**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents environment remained free of accident and hazards to prevent avoidable accidents for 1 (Resident #28) of 1 resident reviewed for safe transfers. The facility failed to ensure mechanical lift #1 was removed from the floor after it was deemed out of order on 01/03/2025. The facility failed to ensure mechanical lift #2 was in working order prior to Resident #28's transfer. The mechanical lift fell on top of Resident #28 and Resident #28 fell to the floor from the lift which resulted in Resident #28 being transferred to the ER to be treated for a lumbar fracture and hemorrhage on 01/03/2025. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 01/15/2025 at 6:15 PM. While the IJ was removed on 01/18/2025 at 6:15 PM, the facility remained at a level of no actual harm at a scope of isolated that is was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who require a mechanical lift for transfers at risk for falls and/or serious injury or death. Findings included: Review of Resident #28 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of wedge compression fracture of second lumbar vertebra (break in the front of the vertebra that causes it to collapse into a wedge shape), memory deficit following cerebral infarction (common cognitive impairment that can affect memory, attention, concentration, and language), Traumatic subarachnoid hemorrhage without loss of consciousness (type of brain injury that occurs when there's bleeding between the brain and skull) and multiple sclerosis (a chronic disease that damages the central nervous system). Review of Resident #28 significant change MDS dated [DATE] revealed, Resident #28 had a fracture and major injury. Further review revealed Resident #28 was dependent on staff for chair to bed and bed to chair transfers. Review of Resident #28 undated care plan revealed Resident #28 was dependent on staff for transfers and required a mechanical lift. Further review revealed Resident #28 fell from mechanical lift on 01/03/2025 with interventions to keep area free of obstructions to reduce the risk of falls or injury. Review of Resident #28 nursing progress note dated 01/03/2025 revealed LVN D was called to Resident #28's room and Resident #28 was on the floor. Progress note revealed CNA N and CNA O tried to transfer Resident #28 from bed to her wheelchair and stated that she fell from lift and laid on the floor. Resident #28 stated she bit her tongue and small amount of blood was noted. Resident #28 stated she hit her head. NP was notified and provided order to send to ER. Review of Resident #28 nursing progress note dated 01/04/2025 revealed Resident arrived back to facility with diagnosis of lumbar spine fracture and subarachnoid hemorrhage. During an interview on 1/15/2024 at 12:02PM Resident # 28 started she remembered falling to the floor after staff tried to get her to her bed with the lift. Resident #28 stated she was scared, screamed and bit her tongue. She stated when she hit the floor, she thought she had broken her back. Resident #28 stated she did not remember going to the hospital or if she had any injuries. During an interview on 1/15/2024 at 1:40pm LVN D she stated she was working on 1/03/2025 and was called to the Resident #28's room. LVN D stated upon arrival Resident #28 was on the floor and he two aides (CNA N and CNA O) told her they tried to transfer Resident #28 from bed to her wheelchair and that Resident #28 fell from the mechanical lift and laid on the floor. She stated Resident #28 was alert and the resident told LVN D that she bit her tongue. LVN D stated she did notice a small amount of blood that stopped bleeding by itself, and that Resident #28 told LVN D she hit her head. LVN D stated she completed vitals and called the NP, which gave the order to send out Resident #28 to the ER for further evaluation. LVN D stated she also called and informed Resident #28's son. During an interview 1/15/2024 at 1:54PM CNA N stated, she worked 6:00 am to 2:00 pm on 01/03/2024 and at 10:00 am she and CNA N went to Resident #28's room to get her out of bed for activities. CNA N stated they had already used the mechanical lift at 6:00 am on Resident #28 and with two other residents without problems and did not have any knowledge of the mechanical lift being out of order. CNA N stated when they moved the mechanical lift from the bed, the top of the mechanical lift fell on top of Resident #28. CNA N stated, Resident #28 screamed out loud when she fell to the floor and fell on her back. CNA N stated that Resident #28 stated she bit her tongue and saw it was bleeding. CNA N stated she ran to contact the charge nurse LVN N and stated LVN N came to the room and completed vitals and Resident #28 was sent to the ER because she hit her head. During an interview on 1/15/2025 at 2:05PM CNA O she stated as they pulled the mechanical lift away from the bed the top of the lift fell on top of Resident #28, and she fell on her back to the floor. CNA O stated Resident #28 screamed out due to the impact. CNA O stated she stayed with the resident while CNA O when to get the nurse. She stated LVN D came immediately. During an interview on 01/15/2025 at 3:05 PM MD stated that the company who serviced mechanical lifts came out earlier in the day on 1/03/2025. He stated that the technician stated he left an out of order sign on a mechanical lift. MD stated he did not confirm there was a sign on the mechanical lift and that later he heard a resident fell. MD stated that the service provider does not inspect the mechanical lift he only calibrates the scale. MD stated that upon his inspection after the fall he saw that a washer separated from the bolt which caused it to come out and what caused the mechanical lift to fall onto the resident. MD stated that he removed the mechanical lift from the floor after the incident. MD stated that he inspected each mechanical lift weekly and the service provide calibrates mechanical lifts monthly. MD stated he does not document his weekly inspections. MD stated that there used to be an app the staff could report issues, but it did not work out and there are maintenance binders that staff write down issues in. During an interview on 01/15/2025 at 3:20 PM DON stated she was not working when the fall happened with Resident #28. DON stated she returned to work on 1/06/2025. DON stated mechanical lift training was completed on 12/24/2024 with staff, but not again after the incident with Resident #28. DON stated no additional training was done regarding safe transfers and it was her intention to do it, but it did not happen. During an interview on 01/15/2025 at 3:57 PM ADM stated that staff said they were transferring Resident #28 and the central arm came loose and she fell off the bed and onto the floor and was between the legs of the lift. ADM stated Resident #28 was sent to the hospital. ADM stated that when the service provider come to service the mechanical lift, they calibrate the lift and do not inspect it. He stated there was not routine maintenance done unless something is was wrong with the lift. He stated that the MD inspected lifts routinely but not in a formalized process. He stated that the service provider was out earlier in the day on 1/03/2025. He stated he had not heard that they marked a mechanical lift out of order. ADM stated they used it for Resident #28's shower earlier in the day and two other residents before her fall. ADM stated that the only thing that was not working was the battery in the scale but that was for weighing purposes. ADM stated if someone stated that there was something wrong with mechanical lift, he would have expected it to be taken it off the floor. ADM stated if the mechanical lift was out of order and used it would risk of someone getting hurt and stated that someone did get hurt, but depended on if something was truly wrong with it. ADM stated he was not sure if he had a policy on servicing mechanical lift. ADM stated he expected service providers to notify management of any issues with equipment so it could be pulled off the floor. In a subsequent interview on 01/15/2025, ADM stated that the service report for the mechanical lift serviced on 01/03/2025 was different than the lift that fell on Resident #28. During an interview on 01/15/2025 at 05:30 PM DON stated all staff should report mechanical lift issues to MD and if it was after his working hours, the staff should inform the immediate nurse and they should contact MD. DON stated all staff were responsible for removing a non-working mechanical lifts from resident care areas. During an interview on 01/15/2025 at 5:30 pm CNA P stated that if the equipment was not working, he would have been able to tell when he felt it not working like it used to. CNA P stated he did not know what the policy was for reporting broken equipment, but stated he would report it to his chain of command. CNA stated he would not know a mechanical lift was broken from the look of it. CNA P stated if it was broken someone could get hurt. Observation and interview on 01/15/2025 at 5:35 PM revealed a second mechanical lift with an orange sign on it wheeled into MD's office that had do not use on it. MD stated that this lift was on the floor and that ADM would have to be asked about if it was being used. MD stated it apparently already had the sign on it not to use but he was unsure where it was and to ask ADM. During an interview 01/15/25 at 5:35 PM, MA Q stated she would not know if equipment were broken unless they put a sign on it. She would not be able to identify something was broken until it was not working properly. MA Q stated if she needed to report it, she would have reported it to her charge nurse. MA Q stated if they used broken equipment, they could hurt themselves or others. During an interview on 01/15/2025 at 5:43 PM, CNA R stated if equipment was not working properly, she would let the nurse know and would write a sign and remove it. CNA R stated she would move the equipment outside the area. CNA R stated if she used a piece of equipment that was broken, it could hurt herself or another resident. During an interview on 01/15/2025 at 5:44 PM, service provider supervisor stated that the company only calibrates the scales on the mechanical lifts. He stated that if there was an issue with the lift, they would notify management. He stated that they would normally not tag the lift that it was out of order and if it was not functioning, they would notify management. During an interview on 01/15/2025 at 5:50 PM, LVN S stated she was a charge nurse. LVN S stated if a piece of equipment was broken a CNA would let her know. LVN S stated she normally worked 10:00 PM - 6:00 AM and they did not use a lot of equipment. She stated they would scan the QR Code that was implemented in May 2024 to notify the MD. LVN S stated CNAs would let us know and then they would go through the steps of reporting. LVN S stated they would remove the equipment, put a sign on it and push it to the back on in a closet if it was not working. During an interview on 01/23/2025 at 11:54 AM, representative from mechanical lift manufacturer stated that it was advised to do at least a monthly inspection of the mechanical lifts to look around for normal wear and tear. Representative recommended that a day be set aside once a month to inspect the lift. Review of service report dated 01/03/2025 revealed mechanical lift #1's serial number matched the service report, and it was serviced on 01/03/2025. Further review revealed service reported noted motor that spreads wheels does not work but scale is accurate left out of tag order on lift. Further review revealed service provider emailed MD a copy of the service report on 01/06/2025. Review of technician kiosk sign in and out information revealed service provider technical checked in at 01/03/2025 at 9:05 am and check out of the facility at 9:58 AM. Resident #28 was reported to have incident at 10:00 AM. Review of undated facility investigation pictures of mechanical lift #2 revealed differing serial number than serial number of mechanical lift #1. Observation on 01/16/2025 at 3:30 PM revealed mechanical lift #2 revealed differing serial number than lift that was serviced on 01/03/2025. Review of facility accident/incident report dated 01/03/2025 revealed equipment as fall contributing factors. Review of manufacture owner's manual titled Battery Operated Patient Lift dated 03/01/2022 revealed the operator of the lift is to inspect the mechanical before each use and included to check all bolts and nuts are tight. Further review revealed at least once a month, the lift should be thoroughly inspected to recognize any signs of wear, and/or looseness of bolts or parts and to replace any worn parts immediately. Review of facility policy dated July 2017 titled Lifting Machine, using a Mechanical revealed make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Further review revealed to test control and ensure emergency release feature works. ADM and DON were notified on 01/15/2025 at 7:17 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/17/2025 at 4:52 PM: F689 This is to confirm the submission of our Plan of Removal provided by this facility. For F689 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The resident went sent to the ER for further evaluation and treatment on 1/3/2025. The resident was treated for L2 transverse fracture and monitored for brain bleed and resolved. On 1/4/2025 Resident returned to the facility at her previous level of care with no changes and remains a two-person mechanical lift assist for transfers. How the facility will identify other residents having the potential to be affected by the same deficient practice; Residents who require a two person assistance with mechanical lifts have the potential to be affected. On 1/16/2025 Administrator reviewed last twelve months of incident reports with no instances mechanical lift malfunction with residents. There have been no other incidents with mechanical lift malfunctions. The mechanical lift used in the incident with this resident (serial number ending 50) was removed from service on 1/3/2025, secured and made inoperable for further use. The mechanical lift noted by the service technician as motor that spreads the wheels does not work (serial number ending 26) has been removed from service and secured from use on 1/15/25. As of 1/16/24 Administrator validated there are three Mechanical lifts in use; lift with serial number ending 35, lift with number ending 79, lift with number ending 500. On 1/16/25 Area Lead Maintenance Director completed a re-inspection of all mechanical lifts on site, all lifts in use are functioning properly. 1/16/25 Administrator and Area Lead Maintenance Director confirmed Director confirmed the two other lifts remain removed from service and secured. On 1/15/24 Maintenance director has been relieved of duty by Administrator pending investigation, retraining, and demonstrated skills competency by VP of Plant Operations. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur; On and beginning 1/15/25 the Director of Nursing and Administrator will conduct re-education including post test with direct care staff on safe transfer and lift operation, and reporting any operational concerns to management. On 01/15/2025 the Director of Regulatory Compliance in-serviced the Administrator and Director of Nursing on Abuse, Neglect, and Resident Rights. Administrator or designees initiated in-servicing all staff on Abuse, Neglect, and Resident Rights on 1/16/2025. Any staff who are not present to complete the in-servicing by 1/18/25 or new staff after that date will be required to complete the in-servicing at the start of their next shift before beginning work. Revised Lift Maintenance and Inspection policies and practices including documentation, and revised lock-out tag-out procedures will be implemented on 1/16/2025 to ensure continued safe operation of lift equipment. Any staff -including maintenance director who are not present to complete the in-servicing by 1/18/25 or new staff after that date will be required to complete the in-servicing at the start of their next shift before beginning work. Administrator and DON in-serviced by Lead Area Maintenance Director 1/17/25. Service provider will be notified of new requirement to personally review all lift inspections with the Administrator or Director of Nursing while on-site completion date 1/17/25. How the facility plans to monitor its performance to make sure that solutions are sustained. Administrator will directly review all mechanical lift inspections weekly for four weeks. Then bi-weekly for two months. Beginning 1/16/25 and ongoing. Beginning 1/16/25 and ongoing Area Lead Maintenance Director will conduct maintenance and safety inspections on all mechanical lifts monthly for three months then monthly thereafter by facility maintenance director . These inspections will be reviewed with Administrator while on-site. Beginning 1/17/25 Nurse Managers will observe five direct care staff a week for four weeks, during care, of residents who require mechanical lifts, to ensure that staff demonstrate competencies with re-education as needed. Then bi-weekly for two months. The Maintenance and Inspection logs, and results of observations will be reviewed at the monthly QAPI meetings for 3 months beginning with 1/17/25 and ongoing. The Administrator is was responsible for implementing the acceptable plan of correction. The POR was monitored from 01/16/2025 to 01/18/2025 as follows: During an interview on 01/16/2025 at 3:32 PM, ADM stated that the lift serviced on 01/03/2025 was identified as mechanical lift #1 and the serial number on the service report was different that mechanical lift #2 which is the lift that was used during the transfer with Resident #28. ADM stated that the lift in the service report was supposedly marked out of order but he was unsure who the technician check out with and notified of this. ADM stated that the lift in the report (mechanical lift #1) was pulled off the floor on 01/15/2025 and marked out of order. ADM stated he had not been made aware that there was an issue with mechanical lift #1 until then. ADM stated that the lift involved in Resident #28's fall was a different lift and had last been serviced on 11/05/2024. ADM stated that normally the MD would be responsible for repairing and ordering parts to service the lift outside of scale calibration. Observation on 01/16/2025 revealed mechanical lift #1 and mechanical lift #2 marks identified as out of order and zip tie through battery compartment to prevent use. Observation on 01/18/2025 of a locked maintenance closet revealed mechanical lift #1 and mechanical lift #2 were stored and tagged as inoperable with a zip tie through the battery compartment and no batteries attached. During an interview with the ADM on 1/18/2025 at 12:15pm he stated that any staff not completing the in-servicing by 1/18/2024 would not be permitted to work until they are in-serviced over the topics related to the IJ. He stated for new hires, nurses would get the change in condition, PHC trainings, and aides would receive the mechanical lift, and flu trainings. During interviews on 01/18/2025 from 12:55pm-3:00pm, the DON, two RN's and four CNA's from both shifts stated they were in-serviced on infection control, the order of donning: sanitize hands, apply gown, apply mask, apply shield, then gloves and once done with their task they must do everything in reverse order, dispose of the PPE, sanitize their hands and put on new mask. They were in-serviced on reporting of ANE, including the ANE coordinator being the Administrator. They were taught that all mechanical lifts are to be used by 2 people at a time, how to identify a resident needing mechanical lift transfers by the electronic record, and how to properly ensure working order and then use of the mechanical lift. They also revealed knowledge of using Proactive Health check in the residents' EMR. During an interview with the DON on 1/18/2025 at 3:45pm she stated she received training from the DCS regarding influenza and infection control, what signs and symptoms need to be reported, change in condition must be reported to the MD, RP, and clinical staff working with the resident. Mechanical lift in-servicing, how to properly don/doff PPE, and that the ADM is the abuse coordinator. The DON, ADM, and DCS had been taking turns providing the mechanical lift, proactive health check, proper PPE application and removal, and outbreak in-services to direct care staff. The DON revealed she will be responsible for providing in-servicing for new hires and any PRN staff must complete the training before working the floor. Review of a inspection log labeled [Mechanical] Lift Preventative Maintenance Inspection Log, reflected 5 lifts were documented as inspected on 1/16/2025. Review of a policy titled Mechanical Lift Maintenance and Inspection Policies dated revised 1/16/2025 reflected maintenance director will complete a visual and function inspection of all lifts weekly. If any area does not pass inspection, the lift with be removed from the service area, and a lock out/tag-out indicator affixed so as to prevent unauthorized use. Review of an email from the ADM to a scale inspector dated 1/17/2025 revealed that the inspector must notify the ADM and be accompanied by the ADM throughout a service technician's inspection of lifts at the facility. Review of document title Mechanical Lift Audit by Nurse Manager 5 per week for 4 weeks revealed an audit conducted on 1/17/2025 by the DCS. Review of in-service titled Abuse/Neglect & Resident Rights reflected it was presented by DCS dated 1/17/2025 was provided to the ADM and the DON. While the IJ was removed on 01/18/2025 at 6:16 PM, the facility remained at a level of no actual harm with the potential for more than minimal harm that is was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intake #557738 Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 7 of 29 residents (Resident #1, Resident #17, Resident #68, Resident #39, Resident #80, Resident #159, Resident #21) reviewed for infection control. 1.The facility failed to test all residents who had flu like symptoms. 2. The facility failed to put place residents on quarantine or droplet precautions when indicated. An IJ was identified on 01/15/25 at 4:45 pm. The IJ template was provided to the facility on [DATE] at 7:15 pm. The plan of removal was accepted on 01/17/25 4:52 pm. While the IJ was removed on 01/17/25 at 5:30 pm the facility remained out of compliance at a scope of pattern and a severity of no actual harm identified as patterned due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 4. LVN E did not follow Enhanced Barrier Precautions by not putting on a gown when conducting medication administration via gastrostomy tube for Resident #17. 5. The SC did not follow Enhanced Barrier Precautions by not putting on a gown before providing peri-care and assistance during wound care for Resident #1. These failures placed the residents at risk of infection transmission, respiratory distress, hospitalization, and even death. Findings included: Resident #68 Record review of Resident #68's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included an acute upper respiratory infection, chronic pain syndrome, heart failure, hyperlipidemia, depression, seasonal allergic rhinitis, arthritis, shortness of breath, dementia, Vitamin D deficiency, and Vitamin B deficiency. Record review of Resident #68's Quarterly MDS assessment, dated 01/09/25 reflected a BIMS score of 15, indicating her cognition was mildly affected. Further review of the MDS revealed Resident #68 required set-up or clean up assistance for meals and oral hygiene, and partial/moderate assistance for her activities of daily living. Further review of the MDS reflected Resident #68 used a manual wheelchair for mobility. Record review of Resident #68's Care Plan dated 01/17/25 reflected she has episodes of shortness of breath and was at risk for respiratory distress. The goal indicated decreased episodes of shortness of breath, and no signs or symptoms of respiratory distress/failure over the next 90 days. Interventions included use of oxygen and take slow deep breaths, nursing to monitor for signs of relief from shortness of breath and provide respiratory treatments per orders, administer medications as ordered, and assess respiratory status by checking breath sounds, respiratory rate, skin color and notify physician of abnormal findings. Record review of Resident #68's Clinical Notes reflected: o 01/13/25 at 02:01 PM - Resident #68 refused to take geri-tussin 10 mL. o 01/13/25 at 04:25 PM - X-ray result came back and notified Nurse Practitioner, who ordered Tamiflu 75mg PO BID x 5 days. Carried out order and faxed to pharmacy. Called her RP and left a message. o 01/13/25 at 05:53 PRM - Nurse Practitioner ordered Influenza testing. Scheduled with [Company Name] to come onsite to get the test, in-house Influenza testing kit is out. Scheduled 01/14/25. No Test Results were available. Observation of resident's room on 01/14/25 at 4:50 pm revealed no airborne precautions or PPE signage outside the door. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #68 room without donning proper PPE. Resident #39 Record review of Resident #39's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic pain due to trauma, a contusion of head, wedge compression fracture 3rd lumbar vertebrae, rheumatoid arthritis, fracture of left femur and nasal bones, repeated falls, severe protein-calorie malnutrition, hypotension, nausea, Record review of Resident #39's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact. Further review of the MDS revealed Resident #39 required moderate to substantial assistance for her activities of daily living, and she used a wheelchair. Record review of Resident #39's Care Plan dated 12/10/24 reflected she was at risk for allergic reaction related to allergies to codeine and gluten. The goal was for Resident #39 to not have an allergic reaction for the next 90 days. Interventions included a review of listed allergies prior to giving new medications, review of diet for food allergies, notify physician if Resident #39 has an allergic reaction to new medications or foods, and document signs and symptoms of allergic reaction. Record review of a Clinical Note for Resident #39 dated 01/12/25 at 12:54 AM reflected Resident #39 felt as if she was getting sick or it may be allergies. Resident #39 denied any pain after the nurse offered her pain meds. Resident #39 stated she was going to continue without any medication and if it becomes worse she would ask for something. Record review of a Clinical Note for Resident #39 dated 01/16/25 at 03:13 PM reflected a Rapid Flu Test Procedure Card showed a negative test result and NP would be notified about negative test . Observation of resident #39's door on 01/14/25 revealed no PPE or airborne precaution signage Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #39 without donning proper PPE. Resident #80 Record review of Resident #80's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included syncope and collapse, urinary tract infection, diabetes mellitus type 2, seizures, encephalopathy, altered mental status, legal blindness, hyperlipidemia, hypertensive heart disease, cerebrovascular disease, and personal history of malignant neoplasm of organs and systems. Record review of Resident #80's 5-day MDS assessment, dated 12/22/24 reflected a BIMS score of 10, indicating her cognition mildly to moderately affected. Further review of the MDS revealed Resident #80 required partial/moderate assistance for her activities of daily living, and she used a walker and a wheelchair. Record review of Resident #80's Care Plan dated 01/16/25 reflected Resident #80 required extensive assistance with bed mobility, bathing, hygiene, dressing and grooming. The goals were for Resident #80 to be odor free, dressed and out of bed daily over the next 90 days, and Resident #80 would assist with her activities of daily living to the highest degree possible. The interventions included transfer status with gait belt with one staff assist and set up assist with her meals . Record review of resident's progress notes revealed no notification between the staff and doctor. Observation of Resident #80's room revealed no signage of PPE outside the room. Observation in resident #80's room on 01/14/25 at 07:25 am revealed RN U entering room to provide a head to toe assessment for resident 80. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #80 room without donning proper PPE. Observation in resident #80's room on 01/15/25 at 12:15 pm revealed CNA N entered room with only a surgical mask on. Interview with Resident #80 on 01/15/25 at 12:15 revealed the resident had been feeling ill over the weekend. She reported symptoms of diarrhea, cough and congestion and body aches. She was not offered a flu shot or flu test. Resident #159 - Record review of Resident #159's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a fracture of right femur and orthopedic aftercare, hypertension, congestive heart failure, mild intermittent asthma, vascular dementia, repeated falls, presence of an implantable cardiac defibrillator, non-Hodgkin lymphoma, coronary atherosclerosis due to calcified coronary lesion, pneumonia, urinary tract infection, depression, and anxiety. Record review of Resident #159's MDS revealed a BIMS of 0 indicating severe cognitive impairment. Record review of Resident #159's Care Plan dated 12/10/24 reflected: o A diagnosis of asthma and she was at risk for shortness of breath and respiratory failure. The goal was for asthma to be relieved by medication within 30 minutes of administration over the next 90 days, and interventions included monitoring for shortness of breath, notify physician of shortness of breath that is not relieved by medication, and administer oxygen for unrelieved shortness of breath. o A potential for fluid volume overload related to Congestive heart failure, with a goal stating she would be free from signs and symptoms of fluid volume overload. Interventions included administering diuretics and monitor for side effects, assess for breath sounds and observe for labored breathing, encourage adequate fluid intake within restrictions as ordered, keep head of bed elevated, monitor for signs and symptoms of fluid overload such as edema, shortness of breath, and report to physician. and turn and reposition every 2 hours and as needed. Record review of Resident #159's Physician Orders reflected: o 12/10/24 - Take vital signs by shift, o 01/14/25 - Regular Ground Continuous diet, o 01/15/25 - Pulse Oximetry every shift, and o 01/17/25 - Droplet Isolation Precautions every shift for 6 days, and a Proactive Health Check (Covid/RTA Prevention) every shift. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #159 room without donning proper PPE. Observation on 01/15/25 at 11:30 am revealed no signage on the door for PPE Precautions. Observation on 01/16/25 at 3:30 pm revealed airborne precaution signage on the resident's door. Interview with Resident #159 on 01/14/25 at 7:30 am stated that they felt very poorly. Resident was moaning in between words and could not answer any further questions. Interview with RN U on 01/17/25 at 4:00 pm revealed that he notified the doctor that day. Resident #159 had been tested for the flu and was positive . Resident #21 Review of Residents admission sheet showed an [AGE] year-old female admitted to the facility on [DATE]. Pertinent diagnoses included coronary artery disease (heart disease), Type 2 diabetes, Dementia, and Heart Failure. Record review of Resident #21's MDS revealed resident had a BIMS score of 06 which indicated severe cognitive impairment and partial to moderate assistance with ADL's Record review on 01/15/24 nursing notes revealed that family had called into the facility and reported that the resident was experiencing flu like symptoms and went to the ER. Observation on 01/15/24 at 12:30 pm of Resident#21 revealed no signage of PPE outside the door . Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to all residents on the 700 and 800 halls without donning proper PPE for residents suspected of having the flu. Interview with CNA N on 01/16/25 at 4:45 pm stated that she noticed Sunday evening the residents were not feeling good. She stated that she had talked to the nurse about it and the nurse had given the residents fever and pain reducing medications. Interview with RN U on 01/14/24 at 8:35 am, he stated that when he arrived at work on 01/13/25 he saw multiple people with a decline in condition. He notified the DON and called the NP to get orders for the residents. He began administering PRN fever reducers, cough, and congestion medicine. He did not focus on putting proper PPE signage on the door because he assumed that was the job of the DON or ADON. He stated he retrieved masks and began to wear a mask while providing care to the residents. He stated that if he did not wear proper PPE the residents could get more sick. Record review of the facility's Performance Improvement Plan dated 1/13/25 reflected the problem area was Resident #21 had tested positive for the flu at the hospital, which initiated an outbreak. Changes implemented to reach baseline: 1. Monitor all residents for signs and symptoms of flu initially and daily. 2. Tested symptomatic patients. 3. Notified Medical Director- plan to treat patients prophylactically and standing orders giving based on lab results. 4. Inservice staff on hand hygiene and flu 5. Deep clean all resident rooms to include side rails and overbed tables. 6. Place all positive patients on droplet precautions 7. Encourage all staff to wear mask, mandatory for unvaccinated staff during flu season. 8. Monitor all positive patients for serious complications - notify Medical Director and /or providers if found. Interview with the DON Interview on 01/15/25 at 09:55 AM with IP/ADON who revealed she had worked a double shift on the east unit, which included the 600 and 700 halls. The IP/ADON stated the first case of Influenza in the facility was on Sunday, 01/13/25. She stated around 10:00 AM many of the residents on the 700/800 halls were sleeping in, and during breakfast she started hearing some of the residents coughing and having congestion. Around noon, the diarrhea and vomiting started. She stated very few residents ate dinner on Sunday. Many had very low appetites. She stated she knew something was going on with the residents, but it was hard to tell because it was a variety of symptoms. Guidance from the DON was to write down resident symptoms as the day went on. She stated she did not contact the doctor and they only tested people who were very sick for the flu because the facility ran out of flu shots . Interview with NP on 12/15/25 at 1:42 pm revealed that he or his doctor had not been contacted by the facility on Sunday, 01/12/2025, when the symptoms had begun. They contacted him Monday morning 01/13/2025 with the symptoms and I directed them to do testing and start treatment. If they were running a fever with cough and congestion, he started them on Tamiflu. Without a fever he wanted to look at them and see what's going on. He expected them to report the symptoms immediately. He reported that they sent two to the hospital with respiratory distress but couldn't recall directly which residents . Interview on 01/15/25 at 04:24 PM with ADM revealed Resident #21 had been out on pass with her family, and they took her to the hospital for flu-like symptoms. The ADM stated Resident #43 had developed upper respiratory symptoms and went to the hospital. He further stated on Monday 01/14/25 the committee had a quick QA meeting and consulted with the physician for parameters for monitoring residents for flu-like symptoms. The ADM stated that he was notified of an Influenza outbreak on Sunday night, 01/13/25. The ADM stated his expectations were for all residents testing positive for influenza and flu-like symptoms to be placed on isolation precautions or cohorted with other residents with similar flu-like symptoms . Interview with LVN V on 01/17/25 at 4:40 pm revealed that she had been in-serviced on outbreak standards, PPE usage, and reportable incidences on 01/16/25. Interview with CNA R 01/17/25 at 4:45 pm revealed that she had been in-serviced on outbreak standards, PPE, and reportable incidences on 01/16/25. Record review of Infection Control Policy of Type and Duration of Precautions recommended for Selected Infections Appendix A stated Human Seasonal Influenza stated single patient room when available cohort mask patient when transported out of the room and give vaccine to control outbreaks. Use gown and gloves according to standard precautions. Duration of precautions for immunocompromised patients cannot be defined. Isolation duration of five days. Review of facility policy titled quick reference for isolation precautions states, in addition to Standard Precautions, use Droplet Precautions for Patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include: o Adenovirus o Influenza o Mumps o Parvovirus B 19 o Rubella Record review of an in-service report dated 1/13/25 covered the topics of the flu with droplet and contact precautions washing hands with soap and water and wearing masks. Record review of an in service on 01/06/25 with the topic of cross contamination prevention that covered: -Hand hygiene as a part of standard and transmission-based precautions. -Sanitize or wash hands with soap and water before and after resident care serving meals applied gloves restroom renews eating etcetera . Plan of Removal This is to confirm the submission of our Plan of Removal provided by this facility. For F880 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Director of Nursing and Administrator will be inserviced on 1/16/25 by the Regional Director of Clinical Services on Influenza Outbreak Management in Long Term Care. On 1/16/25 at 1238 PM the Medical Director and patients assigned providers were updated on all patients with flu symptoms and on all patients that were positive by the DON. All licensed staff to be inserviced on notifying providers of changes in condition to include a pre/post test by the Regional Director of Clinical Services and/or Director of Nursing Services beginning 1/16/25 with a completion date of 1/17/2025. All staff to be educated on Influenza and Outbreak Management in long term care to include a pre/posttest by the Regional Director of Clinical Services and/or Director of Nursing beginning 1/16/25 with a completion date of 1/17/2025. Inservice will include signs and symptoms, precautions to take, prevention measures, isolation and outbreak management. All licensed staff will be inserviced on Proactive Healthcheck orders by the Regional Director of Clinical Services and/or Director of Nursing beginning 1/16/25 with a completion date of 1/17/2025 . The licensed nurse will enter this order for all patients to capture any flu signs and symptoms. The Proactive Healthcheck will be utilized through the remaining of the flu season. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 1/16/25-The Regional Director of Clinical Services completed a 100% chart audit, identifying all residents with flu symptoms to ensure the providers were notified. This was completed on 1/16/2025. All providers were notified by the Director of Nursing Services of all patients with symptoms. On 1/16/25-An audit was conducted by the Regional Director of Clinical Services identifying all patients with active flu and flu symptoms to ensure they were isolated according to the CDC guidelines. Completed 1/16/2025- all patients verified to have the correct precautions in place. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur; On 1/16/2025-Facility is utilizing the PHC Proactive Health Check daily -EHR tool which monitors for abnormal symptoms that may indicate a condition change and other possible illnesses in the residents. The symptoms monitored include-abdominal pain, chills or repeated shaking with chills, diarrhea or other GI upset, headache, loss of smell, loss of taste, muscle pain, nausea, Oxygen saturation, red shadowed eyes or pink eyes, shortness of breath, sore throat, and tingling sensation in face or hands. The PHC dashboard will be reviewed daily during stand up by the DON and/or ED. DON and ED were in serviced on 1/16/2025. This will monitoring will be on going. How the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 1/16/2025. The Director of Nursing Services and/or designee (ADON, UM, ED) will review the 24 hour report (nursing documentation) daily during the clinical stand up meeting with staff monitoring for patient change of conditions and ensuring notification to providers was done. This process will be ongoing. The Sr. Regional Director of Clinical Services will review the 24 hour report (nursing documentation) weekly for four weeks beginning 1/20/2025 to monitor for patient change of conditions and ensure notification to providers was done. The DON and/or designee (ADON and/or IP) will perform a minimum audit of 3 random audits on different hallways daily for 1 week, the bi - weekly for 4 weeks beginning 1/17/2025 to monitor for PPE compliance. Compliance concerns to be addressed immediately by the DON and/or designee. Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months. The state surveyor monitored the POR on 01/18/2025 as followed: Observation of exterior of the 11 resident's rooms' who tested positive for influenza reveal donning/doffing PPE outside the doors with signs that instruct how to properly don and doff PPE as well as signs that read, STOP droplet Precautions, everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit-CDC. During an observation and interview on 01/18/2025 at 1:45pm revealed CNA A and CNA B donning PPE before entering a resident's room. CNA A said she was in-serviced on how to properly don/doff PPE, and how to notice a change in condition and report it to their charge nurse. Interview with the ADM on 1/18/2025 at 12:15pm revealed that any staff not completing the in-servicing by 1/18/2024 will not be permitted to work until they are in-serviced over the topics related to the IJ. For new hires, nurses would get the change in condition, PHC trainings, and aides would receive the mechanical lift, and flu trainings. During interviews on 01/18/2025 from 12:55pm-3:00pm, the DON, two RN's and four CNA's from both shifts stated they were in-serviced on infection control, the order of donning: sanitize hands, apply gown, apply mask, apply shield, then gloves and once done with their task they must do everything in reverse order, dispose of the PPE, sanitize their hands and put on new mask. They were in-serviced on reporting of ANE, including the ANE coordinator being the Administrator. They also revealed knowledge of using Proactive Health check in the residents' EMR . Interview with the DON on 1/18/2025 at 3:45pm revealed that she received training from the DCS regarding influenza and infection control, what signs and symptoms need to be reported, change in condition must be reported to the MD, RP, and clinical staff working with the resident. How to properly don/doff PPE, and that the ADM is the abuse coordinator. The DON, ADM, and DCS had been taking turns providing proactive health check, proper PPE application and removal, and outbreak in-services to direct care staff. The DON revealed she will be responsible for providing in-servicing for new hires and any PRN staff must complete the training before working the floor. Review of in-service titled Abuse/Neglect & Resident Rights reflected it was presented by DCS dated 1/17/2025 was provided to the ADM and the DON Review of in-service titled PHC checks should be done once a shift during outbreak. Notify MD/NP of any abnormal findings. Ensure all new admissions have orders for PHC checks once daily while in outbreak. Presented by the DCS dated 1/16/2025 reflected it was provided to nursing staff. Review of in-service titled Donning/doffing. Influenza symptoms, management, preventing spread of. Droplet precautions. When you exit a room with droplet precautions, you must sanitize your hands, dispose of old mask, sanitize hands, put on clean mask. reflected it was presented by the DCS dated 1/16/2025- ongoing. Review of PHC dashboard dated 1/16/2025 and 1/17/2025 reflected audits conducted by the ADM. Review of in-service titled, Proactive Health Check Monitoring, Clinical notes review, auditing PPE compliance reflected it was presented by the DCS to the ADM and the DON dated 1/16/2025. Review of PPE Observation Audit log dated 1/17/2025 reflected no issues. The ADMIN and the DON were informed the Immediate Jeopardy (IJ) was removed on 01/17/24 at 5:30 pm. The facility remained out of compliance at a severity of no actual harm that was not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #1 Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), vascular dementia (a type of dementia cause by brain damage from impaired blood flow), hemiplegia affecting right dominant side (occurs when parts of the brain that control movement become damaged, affecting muscles on right side of the body), aphasia (a communication disorder caused by brain damage that affects verbal and written language), dysarthria (a motor speech disorder that makes it difficult to form and pronounce words due to nervous system damage), anemia, diabetes mellitus type 2, reduced mobility, and expressive language disorder( a communication disorder in which there are difficulties with verbal and written expression). Record review of Resident #1's Quarterly MDS assessment, dated 12/12/24 reflected a BIMS Score of 9, indicating her cognition was moderately impaired. Further review of the MDS revealed Resident #1 required substantial/maximal assistance for her activities of daily living, and she used a wheelchair. Record review of Resident #1's Care Plan dated 01/16/25 reflected Resident #1 was transferred to and from her bed, chair and wheelchair and was totally dependent on staff. Her goal was to be out of bed daily as tolerated, and interventions included transfer with mechanical lift, and quarter rails as enabler to assist with bed mobility and transfer. Observation on 01/16/25 at 12:40 PM revealed the SC did not follow Enhanced Barrier Precautions by not putting on a gown before providing peri-care and assistance during wound care for Resident #1 . There was no signage on the resident's door for PPE. An interview on 01/16/25 at 1:05 PM revealed the SC had forgotten to put on a gown before providing care to Resident #1. The SC stated the importance of following Enhanced Barrier Precautions was to reduce the spread of infection to the residents. Resident #17 Record review of Resident #17's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (neurological disorder characterized by the permanent stiffness of all four limbs, which can lead to a loss of motor function and mobility), microcephaly (neurological condition where a child has a smaller head and brain than normal), anemia, muscle weakness, dysphagia (difficulty swallowing), epilepsy (seizure disorder), aphasia (a communication disorder caused by brain damage that affects verbal and written language), gastroparesis (a condition that affects the normal muscle movements of the stomach), and gastrostomy status (creation of an artificial external opening into the stomach for nutritional support or gastric decompression). Record review of Resident #17's Annual MDS assessment, dated 11/15/24 did not have a BIMS Score, indicating her cognition was moderately impaired. The MDS indicated Resident #17 had a diagnosis of cerebral palsy and received nutrition and medication via a gastrostomy tube. Further review of the MDS revealed Resident #17 required substantial/maximal assistance for her activities of daily living, and she used a modified wheelchair. Record review of Resident #17's Care Plan dated 01/17/25 reflected Resident #17 was transferred to and from her bed, chair and wheelchair, and was totally dependent on staff. Her care plan further stated she was at risk for impaired nutritional status due to being dependent for enteral feeding, with goal that Resident #17 will not exhibit signs and symptoms of formula intolerance over the next 90 days. Intervention included implementation of Enhance Barrier Precautions. Record review of Resident #17's Physician Orders dated 01/14/25 reflected infection or colonization with an MDRO and requirements included: 1. Gowns and gloves are recommended when performing high-contact resident care activities. 2. Residents are not restricted to their rooms and do not require placement in a private room. 3. Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be a longer-term approach. Observation on 01/16/25 at 12:59 PM with LVN E revealed he did not put on a gown prior to administering medication via gastrostomy tube for Resident #17. Observation on 01/16/25 at 12:59 pm revealed no PPE signage on the door to the resident' room. Interview on 01/16/25 at 01:16 PM with LVN E revealed he should have put on a gown before administering medication to Resident #17. LVN E further stated it was important to follow Enhanced Barrier Precautions when providing care, and following Infection Control protocols was to help stop the spread of infection to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN A documented Resident #1's unwitnessed fall, conducted neuros, and informed the oncoming nurse on 11/28/24. The aides continued to notify the nurses of Resident #1's pain and was not sent to the ER until the late evening on 11/29/24, where she was diagnosed with a hip fracture. The noncompliance was identified as PNC. The IJ began on 11/28/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of not receiving necessary medical care, increased pain, injury, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, pain, muscle weakness, and generalized anxiety disorder. Review of Resident #1's quarterly MDS assessment, dated 10/09/24, reflected a BIMS could not be conducted due to rarely/never being understood. Section E (Behavior) reflected she wandered daily. Section J (Health Conditions) reflected she had falls since the prior MDS assessment with one resulting in injury. Review of Resident #1's quarterly care plan, dated 11/28/24, reflected she was at risk of falls related to dementia, fatigue related to constant pacing, and quick movement with an intervention of supervising her ambulation to prevent falls or other injuries when she was unsteady. It further reflected She had the potential risk for injury due to quick pacing with an intervention of educating patient/responsible party on the risks. Review of Resident #1's incident report, dated 11/28/24 at 5:20 PM (completed on 12/05/24 at 1:16 PM) and documented by LVN A, reflected the following: Fall - Unwitnessed [Resident #1] was noted sitting on the floor in the hallway playing with a box . [Resident #1] was assessed on suspicion of fall. [Resident #1] displayed no signs of pain/discomforts. No changes to skin. Review of Resident #1's progress note, dated 11/28/24 at 5:30 PM (documented on 12/05/24 at 12:23 PM) and documented by LVN A, reflected the following: [Resident #1] noted sitting on the floor. [Resident #1] taken to room for evaluation. Active nosebleed noted. Nostril cleaned and skin is intact with no discoloration. Nose care provided and bleeding subsided. Review of Resident #1's progress note, dated 11/29/24 at 11:25 PM and documented by LVN B, reflected the following: AM an PM CNAs reported that [Resident #1] has been in bed all day and is unable to stand up or walk. I assessed [Resident #1] and she has no bruising, swelling, no abrasions, or other visual signs of fall or injury. I attempted to sit [Resident #1] up to assist with standing. [Resident #1] grabbed her right hip area and yelled. She is shaking and appears to be in discomfort when I assessed her and when I checked her v/s. Her b/p is 160/90, pulse 100. Resp 22 . [Resident #1] left to (hospital ER) at 10:18 PM. Review of Resident #1's hospital paperwork, dated 11/29/24, reflected the following: .presents to ED for right hip pain from nursing home. Unsure if she fell but has been unwilling to stand today and has an abrasion to her cheek and dried blood in bilateral nares. Work up showed: right intertrochanteric femur fracture. .[Resident #1]'s RP stated she was not sure if she would want [Resident #1] to have hip surgery. Review of witness statements obtained by the ADM, on 12/10/24, reflected the following: [CNA D] Worked Thursday (11/28/24) & Friday (11/29/24) with [Resident #1]. Thursday [Resident #1] was up as usual ambulating on the unit. Mid morning she saw [Resident #1] sit on the floor near the windows at the end of the 300 hallway, she spoke to [Resident #1] and [Resident #1] got up on her own and walked back to the common area. Later in the day she also noted that [Resident #1] was sitting on the floor apparently in the living room area by the large armchair and sofa. [CNA D] assisted [Resident #1] to get up without incident. Did not report these instances of [Resident #1] on the floor. Thursday approaching 6:00 PM [CNA D] states she went to assist charge nurse [LVN A] with [Resident #1] who was on the floor just outside the door to her room. [CNA D] says that she and [LVN A] helped [Resident #1] get off the floor and brought her into her room and bed. [CNA D] states it appeared [Resident #1] had difficulty bearing weight on her right side. They noticed blood on her pants so they checked [Resident #1] while changing her brief and noted no source of blood on her body. However [Resident #1] had dried blood on her nostrils from an apparent nose bleed. She noticed a healing abrasion on [Resident #1]'s right cheek. [CNA D] states she finished changing [Resident #1] then stayed in the room and continued to make [Resident #1] 's bed and clean up and that [Resident #1] left the room walking on her own when [LVN A] did. On Friday, [CNA D] again worked with [Resident #1] and that [Resident #1] stayed in bed for breakfast but that was not unusual for [Resident #1]. She fed [Resident #1] and she ate well. She got [Resident #1] dressed but [Resident #1] did not want to get up and leave the room. [CNA D] reported to ADON that [Resident #1] was not getting out of bed. When nearing lunch time [CNA D] again tried to get [Resident #1] up for lunch but she refused and did not want to be repositioned in bed. [CNA D] brought [Resident #1] her lunch which she ate well. On Friday around dinner time [CNA D] again went to check and change [Resident #1] who still did not want to get out of bed and appeared tired. [CNA D] reported to oncoming [CNA E] that [Resident #1] had not been up that day and was sleeping at dinner time and did not yet eat dinner. [LVN A] On Thursday she noted [Resident #1] was up and active and ate well through the day. In the afternoon [Resident #1] was sitting on the floor near her room and had a cardboard box left by another resident's family, it appeared to [LVN A] this was purposefully sitting on the floor. [LVN A] reports that [Resident #1] didn't want to get up off the floor and let the box be taken to be discarded and verbally objected in her native language. [LVN A] noted that [Resident #1] enjoyed playing with the box and considered it safe and let her continue. Around 5:30 PM [LVN A] came to assist [CNA D] who was walking with [Resident #1] to her room. [Resident #1] was agitated and [LVN A] assisted her to bring [Resident #1] to get her cleaned and changed. At this time she noticed dried blood in her nostrils, and what appeared to be blood spots on her pants. She did a head to toe body check and noted no blood, scratches, bruising or discoloration. [LVN A] saw the healing abrasion on cheek. [LVN A] states that [CNA D] cleaned, changed and got [Resident #1] dressed at this time. [LVN A] then left [Resident #1]'s room. Subsequently [LVN A] and on-coming nurse [RN F] went to [Resident #1]'s room. [LVN A] informed [RN F] that [Resident #1] had a nosebleed earlier in the day but had resolved . [CNA E] Worked Thursday evening with [Resident #1]. [Resident #1] was already in bed when she started her shift. She noted [Resident #1] was laying in bed diagonally, provided peri-care to [Resident #1] around 1:30 AM and [Resident #1] indicated pain to her right hip. She informed charge nurse [LVN C]. In the morning around 4:30 AM [CNA E] says she checked and provided peri-care to [Resident #1] who indicated pain to her hip and reported that to oncoming charge nurse [ADON]. Friday evening [CNA E] noted [Resident #1] in bed and changed her brief with charge nurse [LVN B]. [Resident #1] indicated pain to her right hip to [CNA E] and [LVN B]. [LVN B] [LVN B] states that she came in to work around 6:10 PM on Thursday. She says [CNA E] reported to her that [Resident #1] had not been out of bed overnight Thursday into Friday, and [CNA D] told her that she not gotten out of bed on Friday. [LVN B] assessed [Resident #1] and though she had no bruising or swelling to indicate a fall, that [Resident #1] complained of pain to right hip, and was unwilling/ unable to stand . [ADON] On Friday November 29th this nurse worked as a charge nurse on hall 100/200, taking care of [Resident #1]. At 6am I received report from 10-6am nurse coming off shift with no reports of change in report of said patient. I did my own rounds checking on patients starting around 6:10 am and when I went into patient [Resident #1]'s room she was sitting on the side of her bed, AOx1-2 at baseline, talking in her language with no apparent distress noted at that time. I then returned to [Resident #1]'s room to give her medication between 7am-8am and taking her vitals, which were WNL. [CNA D] came up to me around about 8-9am telling me that the pt was not walking around as her usual baseline, and that it had been going on. I stated to her that I noticed pt wasn't walking around as well and that I had assessed her and noted no bruising of any sort and that the pt was sitting up for me and no c/o pain, so I then monitored her throughout my shift. I also checked her chart and noticed there was no documentation regarding any falls or change in her condition. At 10:18 am the DON called my phone and being that she usually covers the MC I asked her about any changes to said patient, and I let her know that since no one else made any documented notes, that I would. My note is in the patient's chart for 11/29/2024. [LVN C] [LVN C] states that [Resident #1] was in bed during her shift and that [CNA E] reported to her that [Resident #1] had difficulty standing when she cleaned and changed her brief. [LVN C] states she went to check on [Resident #1] after that and that she was sleeping, and she decided not to wake her as [Resident #1] usually sleeps through the time. She says she had no other interaction with [Resident #1] during the remainder of her shift. During an interview on 12/10/24 at 10:12 AM, the ADON stated she worked the floor on the MCU (where Resident #1 resided) on 11/29/24. She stated she relieved the night nurse at 6:00 AM (LVN C) and she did not relay any changes regarding Resident #1. She stated she did her initial rounds and Resident #1 did not appear to be in pain. She stated she ate breakfast in bed that morning and she typically walked around throughout the day, but thought she just needed the rest. She stated because her vitals were stable and she noted no abnormal changes, she had no reason to think anything was wrong with her wanting to rest. She stated around 9:00 AM, CNA D came to her and told her Resident #1 still did not want to get out of bed. She stated there were no notes in her chart that anything had happened the day before so she figured she would continue to monitor her since nothing was out-of-whack. She stated around 10:18 AM, she called the DON because she knew she had worked the day prior (11/28/24) and asked her if she knew if anything had happened with Resident #1 because she was not walking around that day. The DON told her she had not been aware of anything. She stated Resident #1 had a history of sitting down on the floor. She stated if an aide found her sitting on the floor, they should get a nurse so an assessment could be done as it should be seen as an unwitnessed fall. She stated if LVN C was notified by the aide during the night of 11/28/24 that Resident #1 was in pain, she should have assessed her no matter what, even if she was sleeping. She stated LVN C should have also documented that. She stated she did notice some dry blood to Resident #1's nose as if she had a nosebleed. She stated because nothing from the day before had been documented, she did not know anything about it (the fall). She stated it would have been important for this to have been documented so that she could have followed up. During an interview on 12/10/24 at 10:40 AM, LVN B stated she came in on 11/29/24 just to assist with medication pass from 6:00 PM - 10:00 PM. She stated CNAs D and E approached her and asked her to go check on Resident #1 as something was very wrong. She stated CNA D told her she had been in bed all day, had not been out of bed since the day before, did not think she could walk, and insinuated she could not get out of bed due to pain. She stated CNA D told her she had told the nurse about her pain and felt like something needed to be done. She stated she immediately went and assessed Resident #1 and she was shaking in excruciating pain while her vitals were elevated. She stated she gave her Tylenol until she could get ahold of the doctor, but it did not seem to alleviate her pain. She stated she still could not get ahold of the doctor, so she called the DON and notified her she was sending her out to the ER because she had been in bed since the day before and that was not normal for her. She stated Resident #1 did not have a history of sitting on the ground but did have a history of squatting to poop on the floor. She stated an aide should never pick her up if she was found on the ground before getting a nurse for an assessment. She stated she had recently been in-serviced on change in condition, reporting incidents, abuse and neglect, and unwitnessed falls by the DON. She stated everything regarding the resident (incidents, falls, changes in condition) should always be documented in residents' progress notes to ensure all staff knew what was going on with the resident. During a telephone interview on 12/10/24 at 11:01 AM, CNA D stated Resident #1 was found three times on the ground on 11/28/24. She stated she helped her up each time because she was her resident. She stated she normally walked around the unit really fast, almost like she was running. She stated she was slow on 11/28/24 and she thought something had happened. She stated the first time she was on the floor she picked her up and Resident #1 ran away. She stated the second time she found her on the floor in the living room around 2:00 PM. She stated the third time she was in the activity room on the ground, so she picked her up and put her in a chair. She stated after her break, she heard Resident #1 screaming in pain. She stated she went to her room where LVN A was and told the nurse she was not normal. She stated between the both of them, they tried to help her stand, but she could not because of weakness and pain to her right side . She stated the next day, 11/29/24, she ate breakfast in bed, which was not abnormal for her. She stated she did not want to get up after breakfast or for lunch. She stated that was when she told the ADON she normally got up for lunch, but she refused. She stated she told her Resident #1 was shaking and had pain to her right side. She stated she left her in bed the whole day because she was in pain, and she felt bad. She stated she told the ADON several times throughout the day. She stated when the night CNA (CNA E) arrived that evening, they talked about how something was wrong with Resident #1 as she was shaking and in pain. She stated they notified LVN B who assessed her. She stated she had recently been in-serviced by the DON on notifying a nurse when a resident was on the ground, falls, pain management, and abuse and neglect . She stated she should never pick up a resident off the floor without notifying a nurse first to ensure they were not injured. During an interview on 12/10/24 at 12:10 PM, the DON stated she went to the MCU on 11/28/24 between 3:00 - 3:15 PM and physically saw Resident #1 sit herself down on the floor. She stated if an aide ever found a resident on the ground, they needed to treat it as an unwitnessed fall. She stated the nurses would need to complete an assessment and start neuro checks prior to getting the resident off the floor. She stated after interviewing staff, she was informed of two other instances where she was found sitting on the ground that day. She stated LVN A told her she found her sitting on the ground, she assessed her, and cleaned her bloody nose from having dry nostril membranes. She stated the reason LVN A documented in Resident #1's EMR seven days later was because she asked her to. She stated LVN A verbally told her she assessed the resident but did not document it, so she verbally asked her to put it in later. She stated that did not meet her expectations as it needed to be documented the same day . She stated she did not hear about anything abnormal with Resident #1 until 11/29/24 at 10:30 AM when the ADON called to ask her if anything had happened. She stated nobody informed her of any falls, being in pain, or not being able to be repositioned. She stated she did not find out about the pain she was in or her not being able to stand until later that night (11/29/24) by LVN B. She stated her expectations were that she be notified of any change of condition . She stated neuro checks should have been completed by LVN A. She stated the nursing team really dropped the ball. She stated she immediately began in-servicing all nursing staff and they did not work their next shift until they were in-serviced. She stated they were just notified that morning (12/10/24) that Resident #1 was discharged to another facility and would not be returning. During an interview on 12/10/24 at 12:51 PM, CNA G stated she had recently been in-serviced on abuse and neglect, change of condition, notifying a nurse when a resident was on the ground, and pain management. During a telephone interview on 12/10/24 at 12:57 PM, LVN A stated on 11/28/24 Resident #1 was very active throughout the day. She stated closer to the evening time she saw her sitting on the floor playing with a box. She stated a little bit later, she saw a CNA walking her to her room and she was fighting her. She stated she noticed blood coming out of her nose, so she went and did a full skin assessment and took her vitals. She stated she had just forgotten to document anything from that shift. She stated she could not remember if she told the on-coming nurse about her sitting on the floor as she did not think it was a big deal. She stated she saw Resident #1 at the end of her shift (around 10:00 PM) and she was sleeping peacefully. During a telephone interview on 12/10/24 at 1:10 PM, LVN C stated she worked overnight on 11/28/24. She told her CNA E did not tell her Resident #1 was in pain, but that she had trouble standing up. She said she went to assess her, but she was sleeping. She stated in the morning she told LVN A she was not able to walk. She stated when she came back that evening (11/29/24), LVN B told her she was still not getting out of bed. She stated she told LVN B she told LVN A that morning that something was wrong, and it had to have been from a fall or something. She stated if she would have known Resident #1 had a fall when CNA E told her she was having trouble standing, she would have notified the NP immediately, tried to get her up, and sent her to the hospital. She stated she had recently been in-serviced by the DON on change in condition, pain management, abuse and neglect and documentation. She stated it was important to document all incidents and resident change of condition to ensure all staff were aware of what was going on with the resident. She stated neuros were important after an unwitnessed fall to ensure the resident did not have a change in their mental status. During a telephone interview on 12/10/24 at 1:20 PM, CNA F stated during the night shift on 11/28/24, Resident #1 was in a lot of pain. She stated when she tried to change her brief and turned her on her right side she started moaning in pain. She stated she immediately notified LVN C and asked her if anything had happened to her. She stated when she changed her before the end of her shift (at 6:00 AM on 11/29/24), she reacted the same way. She stated she told LVN C and the ADON of the pain she was experiencing. She stated she had recently been in-serviced by the DON on pain management, change in condition, and abuse and neglect . She stated she should never get a resident off the floor before notifying a nurse so they could assess for injury. Review of a PIP created by the DON, dated 12/05/24, reflected the following: Problem Area Identified: Inconsistency documenting and following the Accident/Incident process Changes Implemented to reach baseline: 1. Identify all patients with accident/incident reports 2. After morning report, ensure accident/incident process is opened and if not have, have nurse open before returning to the floor. 3. Accidents and incidents discussed daily at stand up and stand down - ongoing. 4. Ensure accident/incident process is opened, reports are completed, treatments are documented, process for unwitnessed falls have neuro checks initiated, and investigations are completed accordingly - ongoing 5. Audit accident/incident reports for completion daily. - ongoing 6. In-services: Accidents/Incidents, Change of Condition, Pain, and MD notification - 12/2/24 7. Education: Pre/Post test on Accidents/Incidents, Pain, and Change of Condition. 12/5/24. Review of an In-service entitled Change in Condition, Pain Management, and MD Notification, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on patient care model systems, pain, change of condition, and physician notification. Review of an In-service entitled Charting and Documentation, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on the importance of documentation and their Charting and Documentation Policy. Review of an In-service entitled Accidents/Incidents, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on their Accident/Incident Report Policy. Review of an In-service entitled Abuse Protocol, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on their Abuse and Neglect Policy. Review of the facility's undated Pain Management Policy, reflected the following: 1. A pain Assessment must be completed for a patient upon admission, including re-admission, the onset or an increase in pain, quarterly, and with any significant change in the patient's condition. Review of the facility's Change in Condition Policy, revised January of 2024, reflected the following: A significant change in Resident's status is any sign or symptom that is: - Acute or sudden onset - A marked change (i.e., more severe) in relation to usual signs and symptoms - New or worsening symptoms Review of the facility's Physician Notification Policy, revised January of 2024, reflected the following: The nurse will: - Recognize the condition change. - Monitor the patient and continue to assess the condition and changes. - Notify the physician, patient and representative of any changes in condition. Review of the facility's Charting and Documentation Policy, revised July of 2017, reflected the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Review of the facility's Accidents/Incidents Policy, dated May of 2016, reflected the following: 1. An Accident/Incident Report must be completed immediately upon facility staff becoming aware of the occurrence an accident/incident . Review of the facility's Abuse and Neglect Policy, dated April of 2019, reflected the following: 1. The patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation . The noncompliance was identified as PNC. The IJ began on 11/28/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.