said he notified the family, physician, hospice company and the DON. He said he entered a change in condition in the MAR. He said it was important for the physician, family and the DON to be aware of what was going on with residents . Interview with the DON on 03/06/24 at 02:07 PM, revealed the DON was aware Resident #2 had a fall on 01/19/24. She said the hospice nurse came to assess Resident #2 on 01/20/24 and the resident denied pain. The DON said on 01/21/24 when physical therapy assessed Resident #2 and moved her left leg, was when Resident #2 screamed in pain. She said the hospice physician ordered x-rays and after results showed a femur fracture, Resident #2 was sent to the hospital. An interview on 03/28/2024 at 12:47 PM with the DON revealed Resident #2 was care planned as a one-person transfer prior to the incident on 01/19/2024, and he believed she was care planned appropriately. He said he thought the care plan was adjusted after that, and he was not aware of the resident ever falling prior to that incident. He said if the MDS said two-person assistance, there would need to be two people there for the transfer. The DOR said therapy was not working with Resident #2 on transfers, but they were working on more positioning-based issues, like seated balance. An interview on 03/28/2024 at 1:29 PM with MDS revealed she was the person who coded Resident #2's MDS assessment. She said in the seven-day lookback period, if a CNA happened to chart a resident was a limited two-person transfer three times, she had to code it that way in the MDS. She said she could have changed the care plan to say Resident #2 needed one to two staff assist for transfers, but the problem with that was transferring someone three times in a seven-day period did not mean the person always needed to be transferred by two people. If they care planned a two-person transfer, then two staff would have to go transfer that resident all the time, even if the resident did not need two people. She said sometimes a resident needed more assistance early in the morning, or in the evening when they were sleepy, but not any other time, and that was the case with Resident #2. Resident #2 was normally a one-person transfer. She said because she did not transfer the resident herself, she went by the documentation the staff entered. She said one MDS where a CNA happened to use limited two-person transfer three times was not enough of a change to have an IDT meeting . The IDT meetings were where they would normally discuss a change in someone's functional needs and make changes to the care plans . An interview on 03/28/2024 at 2:04 PM with the ADON revealed Resident #2 was a one-person gait belt the majority of the time, but required the assistance of two people if she was sleepy, in the morning, or at night. She said the resident was not cognitively able to tell staff if she needed more help, so the staff had to judge for themselves. (Progress notes from 01/19/24 indicated CNA A transferred Resident #2 at night by herself ). An interview on 03/28/2024 at 4:50 PM with the Administrator, DON and RNC revealed when informed of the Past Non-Compliance Immediate Jeopardy, the RNC stated she did not agree that it was an IJ. She said the facility and hospice documentation reflected Resident #2 was a one-person transfer, and that was safe and appropriate for her. The DON stated the staff were all aware they had residents who had changing conditions throughout the day. The DON said the staff based whether a one-to-two-person transfer was done by one or two by considering what the resident needed at the time, and the skill and strength of the CNA doing the transfer. She said her male CNAs or larger, stronger female CNAs, for example, might be able to do a one-person transfer when it might not be recommended for a smaller female CNA. The RNC stated the facility initiated an ad hoc QAPI and were auditing each chart to make sure all transfer status for residents were correct. She stated the MDS should have changed the care plan to one-to-two assist, instead of one-person, when she coded the MDS that way, but the resident was safe to be a one-to-two person assist, and the RAI manual supported this. The Administrator stated they started in-servicing staff after Resident #2's fall, and in-serviced all of the staff in the building, and the ADON went to the building on all shifts, and made sure every nurse and CNA was in-serviced and signed competencies before they worked a shift. Interview on 03/28/24 at 6:20 PM with CNA A revealed when she transferred Resident #1 on 01/19/24, the resident was unable to stand and hold herself up. CNA A stated she yelled for help and LVN B was in the hallway but not close to the room. While CNA A was waiting for LVN B, CNA A let the resident down to the ground. She stated it was not a fall and the use of the gait belt was to let Resident #1 down slowly. LVN B came in to assess. CNA A stated Resident #1 was a one-person transfer. She stated no one told her Resident #1 required two people to transfer. CNA A stated Resident #1 did not have a Hoyer lift sling or anything in the room. She stated Resident #1 was in a reclining chair and not a regular wheelchair. CNA A stated she was trained on transfers and had not worked with Resident #1 before until that day (01/19/24 ), and everyone had received training after that. Interviews on 03/28/2024 between 8:00 AM and 6:30 PM with CNA A, LVN A, ADON, LVN J, CNA K, CNA L, RA M, LVN N, and CNA O , staff who covered all shifts, revealed they received additional training on transfers after Resident #2's fall, which included how to know how a resident needed to be transferred, what to do if a resident appeared to need more assistance than usual or the information they received about the transfer did not seem correct, and included competency demonstrations for all types of transfer. All staff interviewed stated therapy staff were accessible at any time if they had any questions or concerns concerning a resident's transfer. All staff interviewed stated they were always able to get assistance when needed for resident transfers. Review of the hospice IDT assessment, Combined Disciplinary Comprehensive Assessment, dated 01/23/24, reflected, .mobility score: 3 on scale of 10 .ambulation: Mainly sit/lie; Uses device; Two person assist . Review of the facility's In-service Training Report .Falls, revised 06/2020, reflected nursing staff were in-serviced on falls involving procedures to proper transfers such as checking the care plan, body mechanics, transfer techniques and different transfer types. Review of the facility's In-service Training Report .Transfers, dated 01/22/24, reflected nursing staff were in-serviced on transfers involving fall management, resident assessment, care plan, universal fall precautions, documentation, and quality assurance. Review of the facility's transfer competency checklist, dated 01/22/24, reflected staff were tested for transfer competency in: Demonstrating how to correctly perform a pivot transfer with a resident Demonstrating how to correctly perform a pivot disk transfer with a resident Demonstrating how to correctly utilize a gait belt during transfer Demonstrating how to correctly utilize a slide board during transfer Demonstrating how to correctly use a mechanical lift during transfer Demonstrating knowledge of proper body mechanics for safe transfers Review of a list of residents who required two-person assistance with transfers, provided by the Administrator on 03/28/2024, reflected seven current residents . Observations on 03/28/24 between 8:00 AM and 6:30 PM of transfers included a two-person gait belt transfer, and a mechanical lift transfer, by CNAs . Both transfers were done correctly. Review of Employee files for CNA A reflected she was provided Abuse and neglect policy and reporting requirements upon hire on 04/13/23. Review of Employee file for LVN B reflected he was provided Abuse and neglect policy and reporting requirements upon hire on 03/07/23. Review of the facility's Transfer, revised 06/2020, reflected, ( .)check the care plan( .) The noncompliance was identified as PNC. The IJ began on 01/19/24 and ended on 01/22/24. The facility had corrected the noncompliance before the survey began .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one (Resident #1) of 6 residents reviewed for neglect. The facility failed to provide necessary x-ray services in a timely manner and failed to follow up to get results in a timely manner for Resident #1. The facility failed to provide education and training for nursing staff on how to carry out carry out physician orders for x-rays and follow up on the results in a timely manner. The facility failed to follow their policies for laboratory, diagnostic and radiology services and physician orders. Resident #1 fell on 9/28/2023 at 2:00 PM and sustained an injury, the order for an x-ray was obtained on 9/28/2023 at 5pm. The x-ray was completed on 9/29/2023 at 1:15 PM (20 hours delay). The facility was notified of results at 8:00 PM on 9/29/2023. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 5:00 PM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. This failure resulted in delayed diagnosis, medical treatment, and hospitalization. Findings include: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Review of the record revealed Resident # 1 had pain and received pain medication routinely every 4 hours and he received break through pain medication as needed on 9/28/23 at 2:05 PM and on 9/29/23 at 9:35 AM. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on [DATE], in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility policy titled Laboratory, Diagnostic and Radiology Services, revised June 2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . Record review of the facility's policy, Physician Orders revised June 2020, revealed . IV. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order . Review of facility's policy Abuse Prevention and Prohibition Program last revised October 2022 reflected Each resident has the right to be free from .neglect This policy statement also includes .deprivation by any individual, including caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. The Administrator is responsible for coordinating and implementing the facility's abuse prevention polices, procedures, training programs, and systems . The Corporate Administrator was notified on 10/02/2023 at 5:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Identify residents who could be affected. All residents have the potential to be affected. Identify responsible staff/ what action taken. 1. Abuse Coordinator (Corporate Administrator) reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. New Administrator/ Abuse Coordinator educated on abuse/ neglect by Director Clinical Education on 10/3/2023. 2. Director of Nurses and ADON re-educated by the Regional Clinical Nurse on the facility fall evaluation and prevention policy. X-ray ordering and follow up. Education on laboratory, diagnostic and radiology services and educated on carrying out physician orders immediately no greater than 30mins of receiving order from physician on all patients including hospice patients Completed 10/1/23. Reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. 3. All licensed nurses Registered Nurses and Licensed Vocational Nurses educated on carrying out orders for x-rays and Education on laboratory, diagnostic and radiology services on all patients immediately no greater than 30mins of receiving order from physician including hospice patients by Director of Nursing initiated on 10/1/2023 with completion date of 10/2/23. 4. All licensed nurses and LVN were re-educated on abuse/neglect by Director of Nursing initiated 10/2/23 with a completion date of 10/3/23. 5. Training for all licensed nurses RN and LVN's, follow up on x-ray results in a timely manner initiated on 10/1/2023 by the Director of Nursing. with the completion date of 10/2/23. 6. Licensed Nurses RN and LVN's in serviced by the DON on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. Training was initiated on 10/1/2023 with the completion date of 10/2/23. 7. Licensed Nurses RN and LVN's educated on carrying out orders on hospice patients immediately no greater than 30mins of receiving order from physician. Initiated by Director of Nursing on 10/1/2023. with the completion date of 10/2/23. 8. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. 9. An audit on all patients receiving x-ray in last 7 days to assure follow up completed, initiated on 10/1/2023 and completed by the Regional Nurse Consultant with no adverse findings. 10. Self-Report on Neglect made to Health and Human Services on 10/3/2023 by the Administrator. Abuse and Neglect Inservice initiated by the Regional Nurse Consultant on 10/3/2023 with a completion date of 10/4/2023. Abuse and Neglect investigation in process. Resident Safe Survey completed by the director of social services on 10/3/2023 with no negative outcome noted. 11. The licensed Nurse that didn't follow up with the X-ray was suspended on 10/1/2023 and termination of employment effective 10/3/2023. 12. New Licensed Nursing Home Administrator- Abuse Coordinator started at the facility on 10/2/2023. 13. Training and Education on Abuse and Neglect started by the Regional Nurse Consultant on 10/3/2023. In-Service conducted. 1. Abuse Coordinator reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. The New Abuse Coordinator was reeducated on abuse/ neglect by the Director of Clinical Education on 10/3/2023. 2. Director of Nurses and ADON re-educated by the Regional Clinical Nurse on facility fall evaluation and prevention policy. X-ray ordering and follow up and. Education on laboratory, diagnostic and radiology services, and educated on carrying out physician orders on all patients including hospice patients completed 10/1/23. Re-educated on abuse/neglect policy by Regional nurse consultant on 10/2/23. 3. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. 4. All licensed nurses RN and LVN educated on carrying out orders for x-rays and. Education on laboratory, diagnostic and radiology services on all patients including hospice patients by Director of Nursing initiated on 10/1/2023 with completion date of 10/2/23. 5. Training for all licensed nurses RN and LVN's, follow up on x-ray results in a timely manner initiated on 10/1/2023 by the Director of Nursing with completion date of 10/2/23. 6. Licensed Nurses RN and LVN's in serviced by the DON on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. Training was initiated on 10/1/2023 with a completion date of 10/2/23. 7. Licensed Nurses RN and LVN's educated on carrying out orders on hospice patients immediately no greater than 30mins of receiving order from physician. Initiated by Director of Nursing on 10/1/2023 with completion date of 10/2/23. 8. All licensed nurses and LVN were re-educated on abuse/neglect by Director of Nursing initiated 10/2/23 with a completion date of 10/3/23. 9. An audit on all patients including hospice patients receiving x-ray in last 7 days to assure follow up initiated and completed on 10/1/2023 by the Regional Nurse Consultant with no adverse findings. 10. Staff Training and Education on Abuse and Neglect Policy and Process initiated by the Regional Nurse Consultant on 10/3/2023 with completion date of 10/4/2023. Any staff member that doesn't go through the training will not be allowed to work in the facility. All new hires will be trained in Abuse and Neglect policy and Process. 11. The licensed Nurse that didn't follow up with the X-ray was suspended on 10/1/2023 and termination of employment effective 10/3/2023. Implementation of Changes Abuse Coordinator reeducated on abuse/neglect by Regional Nurse Consultant on 10/2/23. New Administrator and Abuse Coordinator reeducated on abuse/neglect by the Director of Clinical Education on 10/3/2023. Director of Nurses re-educated by the Regional Clinical Nurse on facility fall prevention and evaluation, X-ray ordering and follow up Education on laboratory, diagnostic and radiology services. and educated on carrying out physician orders on all patients including hospice patients. Abuse and Neglect policy. Completed 10/2/23. Director of Nursing, Assistant Director of Nursing and Weekend supervisor educated on procedure to pull report on New X-rays ordered and Falls. Completed on 10/2/23 by Regional Nurse Consultant. Licensed nurse's RN's and LVN's re-educated on abuse/neglect policy by Director of Nursing. Initiated on 10/2/23 with completion date of 10/3/23. Licensed staff RN, LVN will review daily Monday through Friday with IDT (Therapy, Nurse managers, social worker, administrator.) all falls, and any patient receiving an X-ray. Weekend Supervisor RN to review all falls and X rays on weekends. The Director of Nursing, Assistant Director of Nursing or designee will run a daily report to identify any resident with fall or new order for X-ray. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 10/1/2023 and training was completed on 10/2/2023. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on fall policy, ordering x-rays and follow-up results, Education on laboratory, diagnostic and radiology services prior to working the floor. The Director of Nursing will ensure competency through signing of in service, verbalization of understanding and completion of returned questionnaire. Director of Nursing will complete audit of falls, x-rays with results daily x 30 days then weekly thereafter. The X-ray company contacted by facility leadership Director of Nursing/Administrator, beginning 10/2/23 all adverse/negative Xray results will be texted to both DON/Administrator phones for notification. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 10/1/2023. The Abuse Coordinator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all falls, new Xray orders and follow up results daily x4 weeks, then weekly thereafter and report any adverse finding during QAPI. Director of Nursing/Assistant Director of Nursing will conduct a daily audit of falls, Xray and result follow up x4 weeks, then weekly thereafter and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 10/2/2023 and conducted an Ad HOC QAPI regarding the facility allegedly failing to provide services, facility failed to provide necessary x-ray services in a timely manner for a hospice resident, who sustained an injury/pain with fall. The facility failed to follow up to get results in a timely manner. The facility failed to follow their policy for x-rays with residents who sustain an injury/pain with fall. The Medical Director was notified about the immediate Jeopardy on 10/2/2023, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 10/2/2023. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 10/2/2023. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated a delay in obtaining and getting results of an x-ray was neglect. RN C stated she would contact physician, DON, and Administrator if a delay in resident x-ray order being completed or getting results. She was knowledgeable of abuse/neglect policy, definition of neglect and reporting requirements for abuse/neglect. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated if there was a delay in obtaining x-ray or getting x-ray results for residents she would contact physician, DON and Administrator of the delay. She stated a delay in obtaining and following up on x-ray results was neglect and must be reported immediately to Administrator Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/01/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she will be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents status with x-ray orders and results. ADON stated she expected all nurses to notify her and the Administrator of abuse/neglect allegations immediately. She was knowledgeable of neglect definition of failure to provide services for a resident. She was knowledgeable of facility's abuse/neglect policy and reporting guidelines. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated she was the abuse coordinator for the facility and any allegations of abuse/neglect must be reported to the state. She was knowledgeable of definition of neglect of failure to provide goods or services for a resident. She stated she just started on Monday as the new Administrator. She stated she expected all staff to report any allegations of abuse/neglect to her immediately. She stated she was responsible for reporting neglect to the state within 2 hours, initiate investigation, and must send in the provider investigation report within 5 days. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering acuity of the facility residents for 4 ( LVN A, LVN B, LVN C, and ADON) of 6 nurses reviewed for competency, in that : The facility failed to ensure: - LVN B carried out an x-ray for Resident #1. - RN C followed up with the x-ray order for Resident #1. - LVN A followed up with the x-ray order in timely manner and to get results for Resident #1. - ADON monitored that the nurses followed up with the x-ray order and received the x-ray results in timely manner for Resident #1 Resident #1 fell on 9/28/2023 at 2:00 PM and sustained an injury, the order for an x-ray was obtained on 9/28/2023 at 5pm. The x-ray was completed on 9/29/2023 at 1:15 PM (20 hours delay). The facility was notified of results at 8:00 PM on 9/29/2023. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 5:00 PM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. These failures resulted in delayed diagnosis, medical treatment, and hospitalization. Findings include: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on [DATE], in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility's policy titled Laboratory, Diagnostic and Radiology Services, revised 06/2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . The Corporate Administrator was notified on 10/02/2023 at 5:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Plan to remove immediate jeopardy. The resident is no longer in the facility and is now at the hospital. LVN B was terminated on 10/03/2023. On 10/01/2023 LVN A and RN C were educated on carrying out orders for x-rays immediately no greater than 30mins of receiving order from physician and Education on laboratory, diagnostic and radiology services on all patients including hospice residents. LVN A and RN C were also trained on carrying out physician orders on all residents including hospice patients. On 10/02/2023 ADON was educated on procedure on how to generate a report on new x-ray orders, falls and to notify the physician of any adverse findings no greater than 30min after receiving results. 10/01/2023 the nurse consultant conducted an audit on all residents receiving x-ray in last 7 days to ensure follow up were completed. No concern has been identified at this time. 10/01/2023 to 10/02/2023 the DON educated all licensed nurses RNs and LVNs on carrying out orders for x-rays immediately no greater than 30mins of receiving order from physician and Education on laboratory, diagnostic and radiology services on all residents including hospice residents. RNs and LVNs were also educated if STAT x-ray was not received within 2hours of x-ray completion, the licensed nurse should call the x-ray company for the reason of delay. The licensed nurse will notify the physician and DON immediately of the delay and seek further guidance. On 10/02/2023 x-ray company was contacted by the DON and the Administrator, beginning 10/2/23 all adverse and negative x-ray results will be texted to both DON, ADON, and Administrator phones, and an alert of x-rays added in the EMAR system. The Director of Nursing, Assistant Director of Nursing or designee will run a daily report to identify any resident with fall or new order for X-ray and immediately report any adverse findings to physician. 10/01/2023 a QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated when she received order for x-ray for a resident who had complaints of pain after an unwitnessed fall she would ask physician if STAT x-ray can be ordered. RN C stated she would contact x-ray company by phone for STAT x-ray and it should be completed within 4 hours. She stated after x-ray obtained by x-ray company, she would follow-up within 2 hours if x-ray results not received. She stated she would contact physician and DON if have any issues with x-ray order not being completed or not receiving x-ray results. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated STAT x-ray orders were to be completed within 4 hours of contacting x-ray company and should follow up with x-ray company within 2 hours after x-ray technician came out to facility if not received results of x-ray. She stated if there was a delay in obtaining x-ray or getting x-ray results, she would contact physician and the DON for guidance. Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/01/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she would be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents' status with x-ray orders and results. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated herself, ADON, and nurse consultant would get critical labs and x-ray results from the x-ray company along with nurses. She stated they would get alerts on their phones. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 (Resident #1) of 6 residents reviewed for radiology services. 1. The facility failed to ensure that an x-ray was completed in a timely manner for Resident #1 2. The facility failed to follow up to get Resident #1's x-ray results in a timely manner. Resident #1 had an unwitnessed fall on 9/28/23 at 2pm and sustained an injury, The order for an x-ray was obtained on 9/28/23 at 5pm. The x-ray was completed on 9/29/23 at 1:15pm (20 hours delay). The facility was aware of results on 9/29/23 at 8:00 PM. Resident #1 had a fracture to the right hip. Thirty hours after the fall with fracture, the resident was sent to the hospital for treatment. Hospital Records indicated Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/02/2023 at 10:38 AM. While the IJ was removed on 10/05/2023 at 4:15 PM, the facility remained out of compliance at actual harm with a scope identified as isolated. These failures resulted in delayed diagnosis, medical treatment, and hospitalization. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 08/13/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), muscle weakness, lack of coordination, unsteadiness on feet, generalized osteoarthritis, and history of falling. He had a BIMS score of 10 indicated his cognition was moderately impaired. Resident #1 required extensive assistance of one-person for physical assistance with bed mobility, dressing, and toilet use. Review of Resident #1's Comprehensive Care Plan, dated 04/23/23, reflected the following: Focus: Resident is at high risk for falls related to gait/balance problems due to Parkinson's with falls recorded on 2/14/23, 8/17/23, and 9/28/23 resulting in skin tear and intertrochanteric fracture of right hip. Record review of nurses note dated 9/28/23 completed by LVN A at 2:31 PM reflected Resident #1 was found laying on the floor, on his right side, in his room. Resident #1 complained of pain to his right leg. Record review of nurses note dated 9/28/23 completed by LVN B at 5:14 PM reflected the hospice nurse and LVN B assessed Resident #1. PCP gave an order to obtain x-ray to right shoulder, right hip, and right leg. Record review of physician order for Resident #1, dated 9/28/20223 at 5:09 PM, stated to obtain x-ray to right shoulder, right hip, and right leg due to fall and complaint of pain. Record review of client coordination note report dated 9/28/23 completed by hospice nurse reflected the hospice nurse called LVN B to notify him to call in the x-ray and to call hospice with the results of the x-ray. Record review of nurses note dated 9/29/23 completed by LVN A at 11:06 AM reflected LVN A called the x-ray company to place a STAT x-ray to right shoulder, right hip, and right leg. Record review of radiology results report dated 9/29/23 reflected an x-ray was done to Resident #1's right hip, right leg, and right shoulder on 9/29/23 at 1:15 PM. The x-ray company sent the report to the facility on [DATE] at 2:01 PM. The radiology results report reflected Resident #1 had facture to the right hip. Record review of a nurses note dated 9/29/2023 completed by LVN B reflected Resident #1 was sent to the emergency room at 8:20 PM. Record review of hospital records dated 10/05/2023 reflected Resident #1 was admitted to the emergency room (ER) on 9/29/23 at 8:50 PM. Resident #1 had a hip fracture and 2 cervical (related to the neck) spine fracture. Resident #1 was hospitalized and had a hip surgery on 9/30/23. In an interview on 10/01/2023 at 2:23 PM, LVN A stated Resident #1 had a fall on 09/28/2023 at 2:00 PM. LVN A stated she assessed Resident #1; he complained of pain to the right leg. She medicated resident for pain. LVN A stated on 9/29/2023 around 11:00 AM, the ADON told her to follow up if the x-ray was done. She checked Resident#1's records; the x-ray was not done. She called the x-ray company for a STAT x-ray. The x-ray technician came on 09/29/23 at 1:15 PM. In an interview on 10/03/2023 at 1:22 PM, MA E stated on 9/28/2023 around 2:30 PM, her and LVN A assisted Resident #1 to change his pants. MA E stated she observed swollen area at the right hip of Resident #1. In an interview on 10/01/2023 at 3:02 PM, LVN B stated he was aware of an order received from Resident #1's PCP for x-ray to right shoulder, right hip, and right leg due to fall and complain of pain. LVN B stated since the hospice nurse was in the building, he assumed the Hospice Nurse would follow up and carry out the x-ray order. In an interview on 10/01/2023 at 5:01 PM, the Hospice Nurse stated on 09/28/2023 around 5:00 PM she assessed Resident #1 after the fall, he complained of pain to the right hip and right leg. She received an order for x-ray to right shoulder, right hip and right leg. Hospice nurse stated she gave the order to LVN B to call the x-ray company. In a follow up interview on 10/03/23 at 12:32 PM, the Hospice Nurse stated she contacted LVN B on 09/28/2023 around 7:00 PM, she told him to call in the x-ray and to inform hospice about the findings. In an interview on 10/01/2023 at 3:45 PM, RN C stated on 09/28/2023, on the change of the shift, LVN B reported to her that Resident #1 had a fall, and an order for x-ray was received. She stated she did not follow-up with the x-ray order. In an interview on 10/02/2023 at 2:00 PM, the Hospice Physician stated he expected the facility to get the x-ray ordered as soon as possible. He stated waiting 20 hours was too long. In an interview on 10/01/2023 at 3:50 PM, the ADON stated on 09/29/2023 around 9:00 AM, in the morning meeting, she learned Resident #1 had a fall on 09/28/2023. The ADON stated she told LVN A to follow up with the x-ray order. The ADON stated she did not know when the x-ray was done, and she did not know when the results of the x-ray were received by the facility. The ADON stated the nurses were responsible to follow up with the x-ray orders and the x-ray results. In an interview on 10/01/2023 at 3:59 PM, the DON stated on the afternoon of 09/28/2023, LVN A notified her about the fall. The DON stated she expected the LVN to follow up the x-ray order and to follow up to get the results in a timely manner. The DON stated she had been working in the facility for about a month and she was still in training. In a follow up interview on 10/02/2023 at 3:16 PM, the DON stated LVN A called in the STAT x-ray on 10/29/2023. The DON stated no documentation showing that the x-ray was called in to the x-ray company on 10/28/2023. The DON stated delay in x-ray would potentially prolong pain and would delay the implementation of appropriate interventions. The DON stated the nurses were responsible for implementing the order of x-ray for Resident #1. In a phone interview on 10/03/23 at 12:19 PM, Resident #1's RP stated a nurse notified her, on 09/28/2023 that Resident #1 had a fall. The RP stated on 09/29/2023, in the morning, she asked LVN A about the x-ray. LVN A told the RP that she ordered the x-ray. The RP stated on 09/29/2023, Resident #1's other family member was in the facility around 7:30 PM, and she insisted Resident #1 go to the hospital or she would call 911. The RP stated Resident #1 was sent to the hospital on [DATE], in the evening and he had a hip surgery on 09/30/2023. In an interview on 10/03/2023 at 4:30 PM, The x-ray company representative stated the x-ray's final reported for Resident#1 was sent to the facility on [DATE] at 2:04 PM via fax to the facility. In an interview on 10/03/2023 at 5:00 PM, the Regional Director of Operations and Nurse Consultant I stated the phone number provided by the x-ray company was an electronic fax where the critical labs and x-ray results were sent to the facility. The Regional Director of Operations and Nurse Consultant I stated they could not find when the x-ray result was sent on 9/29/2023 to the facility for Resident #1. In an interview on 10/02/23 at 4:48 PM, the Corporate Administrator stated he expected nursing management to follow up to ensure x-ray services were provided to residents. Record review of the facility's policy titled Laboratory, Diagnostic and Radiology Services, revised June 2020 reflected . II. The facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic or radiology provider . An Immediate Jeopardy was identified on 10/02/23. The corporate administrator was notified on 10/02/2023 at 10:38 AM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 10/04/2023 at 3:54 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Plan to remove immediate jeopardy. The resident is no longer in the facility and is now at the hospital. LVN B was terminated on 10/03/2023. [Facility's name] submits the following Plan of Removal for the alleged failure to provide diagnostic services. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified resident(s)? Resident with alleged deficient practice was discharged to hospital on 9/29/23. How were other residents at risk to be affected by this deficient practice identified? An audit on all patients receiving x-ray in last 7 days to assure follow up completed, initiated on 10/1/2023 and completed by the Nurse Consultant H with no adverse findings. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? On 10/01/2023 Nurse Consultant H re-educated the DON and the ADON on the facility fall evaluation and prevention policy. X-ray ordering and follow up. She educated them on laboratory, diagnostic and radiology services and educated on carrying out physician orders on all residents including hospice residents. On 10/01/2023 and 10/02/2023 the DON educated all licensed nurses RNs and LVNs on carrying out orders for x-rays and educated them also on laboratory, diagnostic and radiology services on all residents including hospice residents. The DON also educated them on follow up on x-ray results in a timely manner and on the facility policy and procedure regarding facility fall prevention policy, assessment, and notify the physician regarding change of condition. On 10/2/23 by Nurse Consultant H educated the DON, ADON, and weekend supervisor on procedure to pull report on new x-rays ordered and falls. The DON and the Administrator contacted the x-ray company, beginning 10/2/23 all adverse and negative x-ray results will be texted to both DON's and Administrator's phones for notification. LVN B was suspended on 10/1/2023 and termination of employment effective 10/3/2023. How will the system be monitored to ensure compliance? The Administrator, DON, ADON, and Nurse Consultant H will be responsible for monitoring the implementation and effectiveness of in-service on 10/1/2023. The DON, ADON, and Nurse Consultant H will monitor and review all falls, new x-ray orders and follow up results daily for 4 weeks, then weekly thereafter and report any adverse finding during QAPI. The DON and ADON will conduct a daily audit of falls, x-ray and result follow up for 4 weeks, then weekly thereafter and report any adverse findings during QAPI. Quality Assurance A QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 10/1/2023. The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 10/02/23 reflected nursing and nursing administration (ADON, Weekend RN Supervisor and DON) was in-serviced on pulling x-ray and fall reports for residents, nursing documentation, change of condition notification, pain management, physician orders, fall evaluation/prevention and laboratory, diagnostic and radiology services and abuse/neglect policy. On 10/04/2023 between 4:41 PM and 5:54 PM and on 10/05/2023 between 10:13 AM and 12:31 PM eight (8) licensed vocational nurses and 2 registered nurses including Weekend RN Supervisor, were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of hospice residents' orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. In an interview on 10/05/23 at 10:14 AM, RN C stated she received in-service training regarding obtaining x-ray orders including hospice residents facility responsible for ensuring x-ray ordered obtained and followed up in a timely manner. She stated when she received order for x-ray for a resident who had complaints of pain after an unwitnessed fall she would ask physician if STAT x-ray can be ordered. RN C stated she would contact x-ray company by phone for STAT x-ray and it should be completed within 4 hours. She stated after x-ray obtained by x-ray company she would follow-up within 2 hours if x-ray results not received. She stated she would contact physician and DON if have any issues with x-ray order not being completed or not receiving x-ray results. In an interview on 10/05/23 at 11:25 AM, LVN A stated she received in-service training regarding x-ray orders to be obtained from physician and contact x-ray company for STAT x-ray for a resident who had unwitnessed fall and complained of pain requiring pain medication. She stated STAT x-ray orders were to be completed within 4 hours of contacting x-ray company and should follow up with x-ray company within 2 hours after x-ray technician came out to facility if not received results of x-ray. She stated if there was a delay in obtaining x-ray or getting x-ray results she would contact physician and the DON for guidance. Review of the clinical record for Resident #7 who had a fall and x-ray ordered revealed x-ray ordered on 10/02/23 with no issues of lack timeliness of x-ray result for Resident #7. X-ray result revealed negative for fracture. Review of clinical record revealed appropriate notifications to RP, physician and DON. Review of LVN B's employee file revealed facility terminated employee as of 10/03/23. In an interview on 10/05/23 at 12:15 PM the ADON stated as of yesterday (10/04/23) she will be the Interim DON for the facility. She stated x-ray company had been contacted and will be alerting her, Administrator and Nurse Consultant of critical x-ray results so they will be able to follow-up to ensure charge nurses follow up on x-ray results for residents. She stated each morning she will review the log on new labs or x-ray resident orders and check to ensure x-rays were obtained in a timely manner. She stated she expected nurses to contact her and keep her apprised of residents status with x-ray orders and results. In an interview on 10/05/2023 at 1:25 PM, the Administrator stated herself, ADON, and nurse consultant would get critical labs and x-ray results from the x-ray company along with nurses. She stated they would get alerts on their phones. On 10/05/2023 at 4:15 PM, the Regional Director of Operations and the Administrator were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.