Every finding on record at Longmeadow Healthcare Center

Based on observation and interview, the facility failed to right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 4 of 10 residents (Resident#24, Resident#28, Resident#39, Resident #62) reviewed for accommodation of needs. The facility failed on 06/29/2026 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' bathrooms located inside the residents' rooms for Resident#24, Resident#28, Resident#39, and Resident #62 This failure could place residents in the facility at risk of being unable to obtain timely assistance from staff. Findings: Record review of Resident #24's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date of 11/08/2024, diagnoses included Dementia, Alzheimer's disease, type 2 diabetes. Resident #24 had a BIMS score of 09 indicating moderate cognitive impairment. Record review of Resident #24's care plan dated 04/04/2019 reflected resident had impaired visual function related to disease process, diagnosis Presbyopia ( the gradual loss of the eye's ability to focus on nearby objects), she had glasses but refused to wear. Interventions: Observe/document/report . acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss. Record Review of Resident #28's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 05/16/2023, diagnoses included Dementia, Alzheimer's disease, Blindless to left eye, category 5. Resident #28 had a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #28's care plan dated 03/13/2025 reflected Resident #28 had impaired visual function related to left eye blindness, interventions: Arrange consultation with eye care practitioner as required. Record review of Resident #39's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an admission date o 06/24/2025, diagnoses included Dementia (Memory loss), Alzheimer's disease, Diabetic Retinopathy (Blindness caused by high blood sugar levels in blood) and history of falling. She had a BIMS score of 99 indicating severe cognitive impairment. Record review of Resident #39's care plan dated 04/06/2026 reflected Resident #39 had impaired visual function related to diabetic retinopathy, cataract Right eye. Goal: Resident #39 will maintain optimal quality of life within limitations imposed by visual function through the review date. Interventions: Monitor/document/report to MD. of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss. Record review of Resident #62's MDs assessment dated [DATE] reflected she was an [AGE] year-old female with an admission date of 09/26/2025, diagnoses included Dementia, Type 2 diabetes. Resident #62 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #62's care plan dated 10/16/2025 reflected Resident #62 had hypertension (high blood pressure)related to heart disease, interventions: Monitor/document abnormalities for urinary output. Report significant changes to the Medical Director. Observation and interview on 06/29/2026 at 10:18 AM with Resident #39 revealed she was walking through the dining area. Resident #39 was not interviewable. Observation on 06/29/2026 at 10:50 AM revealed Resident #24 and #28's shared bathroom call light pull string was short and about 2 feet above from the floor. Observation and interview on 06/29/2026 at 10:50 AM with Resident #28 revealed he was sitting in his bed. He stated he used the shared restroom and used the call light if needed. Resident #28 stated he was not able to reach the call light in the restroom if he had a fall on the floor. Observation and interview on 06/29/2026 at 11:35 AM with Resident #62 revealed she was walking in the dining room. She stated she used the shared restroom in her room. She could not provide detailed answers due to her memory issues. Observation and interview on 06/29/2026 at 11:37 AM with Resident #24 revealed she was sitting in the dining room. She stated she used the shared rest room in her room. It was observed Resident #24 was able to walk on her own. Observation on 06/29/2026 at 12:14 PM revealed Resident #39 and #62's shared bathroom call light pull string was short and about 3.5 feet from the floor. Observation and interview on 06/29/2026 at 12:21 PM with LVN G, he stated he was not aware of any call light string in the shared toilets being short. He then went to the shared toilets and observed the call light string in the bathroom for Resident#24 and Resident#28 were approximately 2 feet above the floor and for Resident#39 and Resident #62's toilet call light string was approximately 3.5 feet above the floor. He stated if a resident walked into the shared toilet and had a fall, he/she would not be able to reach the call light and that would put residents at risk for injury and delay in care. He stated the Maintenance Supervisor was responsible for ensuring the call light system was appropriately installed and working, and all the staff were responsible for notifying the maintenance when they noticed the call light string was short in the toilet. He stated he had received in-service training on call light system within a month. Observation and interview on 06/29/2026 12:56 PM with maintenance revealed he was responsible for ensuring the call light system in the facility was appropriately installed and working. He stated the facility used a fire safety and security provider to complete any major repairs. He stated of there were maintenance issues related to the call light system he would notify them whenever he noticed an issue related to call light. He stated the maintenance department completed a weekly audit to ensure all the call light system was working and that he was not aware of the policies/regulations related to the height/length of the call light string. Interview on 06/30/2026 at 01:44 PM with CNA H, she stated she had not noticed that the call light strings in the bathrooms for Resident#24, Resident#28, Resident#39, and Resident #62 were short. She stated the maintenance was responsible for ensuring the call light was appropriately installed and working. She stated short call lights in the resident's bathroom would put them at risk of injury, not able to reach the staff at times of emergency, and delay in care. She stated she had received and in- service on the call light system within a month. She stated all the staff were responsible for notifying the maintenance if they had concern about the call light system.

Based on interview and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to privacy of such communications for 8 of 8 confidential resident reviewed for resident rights. The facility failed to deliver residents' mail on Saturdays. This deficient practice could result in residents not receiving their mail in a timely manner and diminished quality of life. Findings include:A confidential group interview with 8 residents on an undisclosed date at an undisclosed time revealed on Saturdays when the mail arrived at the facility, it was not distributed because there was no office staff to check the mail. One of the group members stated they assisted with mail delivery to the residents during the week but had not delivered any mail to residents on Saturdays. An interview with the Business Office Manager on 07/01/2026 at 9:24 a.m. revealed it was her responsibility to check the mail. The Business Office Manager stated she checked the mail every day at 2PM and sorted through the mail Monday through Friday. The Business Office Manager stated all mail was delivered on the same day to residents unopened. The Business Office Manager stated she did not work on Saturdays and therefore was not there to check the mail. The Business Office Manager stated she typically checked the mail first thing in the morning on Mondays to obtain the mail that was delivered on Saturdays. The Business Office Manager stated she had the key to the mail and the mailbox had a key lock due to residents checking the mail on their own. The Business Office Manager stated the residents not receiving mail on Saturdays could affect them receiving mail that was time sensitive and could upset the residents. An interview with the Administrator on 7/1/26 at 1:17 p.m. revealed he gave the mailbox key to the Dietary Manager effective immediately, so she could check the mailbox every Saturday and distribute the residents' mail. The Administrator stated if the Dietary Manager was off the key would be available to dietary staff and they would be responsible for checking mail on Saturdays. The key will be available if she was off for the assistant to check the mail. The Administrator stated residents not having received mail on Saturdays could affect them because they could have potentially missed something that was time sensitive. Record review of the facility's policy Resident Rights (no revised date) reflected .8. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: a. Privacy of such communications consistent with this section.

Based on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 shower rooms (Shower room [ROOM NUMBER]) and 1 or 3 resident bed linens (Resident #300 ) reviewed for a clean homelike environment: The facility failed to provide clean bed linens for Resident #41 on 6/29/26 and 6/30/26.The facility failed to ensure Shower room [ROOM NUMBER] was free from debris and in good working condition on 6/30/26. These failures could place residents at risk of exposure to infectious diseases, other unsanitary health hazards and affect their sense of dignity.Findings Include: 1. Record review of Resident #41's face sheet, dated 7/1/26, reflected an [AGE] year-old female with an admission date of 10/1/25. Resident #41 had the following pertinent diagnoses: Chronic Kidney Disease (long term progressive loss of the kidney's ability to filter waste and excess fluid from your body), Unspecified intellectual disabilities, other recurrent Depressive Disorders (a mental disorder characterized by a persistent feeling of sadness, emptiness and severe loss of interest in activities) and cognitive communication deficit (an impairment in communication caused by various reason). Record review of Resident #41's Care Plan, dated 4/9/26, reflected .[Resident #41] has an ADL Self Care Performance Deficit Date Initiated: 10/02/2025 Revision on: 10/20/2025 [Resident #41] will maintain or improve current level of function in ADLScore through the review date. Date Initiated: 10/02/2025 Revision on: 10/20/2025Target Date: 04/09/2026 Bathing: requires staff x1 for assistanceDate Initiated: 10/02/2025 Bed Mobility: Independent Date Initiated: 10/20/2025 Revision on: 10/20/2025 Discuss with resident/family/POA (Power of Attorney) care any concerns related to loss of independence, decline in function. Date Initiated: 10/02/2025 Dressing: requires staff x1 for assistance Date Initiated: 10/20/2025 Praise all efforts at self care. Date Initiated: 10/02/2025 Physical Therapy/Occupational Therapy evaluation and treatment as per Medical Doctor orders. Date Initiated: 10/02/2025 The resident uses a wheelchair Date Initiated: 10/20/2025 Toilet use: requires staff x1 for assistance. Supervision or touching Date Initiated: 10/20/2025 Revision on: 04/13/2026 Encourage the resident to discuss feelings about self-care deficit. Date Initiated: 10/02/2025 Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 10/02/2025 Encourage the resident to use bell to call for assistance. Date Initiated: 10/02/2025 Monitor/document/report to Medical Doctor as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Date Initiated: 10/02/2025 BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care Date Initiated: 10/02/2025. Record review of Resident #41's Quarterly MDS Assessment, completed 4/10/26, reflected she was moderately cognitively impaired with a BIMS of 9. An observation of Resident #41's bed on 06/29/2026 at 11:22 a.m. revealed a fitted sheet with a yellow circular stain about the size of a fist on the side of her bed. Resident #41 was not in her room at the time. An observation of Resident #41's bed on 06/29/2026 at 2:28 p.m. revealed the fitted sheet still had the yellow circular stain and resident was still not in the room.An observation of Resident #41's bed on 06/30/2026 at 10:48 a.m. revealed resident's sheets to still had the same sheet with the yellow stain on it. Resident #41 was not in the room at the time of the observation. An interview with Resident #41 on 6/30/26 at 10:00 a.m. revealed she was unable to say when her sheets were last changed. Resident #41 was unable to speak coherently to be understood. An interview and observation with CNA I in Resident #41's room on 06/30/2026 at 10:52 a.m. revealed Resident #41's sheets had not been changed, and the yellow stain was still visible. CNA I stated the hospitality aids were changing the bed sheets this morning and should have changed Resident #41's sheet. CNA I stated it looked as though Resident #41's bottom sheet needed to be changed because it was dirty. CNA I stated she had not been in Resident #41's room today. CNA I stated Resident #41 was independent and therefore it was the hospitality aids' responsibility to change her sheets daily. CNA I stated sheets should have been changed daily if they appeared dirty and stated CNAs and hospitality aids could change residents' sheets. CNA I then left the room to get the hospitality aid responsible for changing the sheets. CNA I stated dirty sheets could have affected the residents' sense of dignity and could have caused an infection control issue. Interview and observation with Hospitality Aid J in Resident #41's room on 06/30/2026 at 11:05 a.m. revealed she was helping in all the halls of the facility. Hospitality Aid J stated Resident #41's sheets were soiled and needed to be changed. Hospitality Aid J stated Resident #41 did not like for people to touch her bed and stated when she started her rounds at 8 a.m. Resident #41 was still in bed. Hospitality Aid J began removing items from Resident #41's bed and stated she would change her sheets now. Hospitality Aid J stated she had no idea why Resident #41's sheets had not been changed. Hospitality Aid J stated CNA could change residents' linen, however hospitality aids were responsible for changing sheets daily. Hospitality Aid J stated the risk to the residents of having dirty sheets were infections, UTIs, bed sores and redness on their butts. An interview with CNA K on 06/30/2026 at 1:41 p.m. revealed she changed resident's sheets any time she showered them, when the sheets were soiled or visibly dirty. CNA K stated the hospitality aids assisted in changing sheets, but it was the CNAs responsibility to ensure sheets for residents were cleaned daily. CNA K stated the risk to the residents of not having had clean sheets would have been issues with infection control and skin integrity. An interview with CNA L on 6/30/26 at 1:51 p.m. revealed he changed residents' sheets every morning and when the residents were incontinent and had soiled the bed. CNA L stated it was the CNAs responsibility to ensure residents' sheets were clean and in good condition. CNA L stated hospitality aids helped with the sheet changes as needed. CNA L stated if a resident had dirty sheets, it could have affected their skin, and they could have developed a skin rash. An interview with LVN M on 06/30/2026 at 2:31 p.m. revealed if she observed sheets to have been dirty or soiled, she would have changed them if the aids were not available. LVN M stated the expectation was sheets should be changed every time residents were showered, if the residents spilled something on them or there were stains on them. LVN M stated sheets should have been changed every other day because residents were showers every other day. LVN M stated if linens were soiled, they could cause rashes, skin breakdowns or increase the occurrence of bugs in the facility. 2. Record review of the Maintenance log, from 1/1/26 to 6/30/26, reflected no reports of issues in Shower room [ROOM NUMBER]. An observation and interview with Floor Tech M in Shower room [ROOM NUMBER] on 6/30/26 at 9:06 a.m. revealed the caulking in between the floor and the wall tile was cracked, discolored with green black mold and broken off in the shower. The shower had 5 missing tiles on the floor by the drain and the concrete was jagged and dirty where the missing tiles belonged. Floor Tech M stated he cleaned the tiles weekly and had not noticed the caulking. Floor Tech M stated he would remove the caulking and notify maintenance to redo the caulking. Floor Tech M stated he was unsure when they last caulked Shower room [ROOM NUMBER]. Floor Tech M stated the tiles had been missing for a while and was unsure if it had been reported to maintenance. Floor Tech M stated dirty and broken caulking affected the residents in that it could have gotten caught in their wheelchair and transported to their room spreading any bacteria on the caulking. An interview with the Maintenance Director on 06/30/2026 at 9:23 a.m. revealed he was just notified of the issues with the caulking. The Maintenance Director stated there had been no maintenance requested on the caulking in Shower room [ROOM NUMBER]. The Maintenance Director stated in the two years he had worked at the facility had never caulked Shower room [ROOM NUMBER]. The Maintenance Director was unable to state how long the tile in Shower room [ROOM NUMBER] was missing but he would work on getting them replaced. The Maintenance Director stated caulking should not have been falling off or have been moldy and when it had got to that state it should have been redone. The Maintenance Director stated the missing tile, and broken caulking could have affected the residents because the shower was dirty. An interview with the DON on 7/1/26 at 12:44 p.m. revealed resident sheets should have been changed on shower days and as needed when soiled. The DON stated CNAs, hospitality aids and nurses could change the sheets on residents' beds. The DON stated the risk to the resident for having had dirty sheets were infection control issues especially if they were soiled. The DON stated staff should have reported issues with the shower room in the maintenance care system for it to have gotten repaired. The DON stated she was not aware of the condition of Shower room [ROOM NUMBER]. The DON stated staff would not have had to tell her about the issue with the tile and caulking because they could report it on their own by scanning a QR code to report maintenance issues. The DON stated if a resident was independent and used that shower, it could put them at risk of falling and infections. An interview with the Administrator on 07/01/2026 at 1:09 p.m. revealed the expectation was sheets should have been changed on shower days and as needed. The Administrator stated CNAs should have been changing sheets, however any clinical staff were able to change soiled sheets. The Administrator stated having dirty sheets could have affected residents' comfort level in their beds. The Administrator stated the broken tile and caulking in Shower room [ROOM NUMBER] had not been reported to him. The Administrator stated he would follow up with maintenance to ensure the tiles were replaced. The Administrator stated the missing tiles, and molded broken caulking could have affected residents' satisfaction with showers. Record review of the facility's, undated, policy Resident Rights reflected . Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide: 1.A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. a. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. b. The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; 3. Clean bed and bath linens that are in good condition.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 8 of 8-confidential residents reviewed for activities. The facility failed to provide the residents with scheduled activities on their activities calendar on 6/30/26. This failure could place residents at risk for decline in quality of life, social and mental psychosocial well-being. Findings Include: Record review of the June 2026 Activities Calendar, for 6/30/26, reflected the following activities 11:00 Appetizers, 2:00 Wheelchair Car Wash. During a confidential group interview of 8 residents at an undisclosed date at an undisclosed time revealed the facility's Activities Director was terminated a few weeks ago and they had not been offered all the activities listed on their activities calendar. The residents stated they were frustrated because they were not being provided with the activities as scheduled. An observation and interview with two residents from the confidential group on 06/30/2026 at 11:07 a.m. revealed there were no appetizers being offered in the dining room despite several residents sitting in the dining room. Observation revealed the two residents walking out of the dining room. Interview with the 2 residents revealed no appetizers were served because the Activities Director used to organize it and she was no longer working at the facility. An observation and interview with LVN F on 6/30/26 at 2:36 p.m. revealed she was not aware of a wheelchair car wash scheduled; however, she stated in the past they had collected the wheelchairs and taken them outside to wash them. Observation around the building inside and outside did not reveal any staff or residents engaged in washing wheelchairs. An interview with the Business Office Manager on 7/1/26 at 9:24 a.m. revealed she assisted with activities since the Activities Director was gone, however the Administrator was in charge of the activities. The Business Office Manager stated during the morning meetings the staff would discuss upcoming activities, and the Administrator would ask for coverage for those activities. The Business Office Manager stated she was unaware of who was covering specific activities for the 06/30/26. An interview with the DON on 7/1/26 at 12:44 p.m. revealed all staff were pitching in to help ensure activities were being done until they hired an Activities Director. The DON stated she was not aware the activities calendar was not being followed and stated not following the scheduled calendar activities could affect the resident's mood and could have led to increase negative behaviors. An interview with the Administrator on 7/1/26 at 1:17 p.m. revealed he oversaw activities and ensured staff assisted with running the activities until she hired a new Activities Director. The Administrator stated the Activities Director had been gone for about 1.5 weeks, and he was currently negotiating with someone to offer them the position. The Administrator stated there were several staff who were assigned to specific activities and others who volunteered to cover activities. The Administrator stated the therapy team was actively involved in trying to get the activities completed daily. The Administrator stated not having the scheduled activities could have resulted in the residents getting upset. Record review of the facility's policy Individualized Activity Programs, revised 2011, reflected . Individual programs are developed and implemented regularly consistent with individualized leisure interests and based on the assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for one (lunch on 06/29/26) of one meal observed for dietary services. The facility failed to serve the 06/29/26 lunch meal on time at the scheduled time based on the meal postings which resulted in residents receiving their meals. The scheduled lunch meal time was 400 hall-start service at 11:30 AM-in Hall@11:45 AM Dining room-12:00 PM 300-Hall-12:15 PM 200-Hall-12:30 PM 100-Hall-12:45 PM. The lunch meal was served at 12:30pm on the 400 hall, 12:40pm in the dining room, 1:11pm on the 200 hall and 1:30pm on the 100 hall. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.Findings included: In a confidential group interview with nine of nine residents on 06/30/26 at 10:00 AM revealed lunch meals were served late it can be 45 minutes to 1 hour late. Record Review of Meal Service Begins Dietary (meal times) undated reflected Lunch 400 hall-start service at 11:30 AM-in Hall@11:45 AM Dining room-12:00 PM 300-Hall-12:15 PM 200-Hall-12:30 PM 100-Hall-12:45 PM. Observation on 06/29/26 at 12:15 PM revealed the secure unit (hall 400) meal trays were on the unit. The last resident meal tray was served at 12:30 PM. Observation on 06/29/26 at 12:17 PM revealed lunch meal was not served yet for residents in dining room. At 12:40 PM residents were still being served their lunch meals. Observation on 06/29/26 at 12:57 pm and 1:03 PM revealed hall trays for 100 and 200 halls had not been delivered to the hall. Interview on 06/29/26 at 1:04 PM with LVN D revealed hall lunch meal trays had not been passed yet to .200 hall. Observation on 06/29/26 at 1:06 PM revealed hall 200 meals trays were on the hall cart and being passed to residents. At 1:11 PM hall 200 meals trays had all been served. Observation on 06/29/26 at 1:09 PM revealed hall 100 meal trays had not yet been delivered to the hall. At 1:21 PM hall 100 trays were being served and passed out by staff. At 1:30 PM the last 100 hall meal tray was served. Interview on 06/29/26 at 1:20 PM LVN M stated the 100 hall was the last hall where trays were served. She stated they received the meal trays at 1 PM or later at times. Interview on 07/01/2026 at 1:28 PM with the Dietary Manager revealed when residents did not receive their food per the meal times posted and it placed them at risk of a delay in receiving food. She stated the plating of meal trays for lunch began at 11:30 AM and the secure unit got their meals by 11:45 AM. She stated not getting all the resident meal tickets on time from staff to ensure dietary staff knew what resident preference for meals were, delayed the meal service. Review of the facility's policy Resident Meal Service. undated reflected to provide meals.to all residents in a timely manner.6. The meal schedule will be posted in the dining room.

Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in: 1. The facility failed to ensure the chest freezer was free of ice accumulation. 2. The facility failed to ensure sherbert and ice cream containers were sealed in the chest freezer. 3. The facility failed to ensure dish machine temperatures were at minimum of 120 degrees F. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: 1. Observation on 06/29/26 at 10:04 AM revealed there was ice accumulation of about 1 to 2 inches around the entire inside the chest freezer. 2. Observation on 06/29/26 at 10:06 AM of the chest freezer in the kitchen revealed the following items not sealed:- orange sherbert container dated 06/17/26 had freezer burn on top (3/4 full).- 1 chocolate ice cream container dated 04/28/26 with freezer burn, unsealed and open around the top of the rim, and there was a dead black bug in it.- 1 chocolate ice cream container dated 03/2026 with freezer burn on the inside top/sides of the ice cream about 1/2 full.- 1 vanilla ice cream container dated 05/06/26 was not sealed, with freezer burn on the sides/top of ice cream. Interview on 06/29/26 at 10:12 AM the Asst. Dietary Manager stated she would clean out the chest freezer to get the ice accumulation off. She stated she did not know when the freezer was last cleaned out but thought it was recent. She stated she would throw out the ice cream containers and sherbet. She stated they should be sealed in the freezer to prevent freezer burn and other contaminants like bugs. 3. Observation on 06/29/2026 at 10:19 AM revealed Dishwasher S was using the dish machine prior to the surveyor checking the water temperatures of the wash/rinse. The first observation of the low temperature dish machine was wash 100 degrees F and rinse 110 degrees F. The second observation of the low temperature dish machine was wash 110 degrees F and rinse 115 degrees Fahrenheit. Observation of Dish machine revealed on wash and rinse temperature minimum of 120 degrees F. Observation and interview on 06/29/26 at 10:25 AM the Asst Dietary Manager revealed the wash/rinse water temperatures did not get above 110 degrees F. She stated the low temperature dish machine required 120 degrees F minimum temperature for wash and rinse cycles. Interview on 06/29/26 at10:27 AM Dishwasher S stated she was newer to working at the facility and she did not check the dish machine water temperatures or ppm prior to using it today. Record review of the dish machine log for June 2026 revealed it was blank with no temperatures or ppm checked on 06/28/26 and 06/29/26. Interview on 06/29/26 at 10:29 AM the Assist Dietary Manager stated they would have to have dish machine looked at so they could get it to the minimum temperatures and it could not be used to sanitize the dishes if the water temperatures did not meet the minimum 120 degrees F. She stated she was not aware the water temperatures and the ppm of chlorine was not documented or checked yesterday and today. She stated the dish machine water temperature and ppm should be checked prior to use to ensure it was working Interview on 07/01/2026 at 9:10 AM the Dietary Manager revealed the freezer items should be sealed. She stated the chest freezer was cleaned out about a month ago but it should be free of accumulated ice. The Dietary Manager stated she expected dietary staff to check the water temperatures/ppm prior to use. Follow-up interview on 07/01/2026 at 1:28 PM the Dietary Manager stated the ice accumulation in the chest freezer could cause freezer burn on the food and could contaminate the freezer food if not sealed allowing contaminants to get in the ice cream/sherbert containers. She stated the low temperature dish machine not reaching 120 degrees F minimum for wash/rinse cycles could cause bacteria growth. She stated Dishwasher S was newer to working at the facility but she had been in-serviced on the dish machine, to check temperatures and ppm prior to use. She stated she would in-service Dishwasher S prior to returning back to work. The Dietary Manager expected dietary staff to check the water temperatures/ppm prior to use. She stated she would need to in-service dietary staff to ensure checking water temperatures and ppm prior to use and to document it on the log. Review of facility's policy Storage Refrigerators dated 2012 reflected 5. Food must be covered when stored.6. Refrigeration equipment is to be routinely defrosted and compressor cleaned. Review of facility's policy Dishwashing Preparation and Dishwashing dated 2012 reflected The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure:.2. Automatic dishwasher low temperature machine.c. The wash period shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees F. d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution.no dishes will be washed prior to achieving this standard.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident#60) reviewed for ADLs.The facility failed to ensure Resident #60's facial hair on her chin and upper lip was removed on 06/29/2026.This failure could place residents at risk of loss of dignity, risk of infections and a decreased quality of life. Findings include: Record review of Resident #60's MDS assessment, dated 05/27/2026, reflected a [AGE] year-old female with an admission date of 05/20/2026. Resident #60 had diagnoses which included Dementia (memory loss) and Hypertension (Elevated blood pressure). She had a BIMS score of 06, which indicated severe cognitive impairment. Resident #60 needed supervision or touching assistance with toileting hygiene. Record review of Resident #60's care plan, with revision dated 06/04/2026, reflected she had an ADL Self Care Performance Deficit related to cognitive deficits/Dementia. Intervention: Assist with personal hygiene as required: hair, shaving, oral care as needed. Observation and interview on 06/29/2026 at 11:29 AM with Resident #60 revealed she was sitting in the dining area. Resident #60 had approximately 1/4 inch-long facial hair on her chin and upper lip. She stated she received showers, but the staff had not offered to shave during the past few days. She stated she did not feel comfortable having facial hair and she liked it shaved. An interview on 06/29/2026 at 12:21 PM with LVN G, he stated the CNAs were responsible for residents' showers and grooming which included facial hair removal/shaving for female residents. He stated Resident #60's facial hair should be inspected during shower days and trimmed/shaved according to the resident's liking/ as needed. LVN G stated it was the responsibility of the CNAs for each Hall to make sure residents received appropriate and consistent daily care. LVN G stated the risk to Resident #60 for having facial hair was loss of dignity and self-confidence. He stated he could not find any documentation reflecting Resident #60 refused facial hair removal. Interview on 06/30/2026 at 01:44 PM with CNA H, she stated Resident #60 preferred to have her facial hair removed regularly and it was the responsibility of all the CNAs who worked on the hall to ensure female residents' facial hair was removed during shower days and as needed. She stated the Charge nurse at each hall was ultimately responsible to ensure residents received appropriate and consistent daily care. She stated Resident #60 had not refused facial hair removal, she did not get time to shave her during that shift. She stated the risk for female residents to have facial hair was loss of dignity, infection and overall cleanliness. Interview on 07/01/2026 at 02:10 PM with the DON, she stated the nursing staff were responsible to ensure female residents facial hair was removed/shaved during shower days and as needed. She stated the staff were to reattempt if a resident refused shaving and notify the nurse of refusal. She stated all staff were in-serviced regularly on ADL care. She stated the risk for having facial hair among female residents was loss of dignity and lack of overall cleanliness. Interview on 07/01/2026 at 11:14 AM with the Administrator, he stated the facility did not have a policy on female resident facial hair. A general ADL care policy was requested but not received. He stated the nursing staff were responsible to ensure the female residents' facial hair was shaved as per their liking. He stated it was not normal for females to have facial hair and so it was iimportant to remove facial hair, the risk for female residents with facial hair was not having a clean face and loss of dignity. The facility did not submit a general ADL care policy by the date (07/01/26) and time ( 4:00pm) of exit.

Based on observation, interview and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of eight residents (Resident #13) reviewed for quality of care. The facility failed to ensure Resident # 13 had his splint for his contracture on his left hand on 06/29/26 and 06/30/26. This failure could place residents at risk for decline in range of motion, decreased mobility, pain and decreased quality of life. Findings include: Record review of Resident #13's quarterly MDS assessment, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included traumatic subdural hemorrhage (type of bleeding near your brain that can happen after a head injury), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) and traumatic brain injury (injury occurs when an external physical force damages the brain affecting how it works). Resident #13 had a BIMS score of 9, which indicated he was moderately cognitively impaired. Resident #13 had a limited range of motion on 1 side for his lower and upper extremity. Resident #13's ADL was partial/moderate to substantial/maximal with ADL of mobility. Record review of Resident #13's Comprehensive Care Plan, last reviewed on 05/01/26, reflected Resident #13 has an ADL Self Care Performance r/t [Traumatic Brain Injury]. Intervention included Resident #13 utilized a left resting hand splint.LLE contractures. Assess skin integrity q shift to keep clean and prevent skin breakdown. Date initiated 04/13/2026. The care plan did not reflect Resident #13 refused the hand splint for contracture to left hand. Record review of Resident #13 Occupational Therapy Progress Report, dated 06/11/26, Patient will achieve normal anatomical alignment of the left wrist of 2.5 hours using a resting hand splint in order to facilitate intact skin integrity, in order to achieve proper joint alignment and in order to increase functional use of extremity. Record review of Resident #13's consolidated physician order, dated 06/30/26, reflected order date and start date of 04/14/26 Device: Left resting hand splint.as resident will allow. Assess skin integrity q shift and remove at bedtime. Every shift skin breakdown, yes or no. Record Review of Resident #13's MAR/TAR for June 2026 reflected RN O documented on 06/30/26 on 7 pm to 7 am shift yes for Device: Left resting hand splint.as resident will allow. Assess skin integrity q shift and remove at bedtime. Every shift skin breakdown, yes or no. Observations on 06/29/2026 at 11:08 AM and 12:11 PM revealed Resident #13 sitting in his wheelchair with Resident #13's left hand drawn into a fist with no splint to his left hand. Observation and Interview on 06/29/26 at 12:38 PM revealed Resident #13 sitting in his wheelchair with Resident #13's left hand drawn into a fist with no splint to his left hand. Resident #13 stated in the past he was provided a splint for his left hand and then it was taken away by staff he did not know why they stopped putting the splint on his left hand. He stated he thought it had been a couple of months since staff had last put the splint on his left hand. Resident #13 stated the splint on his left hand helped him and would wear it if provided. Resident #13 stated he did not have pain. Interview on 06/29/2026 at 1:15 PM, CNA L stated he had not seen Resident #13 with the splint for his left hand for at least a month. He stated he did not know where the left hand splint was for Resident #13. Observation on 06/30/2026 at 2:08 PM revealed Resident #13 sitting in his wheelchair with his left hand drawn into a fist with no splint in the therapy room. Observation on 06/30/2026 at 2:10 PM, PTA R stated he had not seen Resident #13 wear his left hand splint for about a month at least. He stated he provided therapy to Resident #13 about 3 times a week. He was not sure if nursing was putting the splint on the resident's left hand or not. He stated the left hand splint could benefit Resident #13 to help with his limited range of motion and prevent any further contracture of left hand. Interview on 06/30/2026 at 2:18 PM with OT Q stated she was the supervising therapist for Resident #13's therapy. She stated Resident #13 would wear the splint on his left hand and wore it up to 1.5 hours at times. OT Q stated she was not sure where Resident #13's left hand splint was and when the left hand splint was put on Resident #13. Interview on 07/01/2026 at 11:47 AM with LVN P stated Resident #13 had a current physician order for a left hand splint. She stated the risk to Resident #13 not wearing the left hand splint could place the fingers at risk of not opening up. She stated Resident #13 did not have a decline in range of motion in his left hand. Attempted phone interview on 07/01/2026 at 1:10 PM with LVN M was unsuccessful. A voicemail was left but LVN M did not return the call. Interview on 07/01/2026 at 1:16 PM, RN O stated he worked the night shift (7 pm to 7 am) and about 90% of the time Resident #13 did not have the hand splint on when he worked. He stated last night (06/30/26) Resident #13 was already in bed when he started his shift, so he did not look specifically to see if Resident #13's splint was on his left hand or asses his skin on his left hand. Interview on 07/01/2026 at 2:06 PM with the DON revealed nurses were responsible to place the splint and to assess skin on Resident #13 if he allowed them to each shift. She stated the way the physician order was written nurses documented once per shift if the resident wore the left hand splint and assessed skin integrity per shift. She stated Resident #13 at times would wear the left hand splint. She stated it was important to wear the left hand splint to prevent any further contractures to the left hand. Record review of the facility's, undated, policy Range of Motion Exercises reflected to exercise the resident's joints and muscles. The policy did not reflect about splint devices for range of motion.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three (Resident #85) residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #85 after an incontinent episode when she failed to clean the resident's scrotum and penis on 06/29/26. This failure could place residents at risk for the development and/or worsening of urinary tract infections.Findings include: Record review of Resident #85's Quarterly MDS assessment, dated 05/02/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included dementia (a decline in cognitive abilities such as memory, thinking, and reasoning, severe enough to interfere with daily life), elevated blood pressure, and diabetes mellitus (elevated blood sugar) . Resident #85's BIMs score was not assessed because Resident #28 was unable to complete the interview. The MDS assessment indicated Resident #85 was dependent on toileting and personal hygiene. Record review of Resident #85's Care Plan, dated 10/23/25, reflected the following: Focus [Resident #85] has bladder incontinence. Goal: [Resident #85] will remain free from skin breakdown . Interventions. Care at least every 2 hours . Monitor for signs and symptoms of urinary tract infection. In an observation on 06/29/26 at 10:32 AM, LVN A and CNA B entered Resident #85's room to provide peri care. Both staff washed their hands and put on gloves. Both staff transferred Resident #85 from Geri-chair to bed. Both staff positioned Resident #85 in the middle of the bed on his back. CNA B unfastened Resident #85's brief, she cleaned resident's front pubic area with several wipes. Observation revealed CNA B did not clean resident's penis and scrotum. LVN A rolled the resident on his side. CNA B wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. CNA B then pushed the soiled draw sheet under the resident, and she placed a clean brief under the resident. Both staff rolled the resident over, and CNA B pulled the brief from between the resident's thighs and closed it. Both staff assisted the resident with dressing. CNA B removed gloves and left the room; she sanitized her hands in the hallway. LVN A removed her gloves, sanitized her hands, and left the room. In an interview on 06/29/26 at 11:00 AM, CNA B stated she realized after she walked out of the room, she never cleaned the scrotum and the penis of the resident. She stated by not performing adequate incontinent care it could increase the resident's risk for urinary tract infections and skin breakdown. In an interview on 07/01/26 at 10:10 AM, the DON stated when providing incontinent care staff were to clean the scrotum and penis of male residents. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated she and the ADONs would be re-training and observing care to ensure staff compliance. Record review of the facility's policy titled, Perineal Care, dated 04/25/22, reflected . Male resident . Pull back the foreskin on uncircumcised males. Hold penis by the shaft. Wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh. Reposition foreskin of uncircumcised males. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 medication carts (Medication Aide Cart Hall 200 and Nurses Medication Cart Hall 200) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure:The blister pack for Resident #50's Tylenol codeine 300-30 mg tablet did not have 1 blister seal broken in the Medication Aide Cart Hall 200 on 6/29/26.Nurses Medication Cart Hall 200 did not have 1 insulin pen for Resident #77 with an open date. Observation of the pen reflected it was used. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion. 1-Obsevation and record review on 06/29/26 at 11:47 AM of Medication Aide Cart Hall 200, with LVN C revealed the blister pack for Resident #50's Tylenol codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. The count sheet was reviewed, the we count was correct. Interview on 06/29/26 at 12:05 PM, LVN C stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk would be potential for drug diversion. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated when a broken seal was observed, she would waist the pill with another nurse. 2- Observation and review on 06/29/26 at 12:18 PM of the Nurses Medication Cart Hall 200, with LVN D revealed the pen of insulin Lantus 100 unit/ml for Resident #77 with no open date. Observation of the pen reflected it was used. Review of the instruction on the pen reflected to discard after 28 days of use. In an interview on 06/29/26 at 12:18 PM, LVN D stated nurses were responsible for checking the Nurses Medication Carts and the insulin pens for the open dates before giving insulin. She stated the nurse was supposed to label the pen with the open date when it was first opened. LVN D stated the purpose of putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective. In an interview on 07/01/26 at 10:10 AM, the DON stated that if a blister pack medication seal was broken the pill would be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issues. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the insulin flex pens and vial, once opened, needed to be dated because each insulin pen and vial had a specific day's shelf life and if not thrown out by that time the insulin could lose its effectiveness. The DON stated the pharmacy consultant checked the carts monthly and she would be doing random checks of the medication carts for monitoring. Record review of the facility's policy titled Medication Administration Procedure, revised 10/25/17, revealed in part . If a controlled medication removed from its packaging and is not to be administered (resident refusal or contamination) the does needs to be wasted to where the drug is unable to be used and/or destroyed and disposed of. Record review of the facility's policy titled Recommended Medication Storage, revised July 22012, revealed in part .Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used . INSULINS (Vials, Cartridge, Pens) . Insulin Glargine (Lantus) . Expires 28 days after initial use regardless of product storage (refrigerated or room temperature) .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #85 and Resident #7) of 3 residents observed for infection control. The facility failed to ensure:CNA B changed her gloves and completed hand hygiene during incontinent care for Resident #85 on 6/29/26.LVN E wore proper PPE while preforming wound care for Resident#7 who was on enhanced barrier precautions for a wound on 07/01/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.1- Record review of Resident #85's Quarterly MDS assessment dated [DATE] reflected Resident #85 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia (a decline in cognitive abilities such as memory, thinking, and reasoning, severe enough to interfere with daily life), elevated blood pressure, and diabetes mellitus (elevated blood sugar) . Resident #85's BIMS score was not assessed; Resident #28 was unable to complete the interview. The MDS assessment indicated Resident #85 was dependent on toileting and personal hygiene. In an observation on 06/29/26 at 10:32 AM revealed LVN A and CNA B entered Resident #85's room to provide peri care. Both staff washed their hands and put on gloves. Both staff transferred Resident #85 from the Geri-chair to the bed. Both staff positioned Resident #85 in the middle of the bed on his back. CNA B unfastened Resident #85's brief, and she cleaned the resident's front pubic area with several wipes. LVN A rolled the resident on his side. CNA B wiped the anal area from front to back and then the buttocks. CNA B then pushed the soiled draw sheet under the resident. With soiled gloves on she placed the clean brief under the resident. She rolled the resident on his back onto the clean brief. Once finished, she fastened the resident's brief. Without changing gloves CNA B assisted the resident with dressing. CNA B removed her gloves and left the room; she sanitized her hands in the hallway. LVN A removed her gloves, sanitized her hands, and left the room. In an interview on 06/29/26 at 11:00 AM, CNA B stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA B stated failing to provide proper care would expose residents to infections. 2-Record review of Resident #7's Quarterly MDS assessment dated [DATE] reflected Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a decline in cognitive abilities such as memory, thinking, and reasoning, severe enough to interfere with daily life) and pressure ulcer (areas of damaged skin and tissue caused by prolonged pressure, friction, or moisture) of sacral region (tailbone). Resident #7's BIMS score of 99, which indicated Resident #7 was unable to complete the interview. Record review of Resident #7's Care Plans dated 03/20/25, reflected focus: Resident is on enhanced barrier Precautions. Goal: There will not be any transmission of infection from or to the resident. Intervention: Gloves and gown should be donned if any of the following activities are to occur linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Posting at the residents room entrance indicating the resident is on enhanced barrier precautions. Observation on 07/01/26 at 09:38 AM revealed there was signage on the door of Resident #7's room that informed visitors/staff she was on enhanced barriers precautions, to perform hand hygiene before and after leaving room, the necessary PPE to wear in the room, and donning/doffing (put on/remove) information. LVN E entered Resident #7's room without any form of PPE. There was a PPE cart outside the Resident#7' room on the right side. LVN E washed her hands, donned gloves and proceeded to do wound care for Residnt#7 without wearing a gown. LVN E finished wound care, she adjusted Resident#7 in her bed and covered her. LVN E removed her gloves, washed her hands, gathered the trash bag, and exited the room. In an interview on 07/01/26 at 09:58 AM, LVN E stated she knew that she was supposed to wear a gown for any high contact with residents on enhanced barrier precaution, but she forgot. She stated she was nervous. She stated she was in-serviced regarding different types of infection control. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms would be exposing herself and others to the development of infection and spreading germs from one resident to another resident. In an interview on 07/01/26 at 10:10 AM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated CNAs were trained to perform hand hygiene between change of gloves. She stated the staff should follow proper infection control policies, and wear gowns before they touch any resident that had a port of entry. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated she would educate all nursing staff and she would do random rounds for monitoring. Record review of the facility's policy, Hand Hygiene, not dated, reflected, . Hand hygiene continues to be the primary means of preventing the transmission of infection. Record review of the facility's policy, Enhanced Barrier Precautions, not dated, reflected, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed toreduce transmission of multidrug-resistant organisms (MDRO) that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 residents (Resident #1, Resident #54, Resident #71, Resident #91) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #1 had her fingernails cleaned and trimmed on 05/04/25. 2- Resident #54 had his fingernails cleaned and trimmed on both hands on 5/04/25. 3- Resident #71 had her fingernails cleaned and trimmed on both hands on 5/04/25. 4- Resident #91 had his fingernails cleaned and trimmed on 5/04/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1-Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following stroke affecting left side non-dominant side (stroke resulting in weakness or paralysis on the left side of the body), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life),. She had a BIMS of 7 indicating she was severely cognitively impaired. Resident #1 required partial/moderate assistance with personal hygiene. Review of Resident #1's Comprehensive Care Plan dated 11/08/24 and last revised 04/25/25 reflected Resident #1 had an ADL self-care performance deficit related to cognitive deficits and impaired mobility. Intervention reflected Resident #1 required 1 staff participation with personal hygiene/oral care. Monitor appearance Observation and Interview on 05/04/25 at 10:50 AM with Resident # 1 revealed she had long dirty fingernails about 3/4 inch from finger tips on her right hand. She stated she did not know the last time her fingernails were trimmed. Resident #1 stated it bothered her that they were long. She stated she did not know who should be trimming them and no one had offered to trim them for her. Resident #1's left hand was in a splint. Observation and Interview on 05/04/25 at 12:38 PM with CNA G revealed Resident #1 did have long fingernails on her right hand and did not know the last times her fingernails were trimmed. She stated Resident #1 did not refuse ADL care. Observation and Interview on 05/04/25 at 1:39 PM with ADON E revealed Resident #1's fingernails about 3/4 inch from fingernail tips on right hand. She stated Resident #1's fingernails were long and should be trimmed. She stated Resident #1 was not a diabetic and CNAs were responsible to ensure fingernails trimmed. She stated nurses were responsible to ensure fingernail trimming was completed. Observation of left contracted hand revealed Resident #1 had long fingernails about 1/2 inch long with 1 finger about 3/4 inch with no cuts or open skin areas on left hand. ADON E asked Resident #1 if she wanted her fingernails trimmed and she said yes. ADON E stated the risk to residents with long fingernails could cause cuts and open skin areas in the hand. 2-Record review of Resident #54's Quarterly MDS assessment dated [DATE] reflected Resident #54 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included Hemiplegia (paralysis that affects only one side of the body) following cerebral infarction (a loss of blood flow to part of the brain, which damaged brain tissue), and need for assistance with personal care. Resident #54's BIMS score of 13, which indicated Resident #54's cognition was intact. The MDS assessment indicated Resident #54 required minimal assistance with personal hygiene. Record review of Resident #54's Care Plan dated 03/19/25, reflected the following: Focus: [Resident #54] has an ADL Self Care Performance Deficit related to impaired mobility/hemiplegia. Goal: Resident will maintain current level of function . Interventions: . Assist with personal hygiene as required . In an observation and attempt to interview on 05/04/25 at 9:18 AM revealed Resident #54 was sitting in his wheelchair. The nails on the right hand were approximately 0.4cm in length extending from the tip of his fingers. The nails were discolored tan and had brownish colored residue underside. The nails on the left hand were chipped. Resident #54's answers to questions did not make sense. 3-Record review of Resident #71's Quarterly MDS assessment dated [DATE] reflected Resident #71 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included diabetes mellitus, and hemiplegia (paralysis on one side of the body) following cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die) affection left side. Resident #71's BIMS score of 13, which indicated Resident #71's cognition was intact. The MDS assessment indicated Resident #71 required maximal assistance with personal hygiene. Record review of Resident #71's Care Plan dated 08/27/24, reflected the following: Focus: [Resident #71] has an ADL self-care performance deficit related to impaired mobility . Goal: . [Resident #71] will maintain current level of function in ADLs through the review date . Interventions: . Personal hygiene/oral care: the resident requires 1 staff participation with personal hygiene and oral care. Monitor appearance . In an observation and interview on 04/22/25 at 9:35 AM revealed Resident #71 was laying in his bed. The nails on both hands were approximately 0.5cm in length extending from the tip of his fingers. The nails were discolored tan and had yellow greenish colored residue underside. Resident #71 stated he did not like his fingernails long and dirty. In an interview on 04/22/25 at 11:50 AM, LVN F stated CNAs were responsible for trimming the nails of residents who were not diabetic, and nurses were responsible for trimming nails of residents who were diabetic. LVN F stated she was busy and did not notice Resident #54 and #71's nails. She stated she would do it. She stated the risk would be infection control and skin breakdown. 4-A record review of Resident #91's admission MDS assessment dated [DATE] reflected Resident #91 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included hypertension (Elevated blood pressure), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), arthritis (a broad term for conditions affecting joints, tissues around joints, and other connective tissues, causing pain, stiffness, and reduced movement), need for assistance with personal. Resident #91 had a BIMS score of 03/15 which indicated Resident #91's cognition was severely impaired. A record review of Resident #91's Comprehensive Care Plan dated 04/25/25 reflected the following: Focus: [Resident#91] has an ADL self-care performance deficit. Goal: [Resident#91] will maintain or improve current level of function in ADL Score through the review date. Interventions: Bathing: .Check nail length and trim and clean on bath day and as necessary . An observation on 05/04/25 at 09:40 AM revealed Resident #91 was sitting at the edge of the bed. The nails on both hands were approximately 0.5 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #91 stated would like his fingernail trimmed. In an interview on 05/04/25 at 12:39 PM, RN B looked at Resident#91 fingernails and stated they needed to be cleaned and trimmed. RN B stated CNAs were responsible to clean and trim residents' nails as needed. RN B stated only nurses cut residents' nails if they were diabetic. RN B stated no one notified her Resident #91's nails were long and dirty, and she had not noticed the nails herself. RN B stated the risk to the resident development of infection, and skin break down if he/she scratched him/herself. In an interview on 05/6/25 at 11:57 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty nails could be an infection control issue, and skin breakdown if residents scratch themselves. Record review of facility's policy, Nail Care, Nursing Policy & Procedure Manual 2003, revealed Nail management is the regular care of the toenails and fingernails to promote integrity of tissue, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenail. It includes cleaning, trimming, smoothing, and cuticle are and is usually done during the bath. NAIL CARE, ESPECIALLY TIMMING, IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERFERAL VASCULAR DISEASE .Goals 1. Nail care will be performed regularly and safely. 2. The resident will free from abnormal nail conditions. 3. The resident will be free from infection. 42971 47690

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food item in the facility reach in refrigerator were dated, labeled, and covered. 2. The facility failed to ensure hot food was held above 135 Fahrenheit (F) or higher on the steam table during lunch service on 5/5/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 5/4/25 at 9:06 AM in the facility reach-in refrigerator revealed: One cup of cut mixed fruit was not dated. Three plates of cut salad that included cucumber, cheese, ham slices, lettuce, tomato were not dated. Six small plastic cups of some kind of white dressing were not labeled or dated. 8-10 Cheese slices were left uncovered, loosely wrapped in plastic wrap, exposing them to air, and not dated. A brown snack bag that included 1/2 sandwich, apple was not dated or labeled. In an observation and interview on 5/5/25 at 11:40 AM in the facility kitchen revealed [NAME] C took the temperature of pureed burger (Pureed food is cooked food that has been processed into a smooth, creamy consistency, often using a blender or food processor) via food thermometer. Surveyor observed the food thermometer read 133.7 F. The surveyor asked [NAME] C the temperature reading for the pureed burger, [NAME] C stated the temperature was at 133.7 F. The surveyor asked [NAME] C if the pureed burger was at appropriate temperature to serve. [NAME] C replied, I guess so. The Assistant Dietary Manager (ADM) then came to the service line and asked [NAME] C what was the temperature of the pureed burger. She replied it was at 133.7. The ADM wrote down the temperature in the temperature logbook. The Dietary Manager then came to the service line and asked what the temperature was for the pureed burger. The ADM replied it was 133.7. The Dietary Manager nodded and asked [NAME] C to start serving the lunch meal since it was getting late. Both [NAME] C and ADM went ahead to plate lunch meals. Observation of tray line revealed pureed burger being served to the residents who needed pureed texture diet. In an interview on 5/4/25 at 9:20 AM with [NAME] C revealed she had been working in the facility for the last 10 months. She stated everyone in the kitchen including cooks, dietary aides, and the dietary manager were responsible for covering, labeling, and dating food items in the kitchen. She stated she was not aware when the sandwiches were prepared or who prepared it. She added the fruit cup may be left over from last night's meal, however, was not sure. She added the plastic cup had ranch dressing that goes with the salad. She stated cheese slices should have been wrapped appropriately and dated with use by date. She also added that the sandwiches should have been dated with use-by date. She added she will discard the sandwiches ,fruit cup and other items. She stated that the snack bag was for a resident on dialysis (medical procedure that replaces the function of the kidneys, filtering waste and excess fluid from the blood when the kidneys are not working properly) and should had use-by date and label with resident's name on it. She stated that risk of improper food storage was food spoilage and increased risk of residents being sick. In an interview on 05/05/25 01:04 PM with the Assistant Dietary manger (ADM) stated that she was working in the facility kitchen for 8-[AGE] years. She stated that the pureed burger was prepared by [NAME] C and the temperature on the holding table was 133.7 F . She stated that holding temperature for hot entrees should be at least 160 F. She stated that the pureed burger did not have the right temperature for service and should have been reheated to 160 F before serving to residents. She stated everyone in the kitchen were responsible for dating, labeling, and covering food items. She stated that she expected cooks and dietary aides to write use by date on perishable food items and snacks. She stated failure to appropriately cover, label and date food items as well as improper holding temperatures can lead to residents being sick and food borne illness. In an interview on 05/05/25 01:11 PM with [NAME] C stated she had prepared the pureed burger that consisted of bread , meat, and grilled onions that were pureed together for residents on pureed texture diet. She added that she thinks the temperature at which hot food should be held for service should be at 165 F and then added she did not remember the actual temperature for hot food holding temperature. She stated that pureed burger was at 133.7 F and stated that it sounded low. She stated that it should have been reheated before serving to the residents. She added the risk to residents for serving foods at improper holding temperature was possibility of residents being sick. In an interview on 05/05/25 at 01:17 PM with Dietary Aide D revealed all food items in the kitchen should be covered, labeled, and dated. She stated that she did not make the salads and weas not aware who or when the salads were made. She stated that everyone in the kitchen including dietary aides, cooks and managers were responsible for appropriate food storage. She stated that she was mostly responsible for making snacks and she was trained to write use-by date, which is three days from the date of preparation on all perishable food items. She added that risk to residents of not appropriately covering, dating, or labeling food items was residents could get sick. In an Interview on 05/05/25 01:17 PM with the Dietary Manager, stated her expectation was the temperature of hot food when held for service should be at least above 160. She stated she liked to serve resident hot food. She added that the pureed burger was at 133.7 F, and stated it was lower than the facility policy which stated that the hot food should be held at 140 F and above. She stated that she expected her cooks and ADM to reheat the pureed burger to ensure the temperature reach at least 140 before serving it to the residents. She added she did not ask the [NAME] to reheat the pureed burger since they were late on Lunch service. She added everyone including cooks and herself were responsible for covering, dating, and labeling all food items in the kitchen. She stated her expectation was the staff write open date on food items on the day they were opened and use by date on perishable food items such as salads, facility prepared snacks, and fruit cup. She stated all foods should be appropriately covered and sealed. She stated the risk to residents of improper food storage that included dating, labeling, and covering food items and improper holding temperatures was possibility of food borne illness. She added that she was responsible for conducting in-services for food storage and food holding temperatures for all kitchen personnel. In an interview on 05/06/25 12:36 PM with facility Dietitian sated that her expectation was all hot foods should be held at 135 F and above. She stated that foods that were held for service longer than 24 hours should be labeled, dated, and covered appropriately. She added risk to residents for improper food storage an improper holding temperature can lead to food borne illness. Record review of facility's document titled , HACCP Production Sheet [Hazard Analysis and Critical Control point - a food safety management system that identifies, assesses, and controls hazards from raw material to consumption to ensure safe food production) dated 5/5/2025 reflected, . Starch (P) .133.7[F] Review of facility's policy titled Daily Food Temperature Control undated reflected, .We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges . All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above . Review of facility's policy titled Food Storage and Supplies undated reflected, .4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened .7. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #28 and Resident #57) of 5 residents observed for infection control. The facility failed to ensure: 1- LVN F and CNA G changed their gloves and performed hand hygiene while providing incontinence care to Resident #28 on 04/04/25. 2- CNA A changed his gloves, performed hand hygiene, and donned appropriate PPE when providing incontinent care for Resident #57 who supposed to be on EBP on 05/05/25. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1-Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included anoxic brain damage (brain injury resulting from a complete lack of oxygen supply to the brain) and need for assistance with personal care. Resident #28's BIMS score not assessed; Resident #28 was unable to complete the interview. The MDS assessment reflected Resident #28's cognitive skills for daily decision making was severely impaired. The MDS assessment indicated Resident #28 was dependent with toileting and personal hygiene. Record review of Resident #28's Care Plan dated 01/13/25, reflected the following: Focus [Resident #28] has bladder incontinence related to cognitive deficits and impaired mobility . Goal: [Resident #28] will remain free from complications such as urinary tract infections and skin breakdown . Interventions: . Monitor for incontinence and provide incontinent care as needed . In an observation on 05/04/25 at 09:45 AM LVN F and CNA G entered Resident #28's room to provide peri care. Both staff washed their hands and put on gloves. Resident was sitting on the edge of the bed, without a brief. Both staff positioned resident in the middle of the bed on his back. LVN F cleaned resident's front pubic area with several wipes. With the same gloves on she cleaned resident's hands with clean wipes. CNA G rolled the resident on his side. LVN F wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. LVN F then pushed the soiled draw sheet under the resident and with soiled gloves placed a clean brief under the resident. Both staff then rolled the resident over, and CAN G pulled the brief from between the resident's thighs and closed it. Both staff changed gloves without hand hygiene. Both staff assisted resident with dressing, and they transferred him from bed to Geri-chair. CNA G removed gloves and left the room without hand hygiene. LVN F removed her gloves, sanitized her hands and left the room. In an interview on 05/04/25 at 12:15 PM, LVN F and CNA G stated they should change their gloves and perform hand hygiene when they went from dirty to clean. They stated they should perform hand hygiene between change of gloves. CNA G stated she should wash her hands before she left the resident's room. LVN F stated she fail to bring sanitizer with her to the room. Both staff stated failing to provide proper care exposed the resident to infections. 2-Record review of Resident #57's admission MDS, dated [DATE], reflected he was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (elevated blood sugar), cerebrovascular accident (Occurs when blood flow to the brain is interrupted, leading to brain cell death and potential neurological damage), neurogenic bladder (a problem in the brain, spinal cord, or central nervous system that make a person lose control of the bladder), and hypertension (High blood pressure). Resident#57 has a BIMS score of 15/15 indicating intact cognition. His Functional status reflected he was dependent on staff for toileting hygiene including incontinent care. Record review of Resident #57's care plan, dated 03/31/25, reflected he Focus. Resident is on enhanced barrier precaution r/t (related to) foley catheter. Goal. There will not be any transmission of infection from or to the resident. Interventions. Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, toileting/incontinent care, .catheter care .or other high-contact activity. Observation on 05/05/25 at 09:05 AM of Resident #57's catheter and incontinent care, provided by CNA A, revealed Resident#57 was on his bed awake. CNA A enter Resident#57 room with basin, towels, and wash clothes. CNA A draped the bed side table with towel and put the wash clothes, and the basin filled with warm water on top of it. CNA A washed hands, donned gloves, and no gown. There was a signage and supplies for EBP outside of the Resident#57's room at the left side of the entrance. CNA A uncovered Resident#57 and unfastened the tape on both sides of the brief, noticed the brief was soiled with feces, he rolled the front portion and pushed it downward on the center. CNA A changed gloves and washed hands. CNA A using warm water, soap and wash clothes cleaned resident catheter going from exit site outward. CNA A disposed of used wash clothes on the towel on the top of bed side table. CNA A changed gloves without any form of hands hygiene. CNA A using warm water and wash cloth rinsed the catheter. CNA A disposed of used wash clothes on the towel on the top of bed side table. CNA A changed gloves without any form of hands hygiene. CNA A using a towel dried the catheter. CNA A removed gloves washed hands and left the room to get supplies for the incontinent care, wipes, and clean brief. CNA A returned with the supplies; donned gloves cleaned Resident#57 groins area using one wipe per stroke. CNA A then instructed and assisted Resident #57 to roll towards the wall. CNA A continued to clean the resident's buttocks area. CNA A rolled, and pulled the soiled brief and threw it on the trash can. CNA A changed gloves without any form of hands hygiene. CNA A placed the new brief on resident's buttocks and instructed the resident to roll back. CNA A fastened the tape on both sides, then pulled Resident #57's blanket to his chest. CNA A folded the used wash clothes on the used towel and put them on the floor, tied the plastic bag and put it on the floor. CNA A removed gloves, washed hands. CNA A donned gloves, and took the plastic bag, the used towels, left the room, and dispose of them in the dirty linen room in the hallway, removed gloves and sanitized hands. Interview on 05/05/25 at 09:40 AM CNA A stated Resident #57 has a foley catheter and that way there was a signage and the supplies for EBP in front of the room. CNA A stated he forget to wear required PPE when he went to provide catheter care, and incontinent care for Resident#57. CNA A acknowledged he was changing gloves without any form of hands hygiene during catheter care and incontinent care. CNA A said it was important to wash hands any time he changed gloves because his hands could be contaminated. CNA A acknowledged that he was not supposed to put trash bag and used linen on the floor, because it can lead to the spread of germs. CNA A stated he supposed to have a plastic bag for the used linen. CNA A stated the risk to resident development of infection. In an interview on 05/06/25 at 11:57 AM, the DON stated they had trained at length on when staff were to change their gloves and sanitize their hands. She stated staff needed to change their gloves when they go from dirty to clean. DON stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of infection. She stated signage was posted outside to the door, which explain what PPE (Personal protective equipment) was to be won and for what task the PPE was to be worn for. She stated the staff had received numerous trainings on the use of Enhanced Barrier Precautions. She stated the risk was increased risk of infections. She stated she and the ADONs would be re-training and observing care to ensure staff compliance. Record review of facility Infection Control Policy & Procedure Manual 2019 UPDATED 03/2024, under title Fundamentals of Infection Control Precautions revealed 1. Hand Hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is .situations that require hand hygiene: .o After removing gloves or aprons. Gloving .Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employ targeted gown and glove use during high contact resident care activities . EBP are indicated for residents with any of the following: . Wounds and / or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 47690

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Shower room hall 100 and 200 hall) of three shower rooms reviewed for resident call system 1. The facility failed to ensure the call light in shower room area of 100 hall shower room had cord so it can be reached. 2. The facility failed to ensure the call light in shower room area of 200 hall shower room was working. These failures placed resident at risk of a delay in receiving assistance from facility staff and being unable to obtain assistance in the event of an emergency. Findings included: Confidential Group Interview on 05/05/25 at 9:38 AM with 8 of 8 residents revealed one of the residents stated he or she had been complaining about the 100-hall shower room not having a call light cord in the shower room area long enough to reach it. He or she stated it was important to have a working call light within reach in the shower area since he or she showered independently without staff assistance. Confidential Group Interview revealed unable to state how long the call light cord had not been accessible to use in shower room. Observation on 05/05/25 at 11:25 AM with LVN H revealed shower room in hall 100 reflected call light in the shower area had no cord. Observation on 05/05/25 at 11:45 AM with LVN H revealed shower room in hall 200 reflected call light in the shower area was not working. Interview on 05/05/35 at 11:59 AM with LVN H revealed CNAs and nurses were responsible to clean the shower rooms and check if the call lights works. She stated if the call light was not working they would notify the maintenance by scanning the QR code for maintenance care. LVN H scanned the QR code hanging in the hall and she reported the non-working call light in the shower room hall 200 and the missing cord for the call light in the shower room [ROOM NUMBER] hall. She stated the facility had residents who independently showered for the Hall 100 and Hall 200 shower rooms. Interview on 05/06/25 at 12:48 PM with Maintenance Director revealed an order was put in yesterday for resident shower room [ROOM NUMBER] hall. He stated he looked at it this morning finding there was no call light cord and he had to order a long cord for the call light in the shower room area for Hall 100. He had not looked at the 200-hall shower room and did not realize the call light in the shower room area for Hall 200 was not working. He stated he would go look at the call light in the shower room area in Hall 200 shower room. He stated he expected facility staff to notify him about any maintenance orders for the shower room and it came to his phone to see what maintenance requests. He stated the risk to residents could be residents can fall or trip and unable to get the assistance they need. Interview on 05/06/25 at 01:27 PM with Administrator stated there could be a delay for assistance and a potential for a fall if call lights in shower room area are not working. He stated he was not aware of call lights in the shower rooms not working properly. He stated he expected facility staff to report any maintenance repairs and the Maintenance Director would be notified on his phone of any maintenance concerns. Interview on 05/06/25 at 01:34 PM with Maintenance Director reflected he had replaced the cord in shower room [ROOM NUMBER] now and he was able to fix the call light in shower room for 200 hall. He stated he checked two rooms on each hall weekly and shower rooms could take up to a month before he checked them. He stated he relied on facility staff to inform him of any maintenance issues including call lights not working. The facility did not have a specific call light policy per the Administrator on 05/06/25.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #28) of three residents reviewed for incontinence care. The facility failed to ensure LVN F provided appropriate perineal care for Resident #28 after an incontinent episode when she failed to clean the resident's scrotum and penis on 05/04/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Findings included: Record review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included anoxic brain damage (brain injury resulting from a complete lack of oxygen supply to the brain) and need for assistance with personal care. Resident #28's BIMS score not assessed; Resident #28 was unable to complete the interview. The MDS assessment reflected Resident #28's cognitive skills for daily decision making was severely impaired. The MDS assessment indicated Resident #28 was dependent with toileting and personal hygiene Record review of Resident #28's Care Plan dated 01/13/25, reflected the following: Focus [Resident #28] has bladder incontinence related to cognitive deficits and impaired mobility . Goal: [Resident #28] will remain free from complications such as urinary tract infections and skin breakdown . Interventions: . Monitor for incontinence and provide incontinent care as needed . In an observation on 05/04/25 at 09:45 AM LVN F and CNA G entered Resident #28's room to provide peri care. Both staff washed their hands and put on gloves. Resident was sitting on the edge of the bed, without a brief. Both staff positioned resident in the middle of the bed on his back. LVN F cleaned resident's front pubic area with several wipes. LVN F did not clean resident's penis and scrotum. CNA G rolled the resident on his side. LVN F wiped the anal area from front to back and then the buttocks, changing to a clean wipe with each swipe. LVN F then pushed the soiled draw sheet under the resident, and she placed a clean brief under the resident. Both staff then rolled the resident over, and CNA G pulled the brief from between the resident's thighs and closed it. Both staff assisted resident with dressing, and they transferred him from bed to Geri-chair. CNA G removed gloves and left the room. LVN F removed her gloves, sanitized her hands, and left the room. In an interview on 05/04/25 at 12:15 PM, LVN F stated she never cleaned the scrotum and the penis of the resident. She stated by not performing adequate incontinent care it could increase the resident's risk for urinary tract infections and skin breakdown. In an interview on 05/06/25 at 11:57 AM, the DON stated when providing incontinent care staff were to clean scrotum and penis of male residents. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated she and the ADONs would be re-training and observing care to ensure staff compliance. Record review of the facility's policy titled, Perineal Care, dated 05/11/22, reflected, . Male resident . Pull back the foreskin on uncircumcised males. Hold penis by the shaft. Wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh .

Based on observations, interviews and record review, the facility failed to review and revise the comprehensive person-centered care plan for each resident consistent with the residents rights' that included measurable objectives and time frames to meet the medical, physical, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care plan reassessment and revision. The facility failed to review and revise Resident #1's comprehensive care plan after her roommate (Resident #2) reported CNA B raised her voice and used inappropriate language while caring for Resident #1 who was on Hospice. CNA B was in the room getting Resident #1 ready for bed. Resident #2 stated she heard CNA B say loudly shut the fuck up to Resident #1 on 03/13/2025. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of Resident #1's face sheet, dated 04/17/2025, reflected the resident was a [AGE] year old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included senile degeneration of the brain (decline in memory, behavior, and cognitive ability), epilepsy (brain condition that causes recurring seizures), and unspecified psychosis (loss of touch with reality) not due to a substance or known physiological problem. Record review of Resident #1's MDS (tool used to assess health status) Assessment, dated 02/28/2025, reflected a BIMS (tool used to assess cognitive function) score of 00 indicating severe cognitive impairment. Section GG indicated Resident #1 was dependent on staff for most self-care needs. Section O reflected Resident #1 was on hospice care services. Record review of Resident #1's Comprehensive Care Plan, dated 02/20/2025, reflected the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t disease process Interventions included All staff to converse with resident while providing care and Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities. During an observation and interview on 04/17/2025 at 10:27 AM, Resident #1 was sitting in the hall in her wheelchair across from the nurse's station. Resident #1 did not reply when surveyor said hello to the resident. She smiled and looked ahead. The staff member brought Resident #1 to her room so the surveyor could interview her and stated Resident #1 was hard of hearing and you had to talk loudly for her to hear you. Resident #1 was not able to answer questions due to her cognitive status. Resident #1 did not want to be in the room, moved her wheelchair toward the door, and called help me. Staff assisted Resident #1 back into the hall where she was content to sit across from the nurses' station. During an interview on 04/17/2025 at 10:32 AM, Resident #2 stated Resident #1 had been her roommate for quite a while. She stated Resident #1 did not like to stay in the room and preferred to sit in the hall. She stated Resident #1 did not communicate other than saying help me. She stated a few days prior, CNA B was in the room getting Resident #1 ready for bed. She stated she heard CNA B say loudly shut the fuck up. Resident #2 stated she reported it to the ADON. She stated she believed CNA B was talking to Resident #2. Resident #1 stated she did not see anyone else in the room and did not think CNA B was talking on her phone. She stated after CNA B put Resident #2 to bed, she shut the door and left the room. Resident #1 stated she had never heard CNA B talk like that. She stated she had not observed any changes in Resident #2's behavior since the incident. She stated you have to talk loudly and make sure Resident #2 can see your lips when speaking to her. Resident #2 stated she had no concerns about her care. She stated the staff was respectful to her and she felt safe. Resident #2 said the incident didn't bother her because she had heard worse in her life. She stated staff members came several times to talk with her and make sure she was ok after the incident. Record review on 04/17/2025 at 11:45 AM revealed Resident #1's Comprehensive Care Plan was not updated, after CNA B raised her voice and used inappropriate language while providing care for Resident #1, to include interventions ensuring Resident #1's needs were met. During an interview on 04/17/2025 at 12:01, the DON stated she was told Resident #1 was lying in bed and CNA B was changing her when Resident #2 heard CNA B yell those words. The DON stated she had been at the facility for about nine months and CNA B was working at the facility when she started. She stated there had been no complaints about CNA B from any other residents. She stated the ADON reported the incident to her after Resident #2 told the ADON what she heard. The DON stated she immediately reported it to the administrator. She stated CNA B was not working the day it was reported but was scheduled to work the weekend. She stated CNA B was immediately suspended pending an investigation. The DON stated the following Monday CNA B came to the facility and spoke with her. The DON stated CNA B said she was flustered but was not yelling at the resident and would never yell at a resident. She stated CNA B was terminated. She stated if CNA B was talking to a resident or in their presence, that type of behavior was not tolerated. She stated it could affect both residents emotionally. She stated they had observed no changes in Resident #1's behavior and there were no medication changes. The DON stated in-service training was provided on abuse and neglect and residents' rights. The DON looked at the resident's chart and stated the resident's care plan was not updated after the report but she would immediately update it. During an interview on 04/17/2025 at 3:34 PM, the MDS Coordinator stated when concerns are presented at morning staff meetings, they discuss at that time who will put in a care plan. She stated a care plan could be added or updated by the MDS Coordinator, the DON, social worker, or another nurse. She stated the MDS Coordinators did not add acute care plans. She stated she had seen care plans for resident-to-resident interactions but was not sure about a staff member to resident incident. Review of facility policy, Comprehensive Care Planning reflected Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. Undated.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to notify Resident #1's attending physician and representative after Resident #2 reported CNA B raised her voice and used inappropriate language while caring for Resident #1 who was on Hospice. CNA B was in the room getting Resident #1 ready for bed. Resident #2 stated she heard CNA B say loudly shut the fuck up to Resident #1 on 03/13/2025. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of Resident #1's face sheet, dated 04/17/2025, reflected the resident was a [AGE] year old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included senile degeneration of the brain (decline in memory, behavior, and cognitive ability), epilepsy (brain condition that causes recurring seizures), and unspecified psychosis (loss of touch with reality) not due to a substance or known physiological problem. Record review of Resident #1's MDS (tool used to assess health status) Assessment, dated 02/28/2025, reflected a BIMS (tool used to assess cognitive function) score of 00 indicating severe cognitive impairment. Section GG indicated Resident #1 was dependent on staff for most self-care needs. Section O reflected Resident #1 was on hospice care services. Record review of Resident #1's Comprehensive Care Plan, dated 02/20/2025, reflected the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t disease process Interventions included All staff to converse with resident while providing care and Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities. During an observation and interview on 04/17/2025 at 10:27 AM, Resident #1 was sitting in the hall in her wheelchair across from the nurse's station. Resident #1 did not reply when the surveyor said hello. She smiled and looked ahead. A staff member took Resident #1 to her room and stated Resident #1 was hard of hearing and you had to talk loudly for her to hear you. Resident #1 was not able to answer any questions due to her cognitive status. Resident #1 moved her wheelchair toward the door and called help me. Staff assisted Resident #1 back into the hall where she was content to sit across from the nurses' station During an interview on 04/17/2025 at 10:32 AM, Resident #2 stated Resident #1 had been her roommate for quite a while. She stated Resident #1 did not like to stay in the room and preferred to sit in the hall. She stated Resident #1 did not communicate other than saying help me. She stated a few days prior, CNA B was in the room getting Resident #1 ready for bed. She stated she heard CNA B say loudly shut the fuck up. Resident #2 stated she reported it to the ADON. She stated she thought CNA B was talking to Resident #1. Resident #2 stated did not see anyone else in the room and did not think CNA B was talking on the phone. She stated after CNA B put Resident #2 to bed, she shut the door and left the room. Resident #2 stated she had never heard CNA B talk like that. She stated she had not observed any changes in Resident #1's behavior since the incident. She stated you have to talk loudly and make sure Resident #1 can see your lips when speaking to her. Resident #2 stated she had no concerns about her care. She stated the staff was respectful to her and she felt safe. Resident #2 said the incident didn't bother her because she had heard worse in her life. She stated staff members came several times to talk with her and make sure she was ok after the incident Record review on 04/17/2025 at 11:45 AM revealed no documentation of Resident #1's representative or physician being notified. During an interview on 04/17/2025 at 12:01 PM, the DON stated she was told Resident #1 was lying in bed and CNA B was changing her when Resident #2 heard CNA B yell those words. The DON stated she had been at the facility for about nine months and CNA B was working at the facility when she came. She stated there had been no complaints about CNA B from any other residents. She stated the ADON reported the incident to her after Resident #2 told the ADON what she heard. The DON stated she immediately reported it to the administrator. She stated CNA B was not working the day it was reported but was scheduled to work the weekend. She stated CNA B was immediately suspended pending an investigation. The DON stated the following Monday CNA B came to the facility and spoke with her. The DON stated CNA B said she was flustered but was not yelling at the resident and would never yell at a resident. She stated CNA B was terminated. She stated if CNA B was talking to a resident or in their presence, that type of behavior was not tolerated. She stated it could affect both residents emotionally. She stated they had observed no changes in Resident #1's behavior and there were no medication changes. The DON stated in-service training was provided on abuse and neglect and residents' rights. The DON reviewed the resident's medical record and the facility's investigative report and stated there was no record of any staff member reporting the incident to the resident's family or physician. During an interview on 4/17/2025 at 12:11 PM, Resident #1's family member stated the facility had not told her about the incident. She stated Resident #1 cannot hear and you had to yell when speaking to her. She stated she came to the facility daily to visit Resident #1 and the CNAs were all great. She stated staff called her with any changes. She stated the roommate tells her everything but had not mentioned the incident. During an interview on 04/17/2025 at 1:15 PM, the Social Worker stated she had worked at the facility for about 6 months. She stated she was not aware of a facility report involving Resident #1. She stated Resident #1's family member came to the facility daily to bring a snack and visit. During an interview on 04/17/2025 at 2:33 PM, LVN A stated a nurse should call any report any changes of status to the resident's family and physician. She stated if a resident falls, you call and report to the physician and family. She stated she would ask the DON or Administrator for guidance because she had not experienced a resident reporting something like that. During an interview on 04/17/2025 at 2:43 PM, the ADON stated Resident #2 reported the incident to her on a Wednesday and Resident #2 told her it happened the prior Thursday. The ADON stated Resident #2 told her CNA B was in the room proving care for Resident #1 and Resident #2 heard CNA B say, shut the fuck up. The ADON stated she reported it immediately to the Administrator and DON. She stated CNA B was off work when Resident #2 reported the incident. The ADON stated she wrote a statement about what she was told. The ADON stated she did not write an incident report. She stated she was uncertain about the protocol for reporting to family and physician when an employee was involved in an incident. She stated the facility made sure CNA B had no further contact with any residents. She stated that behavior could make residents afraid to ask CNA B for help after hearing her yell. During an interview on 04/23/2025 at 1:45 PM, the Hospice Administrator stated a hospice nurse went to the facility after the physician's office received a message to call the surveyor. She stated the hospice nurse's note reflected upon arriving at the facility she was told about the self-reported incident. The Hospice Administrator stated the facility provided the hospice nurse with a copy of the report. The Hospice Administrator stated if the facility had not reported it, hospice would be required to. She stated the hospice nurse's report reflected she educated the facility on notifying hospice at the time an incident occurred. Attempts were made to interview CNA B on 04/17/2025. There was a recorded message the person was unavailable with no option to leave a voicemail. Review of facility policy Notifying The Physician of Change in Status, Revised March 11, 2013, reflected 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 105 residents reviewed for supervision. The facility failed to provide a lid which screwed onto the cup per Resident #1's care plan and failed to provide one-person supervision while eating per Resident #1's MDS assessment. This resulted in Resident #1 spilling coffee on himself, which went unwitnessed and unassessed for an undetermined amount of time and Resident #1 sustaining burns to his forearm, hip, and waist on 12/14/2024. The noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ). The Immediate Jeopardy began on 12/14/24 and ended on 12/15/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet dated 12/14/24, revealed he was a [AGE] year-old male, admitted to the facility 09/01/17. Diagnoses included Cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, aphasia, and lack of coordination. Record review of Resident #1's Minimum Data Set, dated dated dated [DATE], revealed his brief interview for mental status was 06, which means he was severely impaired. Requires extensive two-person assist for most Activities of Daily Living, total dependence with two-person assist for transfers, and supervision of one-person for eating. Record review of Resident #1's Care Plan dated 10/30/24, revealed Focus: Risk of burns due to hot liquids. Goal: Resident will not suffer any injury related to hot liquids. Intervention: Coffee and other hot liquids should not be served if over 140 degrees. If hot liquid was spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident. Resident to use a cup with a screw on lid. Resident will utilize specialized cup for hot liquids. Should be seated in upright position with table or overbed table when hot liquids are being consumed. Record review of Resident #1's Progress Note entered by Nurse B, at 10:46 AM and dated 12/14/24, revealed Note Text: at 1030 (standard time) aide went into the resident room to change the resident and found redness on the right side of the resident body. Right hip, waist (with blisters), and right wrist with a blister. Aide came and got the (Nurse B) then asked for assistance from (Nurse C). nurse found the resident not expressing pain. skin impairment. when the resident was asked when he spilt the coffee he said about 1 hour prior. he was also asked if he told anyone, he shrugged. (Nurse C) called Director of Nursing (DON) while (Nurse B) applied Silvadene to the wounds. (Medical Staff) was also informed of the incident. with the orders stating cleanse with Normal Saline, pat dry, apply silver sulfadiazine to the affected area daily. until healed. on coming nurse will be informed via report. Record review of Resident #1's Progress Note entered by Nurse B, at 11:07 AM and dated 12/14/24, revealed Note Text: Blood Pressure-126/74. Temperature-97.7. Pulse-81. Respiratory-18. Burn to right hip, waist, forearm, and wrist caused by coffee, tea, or other hot liquid, discovered/occurred in Resident Room. Details of injury: upper forearm 2x3 blister wrist 4x4 blister 5x20 redness hip 28x11 buttock 11x2 waist 11x20 right side. Cognition / Behavior at Time of Event: Cognitive Impairment, patient found with burns on his right side by the aide that went to change him. Initial Treatment/New Orders: cleansed normal saline, pat dry, Silvadene applied. orders given cleanse with normal saline, pat dry, apply silver sulfadiazine, until healed Resident Statement: 'spilt my coffee on me' (Medical Staff) notified: 12/14/2024 10:45 AM. (Family) notified: 12/14/2024 10:45 AM. Record review of Resident #1's Progress Note entered by Nurse D, at 12:38 AM and dated 12/21/24, revealed Visit Type: SKIN AND WOUND NOTE Details: Healing Partners Skin and Wound Note PATIENT NAME: Resident #1 DATE OF SERVICE: 12/20/2024 DOB: 06/15/1954 12.20.24: Consult requested due to resident spilling hot coffee on him approximately 5 days ago. He reports 'some' pain to wounds, reports it is tolerable. Educated on ways to decrease risk of spilling coffee on self. Understanding voiced. REVIEW OF SYSTEMS: SKIN: no history of pressure ulcers, no history of chronic wounds MEDICATIONS: . Silvadene External Cream 1 % two times a day . WOUND ASSESSMENT: Wound: 1 Location: right arm Primary Etiology(cause): Second Degree Burn Stage/Severity: Full Thickness [full thickness, permanently destroyed tissue, and painlessness is indicative of 3rd degree burns] Wound Status: New Odor Post Cleansing: None Size: 20.5 cm x 4.1 Location: right hip/thigh Primary Etiology: Second Degree Burn Stage/Severity: Full Thickness Wound Status: New Odor Post Cleansing: None Size: 22 cm x 17 cm x 0.1 cm. Calculated area is 374 sq cm. PROCEDURES: A sharp debridement was not performed today due to patient/family refusal. Record review of Nurse C's written statement, revealed on 12/14/24 at 10:30 AM, she was asked by Nurse B to look at Resident #1. She stated the resident had redness and blistering to right posterior forearm and redness to right outer thigh and redness and blistering to right hip. Resident #1 reported to C.N.A. A that he had spilled his coffee. The aide cleaned the resident up. Nurse C stated she notified the DON and medical staff for treatment orders. She stated she met with the kitchen staff for the coffee temperature which was within range and was less than 140 degrees Fahrenheit. She stated she interviewed the resident and he told her that the coffee was in his water cup with a lid, straw, and handle. The resident told her that he dropped his cup and the lid fell off. She stated the resident said the spill happened about an hour prior to her speaking with him. She stated the resident told her that he did not feel it and he denied pain. Resident #1 told her that he asked for the coffee in the large water jug due to easier use with his poor dexterity and inability to use regular coffee cups without severe difficulty. Nurse C stated Resident #1 had received coffee in this manner since his admission in 2017 and this was his first incident. Record review of C.N.A. I's written statement, revealed on 12/14/24 at 9:15 AM, she took Resident #1's breakfast to him. He told her to put his coffee in his cup and she went to the kitchen to get the coffee. She stated she brought the coffee to him and placed it on his table, as he had asked her to do. Observation of Resident #1's wounds on 12/27/24 at 1:46 PM, revealed the resident's wounds were healing. The pink areas had reduced in size. The pink areas were reduced to only the skin which surrounded the wounds which were still draining. Those drainage sites were smaller in size, as well. The measurements of the wounds were as follows: Forearm-3.7 cm x 4 cm, Wrist-3 cm x 4 cm, Waist-4 cm x 4 cm, Hip-9.5 cm x 2.5 cm. The rest of the wounded skin had resolved. During an interview on 12/27/24 at 2:00 PM with the ADON, revealed reason the measurements from Nurse D's Progress Notes were so large, was because she measured the span of the wounds instead of each individual wound. Observation and interview with Resident #1 on 12/23/24 at 2:54 PM, revealed he had burn wounds on his right forearm, wrist, and at the joint of the thumb. He also had burn wounds on his right hip and waist. The wounds were pinkish red in color. One of the areas on the forearm was about the size of a half dollar and it was draining. The area at the joint of the thumb was about the size of a quarter and it was draining. On his hip and waist area, there was an elongated area which was about three inches long and it was draining. Resident #1 stated the burns occurred when he accidentally knocked over his coffee and it fell on to his right side. He stated when Certified Nurse Aide (C.N.A.) A came in to check if he needed anything, he told her that he had spilled his coffee on himself. He stated he did not know how much time had passed between the spill and him telling the aide about it. He stated he did not remember if the lid was on the cup; however, he stated it usually was on, so he guessed it was on that day. During an interview on 12/27/24 at 3:56 PM with C.N.A. A, revealed she entered Resident #1's room to provide incontinent care and she saw that his skin was red and blistered. She stated, after she changed his brief, she notified Nurse B about the condition of his skin. She stated the reason he did not tell staff about the spill sooner was because he could not feel anything on his right side. She stated Nurse B and Nurse C entered the room, to assess the resident. She stated she replaced the wet linen with clean linen and she changed the resident's clothes, once the nurses were done taking care of his wounds. She stated this was the first time the resident had spilled his drink. She stated he was an avid coffee drinker. She stated she had had a previous talk with the resident and told him that if his coffee was ever too hot, he should let it sit for a while so it could have time to cool off. She stated he said he understood what she told him and agreed to do so. She stated the day after the he spilled his coffee, the DON brought him a new insulated cup which had a screw-on lid. She he had also been provided with a preventative apron; however, he refused to use it. She stated he was very vocal how he wanted things to be and if things were not to his liking. She stated staff were in-serviced on how certain residents must use specific no-spill cups or mugs. She stated the residents who have to use those cups were the residents who had shaky hands. She also stated staff were to obtain coffee for the residents, from the temperature regulated coffee machine. She stated she would put a towel over the resident whenever she assisted him with eating or drinking. She stated he doesn't like the towel, but he will allow it over the apron. During an interview on 12/23/24 at 3:23 PM with Nurse B, revealed she was notified by C.N.A. A Resident #1 had spilled coffee and his skin was red and blistered. She stated she assessed the resident and called for Nurse C. She stated she and Nurse C assisted the resident out of bed, so his linen could be changed. She stated the resident's skin was red and blistered. She stated she and Nurse C cleansed the resident's wounds and dressed them. She stated once they completed the dressings, C.N.A. A dressed the resident in clean clothes. She stated she notified the medical staff, DON, Administrator, and family. She stated the medical staff ordered Silvadene and pain medication. She stated once the medications were received, they were applied to the wounds. She stated after assessment and consultation with the medical staff, they determined that Resident #1's wounds did not require for him to go to the hospital to be treated. During an interview on 12/23/24 at 3:34 PM with Nurse E, revealed the regulated temperature machine was purchased in December of 2022, after the facility's first burn incident. During an interview on 12/27/24 at 10:45 AM with the Dietary Manager, she stated she learned about Resident #1's injury from Nurse C, who told her that C.N.A. I had gotten coffee from the temperature regulated machine, and she wanted the coffee from that machine to be checked. She stated when she checked the temperature of the coffee, it was 136.2 degrees Fahrenheit. She stated it was about 10:30 AM, at that time. She stated the temperature regulated coffee machine was set not to exceed 138 degrees Fahrenheit prior to 12/14/24. She stated she began logging the temperature of the coffee from the machine on 12/14/24, after the Resident #1 was injured from spilling coffee on himself, as a precautionary measure. During an observation, interview, and record review on 12/27/24 at 11:00 AM with the DON, revealed the facility provided a standard mug which has a snap-on lid and flexible straw to all residents who when they are admitted to the facility. She showed me the supply of the mugs in the storage closet. The mugs were similar to the ones issued in hospitals; except they were smaller in size. She stated all residents use cups or mugs which have some form of lid affixed to them, to prevent spills. She stated all staff were in-serviced, after Resident #1's injury. She stated a Hot Liquid Assessment was completed on all residents. A call was made to C.N.A. I on 12/27/24 at 1:25 PM, in an attempt to interview them. A message could not be left as no opportunity to leave a message was offered. A call was made to the Medical Staff on 12/27/24 at 1:28 PM, in an attempt to interview them. A message was left on their voicemail. A call was made to Nurse D on 12/27/24 at 1:33 PM, in an attempt to interview her. A message was left on her voicemail. During an interview on 12/27/24 at 4:44 PM with the Administrator, revealed the facility had made preventative changes prior to Resident #1's injuries and due to a similar incident with another resident in 2022. He stated Resident #1's incident was his first of this kind, so they used the same interventions which were in place for the previous resident. He stated all staff were in-serviced, following the resident's accident. Record review of the facility's undated Guidelines on Serving Coffee, reflected 1. As there is no published federal regulation for minimum or maximum coffee temperature, the decision as to the temperature at which to serve the coffee rests with the administration .the safety of their individual residents and their physical and mental limitations. 3. Any residents who have risk factors for coffee burns, such as significant cognitive impairment or extreme shaking may be evaluated for additional safety precautions using a hot beverage risk assessment. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee services at lower temperatures, or restricted coffee availability. 5. An investigation and evaluation will be performed for any resident who receives a coffee burn, and a plan to reduce this resident's risk of receiving future burns will be developed and implemented. The Administrator and DON were notified on 12/27/24 at 5:45 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 12/14/24. The facility implemented the following interventions: Record review of the hot liquid assessments revealed all residents were assessed. The dates on the report ranged from 12/14/24 - 12/19/24. Record review of the December 2024 Coffee Temperature Log for the Regulated Machine revealed the temperatures from 12/14/24 through 12/27/24, all temperatures were below 140 degrees Fahrenheit. Observation of the dining room on 12/23/24 at 1:24 PM, revealed a resident was getting coffee from the temperature-regulated machine. The resident was ambulating independently and was able to hold their mug steadily. The resident's mug was made of a clear plastic with blue measured lines and a snap-on blue cap. It also had a handle. During an interview on 12/23/24 at 3:17 PM with Resident #2, he stated he was told by another resident that everyone needed to have a cup or mug which had a screw-on lid. He stated he was happy with the mug, which the facility provided when he was admitted to the facility. He stated he had no problem with the mug and that he knew the screw-on lid was for residents who could not handle their cups well, on their own. He stated he did not need assistance with getting his coffee. He stated he gets his coffee from the machine in the dining room. He stated the coffee from that machine is always warm, but for him, it was never hot enough. Observations on 12/27/24 between 11:22 AM and 2:00 PM, revealed residents were carrying or drinking from cups which had lids affixed to them. Three residents in wheelchairs were observed with the cups, which had the screw-on lids. Residents in their rooms were observed to have the facility-provided mugs within their reach. Residents who were drinking coffee in the dining room, during lunch, received their coffee in the plastic coffee cups from the kitchen, and there were plastic lids in place. Record review of the in-services conducted on 12/14/24. The topics of the in-services were Hot Liquids/Food Spills, Coffee, Hot Liquids Serve Temps, and Acceptable Mugs for Serving Coffee. During an interview on 12/23/24 at 3:23 PM with Nurse B, revealed staff were in-serviced on making sure hot liquids are served in cups which have lids on them and making sure the coffee comes from the temperature regulated machine. During an interview on 12/23/24 at 3:34 PM with Nurse E, revealed all staff were in-serviced on ensuring residents are being served coffee from the temperature regulated machine, in the dining room. She stated all warm or hot liquids have During an interview on 12/27/24 at 10:45 AM with the Dietary Manager, revealed staff received an in-service about residents were to be served hot drinks in cups with lids on them. She stated residents can only get coffee from the temperature regulated machine in the dining room and if coffee is retrieved from staff, from the brewing machine in the kitchen, it has to come from kitchen staff who have ensured its cooled down to 140 degrees Fahrenheit or below. During an interview on 12/27/24 at 11:00 AM with the DON, revealed all staff were in-serviced on hot liquids, food spills, serving temperatures for hot liquids, and acceptable mugs for hot liquids. During an interview on 12/27/24 at 3:56 PM with C.N.A. A, revealed staff received an in-service on what to do if a resident spills hot coffee, coffee is to be retrieved from the temperature regulated machine in the dining room, for residents, and residents have to have a lid on their coffee cups. During an interview on 01/09/25 at 9:52 PM with C.N.A. G, revealed staff received an in-service on making sure residents are not served excessively hot drinks. She stated coffee is to be served to residents in cups that have lids on them. She stated they are to be mindful of where they placed the resident's drinks to ensure the residents can reach the drinks without knocking them over. During an interview on 01/10/25 at 12:13 AM with Nurse H, revealed staff received an in-service on hot drinks, focused on coffee. She stated the coffee it to come from the machine in the dining room. She stated coffee is to be served to residents in cups that have lids. She stated they talked about spill prevention.

48560 Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 4 of 8 (Residents #15, #68, #58 and #30) residents reviewed for respiratory care, in that: 1- The facility failed to ensure Resident #15, and Resident #68 nasal cannula tubing and humidity bottle were labeled or dated. 2- The facility failed to ensure Resident #58, and Resident #30 nasal cannula was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. The findings were: Review of Resident # 15's Quarterly MDS assessment dated [DATE] reflected resident was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included stroke (blood supply to brain is interrupted), hypertension (high blood pressure), Peripheral vascular disease (circulation disorder caused by narrowing of blood vessels), Diabetes Mellitus (high blood sugar), hemiplegia (paralysis of one side of the body) and was on oxygen therapy in the facility. Review of Resident #15's care plan dated 2/1/2024 reflected Resident #15 has Oxygen Therapy at bedtime and one of the interventions included Oxygen at 2 lpm per nasal canula at bedtime. Review of Resident #15's Physician order dated 10/18/2023 reflected Change Oxygen tubing every Wednesday night, rinse filter. Place change Wednesday sticker on tubing with date and initials on Every night shift every Wednesday. Review of Resident #15's Physician order dated 9/20/2023 reflected oxygen 2 Liter via Nasal Cannula at bedtime. Observation on 03/26/24 at 01:01 PM, revealed that Resident #15 was in his wheelchair with oxygen concentrator on via nasal cannula and oxygen humidity bottle and nasal cannula tubing was not dated or labeled. In an interview with ADON B on 3/26/2024 at 1:04 PM, revealed she was working the floor today. She stated that nurses were responsible for dating and labeling oxygen supplies including nasal cannula and humidity bottle. She stated that night shift nurses were to change and date oxygen tubing and humidity bottle every Wednesday and oxygen supplies can be changed and dated on as needed basis. ADON B revealed that dating and labeling oxygen supplies was a part of nursing protocol and should be reflected on resident's physician orders. She stated risk to resident of not dating or labeling oxygen supplies was infection control. She stated as an ADON, she had a weekly checklist and checking oxygen tubing for dates and labels was a part of it. She stated that her last weekly check was on 3/21/2024. Resident #68 Review of Resident # 68's Quarterly MDS dated [DATE] reflected a [AGE] year-old male readmitted to the facility on [DATE]. Relevant diagnoses include heart failure (condition that develops when heart does not pump adequate blood), hypertension (high blood pressure), pneumonia (infection in lungs), Diabetes Mellitus (high blood glucose), Respiratory failure (condition that makes it difficult to breathe on your own) and was on oxygen therapy in the facility. Review of Resident #68's comprehensive care plan revised 10/24/2023 reflected Resident #68 had Oxygen therapy and one of the interventions included OXYGEN SETTINGS: PRN Oxygen 2-4 LPM via Nasal Cannula to keep saturation above 92%. Review of Resident #68's Physician order dated 10/18/2023 reflected Change Oxygen tubing every Wednesday night and rinse filter. Place a change Wednesday sticker on tubing with date and Initials, every nightshift every Wednesday. Review of Resident #68 Physician order dated 8/25/2023 reflected Check Oxygen saturation every 8 hours and apply Oxygen at 2-4 Liter to keep Oxygen saturation more than 92% every 8 hours. Observation on 03/26/24 at 11:17 AM revealed resident resting in bed, oxygen not running, and oxygen humidity bottle and nasal cannula tubing was not dated or labeled. In an observation and interview with LVN A on 03/26/24 at 11:22 AM, revealed she was not sure when the nasal cannula and humidity bottle was last changed since she could not see a label or date on it. She stated that Resident #68 was on her list to change nasal cannula tubing and humidity bottle today; was usually changed on the night shift nurses. LVN A checked Resident #68's oxygen saturation, which was 98%. LVN A added risk to resident for not dating and labeling Oxygen supplies was major risk of infection. In an interview with DON on 3/28/24 at 11:14 AM, revealed her expectation was that all oxygen tubing and supplies should be dated and labeled. It should be changed weekly and on as needed basis. the DON added it was the responsibility of night nursing staff every Wednesday to change and date all oxygen supplies. She stated that the risk to residents for not following procedures for respiratory care was infection control. She started as a DON, she ensured that she conducted floor rounds at least bi-weekly to address any concerns with quality of care was not compromised. Review of Resident #58's Face Sheet dated 03/27/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included neoplasm (abnormal growth in the tissue) of the breast and history of COVID-19. Review of Resident #58's Comprehensive MDS assessment dated [DATE] reflected Resident #58 was cognitively intact with a BIMS score of 14. Resident #58 was on oxygen therapy while a resident of the facility. Review of Resident #58's Care Plan dated 02/01/2024 reflected resident had oxygen therapy related to long COVID and one of the interventions was O2 via nasal cannula at 2 liters per minute as needed to maintain O2 saturation at or above 92%. Review of Resident #58's Physician Order dated 12/13/2023 reflected, May use oxygen @ 2 L/M via nasal cannula every shift for O2 sats below 92%. Observation on 03/26/2024 at 10:46 AM, revealed Resident #58 was on her bed, sleeping. Resident #58 had an oxygen concentrator at bedside with a nasal cannula attached to it. There was a plastic bag behind the oxygen concentrator. The nasal cannula was not bagged and was hanging on top of the oxygen concentrator. Resident #58 also had a nasal cannula at the back of her wheelchair attached to an oxygen tank. The nasal cannula not bagged and was hanging on top of the oxygen tank. Observation and interview with LVN A on 03/26/2024 starting at 2:23 PM, LVN A stated Resident #58 had been on oxygen for a while. LVN A said she not aware the resident was back in her room, so she was not able to put back the oxygen. When she was about to get the nasal cannula, LVN A noticed the nasal cannula was hanging on top of the oxygen concentrator. LVN A said she needed to get a new nasal cannula because it was just lying on top of the oxygen concentrator. She said it should be bagged when not in use. LVN A disconnected the nasal cannula from the oxygen concentrator. When LVN A was about to leave the room, she also disconnected the nasal cannula connected on the oxygen tank behind the wheelchair. She said she would also replace it because it was lying on top of the oxygen tank. LVN A left the room and returned with two nasal cannulas. LVN A connected one of the nasal cannulas on the oxygen concentrator and put the prongs of the nasal cannula on the resident's nostril. The other nasal cannula was also connected to the oxygen tank at the back of the wheelchair. Only the part to be connected to the oxygen tank was taken out of the plastic while the rest of the tubing remained inside the plastic. LVN A stated the nasal cannula should be bagged when not in use because it could cause contamination and eventually infection. LVN A said she must make sure the nasal cannula was bagged if the residents were not using them. Review of Resident #30's Face Sheet dated 03/27/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included acute respiratory failure with hypercapnia (higher than normal level of carbon dioxide in the blood) and hypoxia (low blood oxygen). Review of Resident #30's Quarterly MDS assessment dated [DATE] reflected that Resident #30 was cognitively intact with a BIMS score of 13. The Quarterly MDS also indicated that the primary reason for admission was medically complex conditions such as chronic lung disease and respiratory failure. Resident #30 was on oxygen therapy while a resident of the facility. Review of Resident #30's Comprehensive Care Plan dated 02/05/2024 reflected resident had oxygen therapy and one of the interventions was oxygen at 2 LPM per nasal cannula as needed for O2 < 92%. Observation on 03/27/2024 at 8:28 AM, revealed Resident #30 was not inside the room. Resident had an oxygen concentrator at bedside and a nasal cannula was connected to the oxygen concentrator while the prongs of the nasal cannula were on the trash. A plastic bag was attached at the back of the oxygen concentrator. Interview with ADON B on 03/27/2024 at 10:05 AM, ADON B stated the nasal cannula should had not been exposed nor touching anything because it could cause infections. ADON B said the nasal cannula should had been bagged when not in use to ensure cleanliness. ADON B said she would disconnect the nasal cannula and connect a new one to make sure Resident #30 would use a clean one when he returned to his room. Interview with the DON on 03/28/2024 at 9:15 AM, the DON stated the nasal cannula should be bagged when not in use. The DON said it was the proper way to store the nasal cannula. The DON added if those nasal cannulas was not bagged and touching surfaces that were not sure clean, the oxygen administration could be compromised. The DON said the staff, including her, were responsible in monitoring that the equipment used in oxygen therapy were bagged when not in use. She said the expectation was the nasal cannula would be stored properly if the residents were not using them. The DON said she would continually remind the staff to be diligent in making sure the procedures for respiratory care were followed. Interview with the Administrator on 03/28/2024 at 10:07 AM, the Administrator stated he was not familiar with the clinical policies but said that whatever the residents were using should maintained clean. He said that for this concern, the nasal cannula should be stored properly to prevent more respiratory issues. The Administrator said the expectation is for the staff to be diligent in order to provide the highest level of care. Policy for Respiratory Care, specifically for nasal cannula being bagged and dating and labeling Oxygen supplies was requested on 03/28/2024. The DON stated they do not have a policy about nasal cannula being bagged or dating and labeling oxygen supplies.

Based on observations, interviews, and record reviews the facility failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 3 residents (Resident #1) reviewed for supervision. The facility failed to ensure the Memory Care unit of the facility was secure when Resident #1, who had a diagnosis of Alzheimer's disease with severely impaired cognition and a history of elopement and exit seeking behaviors, eloped from the facility on 10/09/23. The noncompliance was identified as PNC IJ. The IJ began on 10/09/23 and ended 10/09/23. The facility had corrected the noncompliance before the survey began. The Administrator was notified of the PNC IJ on 10/13/23 at 5:55 PM. The noncompliance was determined to be PNC because the facility corrected the issues with the door security and had monitoring in place to ensure Resident #1 did not elope again. This failure could place residents at risk of accidents, hazards, and improper supervision. Findings Included: Record review of Resident #1's quarterly MDS assessment, dated 09/11/23, reflected she was a [AGE] year-old female whose cognition was severely impaired. The resident admitted to the facility on [DATE]. The resident wandered daily. The resident required limited assistance of one staff for ambulation on and off the unit. The resident's diagnosis included Alzheimer's disease, lack of coordination. Record review of Resident #1's care plan, dated 08/31/23, reflected: Resident resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Disoriented to place, memory loss. Interventions included: 10/09/23 Dining room door lock changed. Record review of Resident #1's Order Summary Report, dated 08/31/23, reflected: Admit to secure unit due to history of elopement with active exit seeking behavior. Record review of Resident #1's progress notes, reflected: 10/09/23 at 6:48 AM Upon arriving to facility, noted resident walking down street in front of facility. Stopped vehicle and called to resident. Exited vehicle and walked resident to side door facility and escorted her into building. Resident in no signs of distress. No shortness of breath noted, color WNL. DON took resident back to unit. - MDS Nurse 10/09/23 7:36 AM Resident was found out front of the facility. The resident does not have any injuries or falls related to this incident. Appears that the resident was able to get out of the side gate. We returned the resident to the unit, and we did a head count to make sure that all of the residents were accounted for, and they were. - LVN A Review of the facility provider investigation report, not dated, received from the Administrator on 10/13/23, reflected: Resident #1 Information Pertinent Medical Diagnosis: Alzheimer's disease and abnormalities of gait and mobility. Resident #1 resides in our secure memory care unit, but no special supervision is required within the unit. Date/Time you first learned of incident: 7:15am, 10/09/23 Date/Time the incident occurred: approximately 6:30am, 10/09/23 Brief narrative summary of the reportable incident: At about 6:30 AM this morning, 10/09/23, staff member CNA B walked Resident #1 to the dining room in the secure care unit. CNA B then went to the end of the 400 hall to put the trash in the trash bin just outside the door. The secure care unit (400 hall) was all COVID positive, so trash and dirty linens were placed outside the back door to be picked up and disposed of or taken to laundry. In order to open the door at the end of the hall, LVN A pushed the exit button to release the door locks. In doing this the doors at the two ends of the hall released as well as the gate in the courtyard. LVN A was watching down the hall and at the entrance doors to the secure care unit. LVN A assumed that the door from the dining room to the courtyard was locked and secure, as it did not release with the other doors. Apparently, the dining room/courtyard door was not fully shut and thus not locked. While LVN A and CNA B were engaged in taking out the trash, Resident #1 walked outside onto the courtyard patio and then out through the exit gate. She walked to the front of the building, following the sidewalk and then walked down the driveway to the road in front of the facility where the MDS nurse, was arriving for work and walked her back to the building. Staff walked her back to the secure care unit. The date and time of the assessment: 10/9/23, 7:00am Name and title of person who completed assessment: LVN A Results of the assessment including extent of injuries: Resident #1 had no injuries or apparent ill effects. Provide all steps taken immediately to ensure resident(s) are protected: Examined the dining room/courtyard door. Changed out the lock on the door to one that will always automatically lock after entering the code. Maintenance adjusted the door so it was a smoother and dependable full closer, thus ensuring the door would relatch each time it is closed. Ensured the closure mechanism is working correctly. Conducted an in-service with staff on the precise sequence of steps for releasing and relocking the doors. Contacted our Fire System vendor to come out and install a new mag lock at the end of the 400 hall to allow for independent ingress and egress through just that door. In-service on the procedure for releasing and relocking the secure doors and the precautions to ensure it is done safely. The resident was out of the building for approximately 15 minutes on 10/09/23. She was found on the road in front of the building which was next to the driveway of the facility. It was not a busy street. An observation of Resident #1 on 10/13/23 at 1:05 PM reflected she was in the secure care unit. She was standing in the dining room. She was not interviewable but was awake and alert. She wandered around the dining room. The dining room door was locked with a keypad and the door would automatically shut and lock by itself. The back door, front door, and courtyard gate were locked. An interview on 10/13/23 at 5:45 PM with CNA B revealed at around 6:00 AM on 10/09/23 CNA B took Resident #1 to the dining room. She said she did not realize the dining room door was unlocked. She said there was a staff coming to the back door of Hall 400 to drop off papers. She said she was watching two residents who were close to the back door to make sure they did not go outside the door after LVN A unlocked it. She said after the door was relocked CNA B went to get a resident up for breakfast and the DON walked onto the unit with Resident #1. CNA B said when the button at the nurse station was pressed, it unlocked the back door, front door, and the outside gate. CNA B said she received in-services about the doors and following the incident. The dining room door lock was changed and now closed by itself. She said staff no longer pressed the button at the nurse station because the residents were no longer COVID positive. An interview on 10/13/23 at 5:40 PM with LVN A revealed on 10/09/23 the button at the nurse station was pressed to allow someone to come into the secure unit through the back door. LVN A said she did not realize the button also opened the outside gate, and she did not know the dining room door was unlocked. She said it was no longer necessary to press the button to open the back door because the residents on the secure unit no longer had COVID. She said the button was an emergency button and she had received in-services to make sure all of the doors were locked if the button had to be pressed and to do a resident head count. She said the dining room door lock was changed to one that locked automatically after the incident. An interview on 10/13/23 at 4:50 PM with the MDS Nurse revealed on 10/09/23 at around 6:45 AM, she arrived to work and saw Resident #1 walking close to the building. The MDS Nurse said she called the resident's name and walked her back into the building. She said the resident was happy and pleasant and did not have any signs or symptoms of injury. The MDS Nurse said she took the resident to the DON. An interview on 10/13/23 at 2:25 PM with the DON revealed the facility failure related to Resident #1's elopement occurred because the facility was following their COVID protocol. She said staff were not allowed to use the front door to enter the unit from the facility. Staff had to enter the unit from the outside by going through the back door. The DON said when staff entered the back door, a button at the nurse station had to be pressed because the back door did not have its own locking mechanism. The DON said when the button was pressed, it unlocked the front door (which had its own separate lock), the back door (which did not have its own separate lock), and the outside gate in the courtyard. The dining room door had its own lock that was a manual lock. She said on 10/09/23, LVN A was watching the front and back doors after she pressed the button to unlock them. The dining room door was not securely locked, and the resident went out the door to the courtyard, and then out the gate. The DON said following the elopement the facility changed the lock on the dining room door so it would automatically lock. She said COVID protocol was no longer in place and the button did not have to be pressed. She said the staff also had a monitoring tool that they had to fill out following the incident anytime the button at the nurse station was pressed. An interview on 10/13/23 at 4:05 PM with the Administrator revealed if the button at the nurse station was pressed, the front door, back door, and outside gate all opened. He said on 10/09/23, no one knew the dining room door was unlocked and so no one was watching that door when the button was pressed. He said the facility failure was that the dining room door was unlocked, but now the dining room door had an automatic lock that did not require staff to secure it. He said the button was no longer being pressed unless there was an emergency, and a monitoring tool was in place and filled out anytime the button was pressed to ensure the doors were all relocked and all residents were accounted for. He said there had not been an elopement before. He also said a 3rd party vendor had been hired to put a separate lock on the back door so that the button would not have to be pressed at all. It was determined these failures placed Resident #1 in an IJ situation from 10/09/23-10/09/23. The facility took the following action to correct the non-compliance on 10/09/23. 1. The facility fixed the dining room door, that Resident #1 eloped through, by installing a new key pad and mechanism that allowed the door to lock automatically. 2. The facility put a monitoring tool in place to ensure the doors were locked after the exit button in the secure unit was pressed and all residents were accounted for. A record review of the facility Monitoring Tool used to check the secure unit doors was reviewed. The staff documented checking the doors on 10/09/23, 10/10/23, 10/11/23, 10/12/23, and 10/13/23. Record review of the facility policy, Elopement Prevention, revised 10/27/10, reflected: Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement . Environmental Modification 1. Allow the resident to wander in a safe and secure setting (e.g., closed courtyard or hallway free from obstacles or stairs) . 5. Use door locks that are out of reach/sight to prevent wanderers from opening doors. 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility .

Based on observation, interview, and record review, the facility failed to ensure the physician was consulted immediately when a there was a an accident involving the resident which resulted in injury and had the potential for requiring physician intervention and a significant change in the resident's physical status that is a deterioriation in health one (Resident #1) of eleven residents reviewed for change of condition. The facility failed to consult with Resident #1's physician when Resident #1 showed signs and symptoms of pain after a fall. Resident #1 was determined to have a fracture of the right femur and hip and required hospitalization and surgical intervention. An Immediate Jeopardy was identified on 07/25/23. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because (e.g.) all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's MDS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at high risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires SKIN inspection at least weekly by licensed nurse. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 AM written by LVN C reflected, Late Entry CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected, Late Entry Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Sacred cross called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected, Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U documented Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 08:35 written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of the accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's physician order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report dated 07/17/23 at 4:21 PM revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's hospital records dated 07/17/23 reflected: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visited almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C also informed her Resident #1 had an injury. The family member stated when she entered the resident's room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and her roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. The family member stated Resident #1 told her she fell on her bottom and hit her head. The family member stated when she pulled the covers back, it was obvious when looking at her right leg that there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized, told her the facility should have contacted her immediately, and told her he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, who was Resident #1's roommate, revealed on 07/15/23 during the 7:00 PM -7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. At 9:00 PM, when Student Aide D assisted the resident to bed for the evening and at 12:30 AM when the resident requested a brief change and to be repositioned. Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was awakened by a loud noise, and she heard Resident #1 complaining and moaning. Resident #2 stated she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were working, and she was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23 for the 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nurses' station. The resident was complaining of pain and saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what the aides or nurses on 200 Hall had done to treat Resident #1's leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 Hall and noted the resident's behavior was not normal so she advised the aides on 200 Hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F, she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning on 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and for breakfast due to her complaints of pain. CNA F stated she entered Resident #1's room to complete care, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's right leg just fell to the side. CNA F stated at that point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23. The Nurse Practitioner stated she was able to reveal on her phone that LVN C contacted the Physician through the communication app they used with the Medical Director on Monday 07/17/23 at 10:45 AM due to Resident #1's right leg being bent, the resident guarding that leg, complaining of right leg pain, and a notation that when the aide was completing care the aide felt movement in the right leg when transferring. The Nurse Practitioner stated the doctor saw the resident via video and was able to provide an order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician via their electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during the morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. The DON stated Resident #1 told them she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted of Resident #1's pain and injury on Monday 07/17/23 morning, contacted the Physician, followed orders for x-ray. The DON stated following findings of the x-ray Resident #1 was transferred to the hospital on 07/17/23 with findings of fractured femur which resulted in surgery. According to the DON, it was the facility policy for the charge nurse to contact the Physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting the family or the responsible party and herself along with the Administrator (the abuse coordinator) when residents were exhibiting a change of condition or had been involved in an injury. The DON stated it was the responsibility of all staff to report any neglect or failure to treat residents to charge nurse, ADON, DON or to the abuse coordinator. According to the DON, the abuse and neglect policy was often reviewed during in-services. The DON stated LVN B should have completed a full assessment on Resident #1 to identify Resident #1's pain and then reported the findings to the Physician, DON, and the Administrator immediately. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM-7:00 AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room three times throughout the shift and abruptly left the facility about 2:17 AM. After Student Aide D left the building, CNA E stated she did a round to Resident #1's room and observed the resident in bed sitting straight up sleeping. CNA E stated she left the room to prepare for a brief change. Upon returning Resident #1's room, the resident was making sounds of moaning and groaning which she thought was her normal communication to leave her alone. CNA E stated Resident #1 was not wet so she left her alone. CNA E stated when she returned to Resident #1's room at 5:30 AM to get her up for the day, the resident yelled out differently. She stated the resident's cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down. CNA E then lifted Resident #1's right leg and the resident screamed. When she lowered Resident #1's leg, the resident screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA E stated she did not observe LVN A do any type of assessment. CNA E stated the next night (07/16/23) Resident #1 was already in the bed sleeping. CNA E stated Resident #1 slept the whole night and did not wet the whole night. When she attempted to wake the resident the next morning, the residents grabbed the covers and requested water. CNA E stated the resident refused to get up for the day. CNA E stated she then alerted LVN A that Resident #1 had no incontinence care all night, refused to get up, and had requests for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert the charge nurse when there was a change in condition with residents. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted the Physician via their electronic communication app and had a video call within two minutes, and she received an order for Resident #1 to have an x-ray and Tramadol for pain. LVN C stated the x-ray was completed within four hours, and the x-ray revealed Resident #1 had a femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. During her assessment, Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. When she asked Resident #1 and Resident #2 how the injury took place, neither of them said anything until Resident #1's family member entered the room. It was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all three previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knew now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23. CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping everyone and anyone trying to get their attention. CNA T stated Resident #1 was trying to say something, but because she did not work with her on a regular basis, she grabbed CNA G. CNA T stated Resident #1 was moaning, and she thought the resident said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse that Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nurses' station. CNA G stated Resident #1 told her about having knee pain. CNA G stated when LVN B arrived she notified him about Resident #1's knee pain. CNA G stated, During breakfast, I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated she brought Resident #1 to the dining room, but the resident wheeled herself back to the nurses' station. The resident refused breakfast, lunch, and dinner on that day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg, and they both had told LVN B about the resident's knee pain more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23. Student Aide H stated when she arrived to work, Resident #1 was in her usual spot near the nurses' station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, and complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that Resident #1 was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nurses' station when he arrived. LVN B stated Resident #1 appeared normal to him, and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not conduct a full assessment for pain, and he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow-up with her throughout the day to see how she was feeling or to see if he needed to alert the Physician that the resident was in pain, had a change of condition, or refused to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner, he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A stated she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when CNA E went to get the resident up, the resident stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, her legs were sideways, and her legs stiff. LVN A stated when she went to check Resident #1, the resident was dressed, in a wheelchair in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23, she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23, and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained the resident was in pain. LVN A stated she did not contact the Physician, DON, or the oncoming nurse that she was informed Resident #1 was in pain. According to LVN A not completing a full assessment or identifying a change of condition could place residents at risk of not receiving immediate care. Review of facility's current Notifying the Physician of Change in Status policy, dated 03/11/13 reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2.the nurse will gather medications, vital signs, signs and symptoms, and interventions that have currently been implemented. 3. the nurse is responsible for responding to a change of condition in a timely and effective manner. 4. If the situation is an emergency and the attempts to the physician was unsuccessful, the nurse will contact the nearest ambulance service for assistance. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with the ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aide staff regarding neglect, not moving resident after a fall, and contacting the charge nurse when a resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain, and he should have done a complete assessment for pain, administered pain medication, and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM, Resident #1 was in bed, which no one alerted her of Resident #1 in pain, the ADON stated had LVN B communicated Resident #1 complained of pain, LVN A would have completed proper care regarding Resident #1's pain. The ADON stated LVN B not communicating Resident #1's pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse for one (Resident #1) of eleven residents reviewed for abuse. The facility failed to ensure Resident #1 was free from deprivation of goods and services by staff regarding help with pain, assessing the resident as needed, and consulting with the physician from 07/16/23 midnight until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete the assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. The resident required extensive assistance from two people for ADLs to include eating, transfers and toileting. The resident also required supervision and set up assistance with locomotion on and off the unit. Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with Resident #1's family member revealed she visited almost daily at 3:00 PM, when she entered the facility on Monday 07/17/23, the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room LVN C followed expressing the same thing that Resident #1 had an injury. The family member stated when she entered the room Resident #1 was moaning, groaning and grimacing from pain. The family member stated both Resident #1 and her roommate started to explain the cause of Resident #1's pain. They informed her late Saturday night 07/15/23, early Sunday morning 07/16/23 about midnight, that she was reaching for the call button, fell and the aide came in and threw her back in bed. The family member stated Resident #1 told her she fell on her bottom and hit her head. The family member stated she pulled the covers back, and it was obvious there was a fracture to Resident #1's right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately, and he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, roommate to Resident #1, she revealed during the 7:00 PM -7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. She stated Student Aide D entered the room at 9:00 PM when she assisted her to bed for the evening and again at 12:30 AM when she requested a brief change and to be repositioned. The third time was when she overheard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was wakened by a loud noise, and Resident #1 complaining and moaning, and she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were working, and they was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nurses' station. The resident was complaining of pain, saying that her right leg was hurting. CNA F stated on that day she worked a different hall and was not sure what aides or nurses on 200 Hall had done to treat the resident's leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 Hall and noted the behavior was not normal so she advised the aides on 200 Hall to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F, she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 Hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at that point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C used the facility's electronic communication app to contact the Physician on Monday 07/17/23 at 10:45 AM due to right leg pain, Resident #1's leg was bent, the resident guarding the leg, and when the aide was completing care she felt movement in the leg during a transfer. The Nurse Practitioner stated the Physician saw Resident #1 via video and was able to provide an order for x-ray and tramadol for pain. According to the Nurse Practitioner, the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician using the electronic communication app when residents experienced a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during the morning clinical meeting on 07/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted to Resident #1's pain and injury on Monday 07/17/23 morning. She stated LVN C contacted the physician and followed orders for x-ray. The DON stated following findings of the x-ray Resident #1 was transferred to the hospital on 07/17/23 with findings of fractured femur which resulted in surgery. According to DON, it was the facility policy for the charge nurse to contact the Physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting the family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents were exhibiting a change of condition or had been involved in an injury. The DON stated it was the responsibility of all staff to report any neglect or failure to treat residents to the charge nurse, ADON, DON or to the Abuse Coordinator. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM - 7:00 AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room three times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed the resident in bed sitting straight up sleeping. CNA E stated she left the room to prepare for a brief change, and when she returned to the room, Resident #1 was making moaning and groaning sounds which she thought was the resident's normal communication to leave her alone. She stated the resident was not wet so she left the resident alone. CNA E stated when she returned at 5:30 AM to get the resident up for the day the resident yelled out differently. She stated Resident #1's cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and the resident screamed. She stated she then lowered Resident #1's leg, and the resident screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA E stated she did not observe LVN A do any type of assessment. The next night when she worked again, Resident #1 was already in the bed sleeping. She stated the resident slept the whole night and did not wet the whole night. When she attempted to wake the resident the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E then alerted LVN A that Resident #1 had no incontinence care all night, refused to get up, and her request for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert charge nurse when there was a change in condition with residents. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via Spruce, video call within two minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within four hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C, when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all three previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knew now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected: Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: [CNA F] reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 5:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called, and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by nurse documented: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 PM written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23-07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip and femur one time only for right leg pain for 1 day Record review of Final X-Ray Report, dated 07/17/23, revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HCI oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on July 17th prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 house as needed for pain) for the month of July was not administered on July 15th, 16th or 17th prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records, dated 07/18/23 reflected the resident completed surgery on 07/18/23. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she didn't have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when the CNA E went to get Resident #1 up, the resident stated her knee was hurting, and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, who and how soon would they report suspected abuse? Ask 5 residents how staff is treating them. Document date/time, resident name, if there was any negative response. Document any corrective action if needed on the back of this form. During incident/event review in standup, was there any evidence of any potential neglect. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, completing full assessments and identifying source for pain and resident neglect and following facility policy.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse/neglect of a resident for one (Resident #1) of eleven residents reviewed for abuse. The facility failed to ensure Resident #1 was free from deprivation of goods and services by staff when they failed to: pain management, assess the resident as needed, and consult with the physician from 07/16/23 midnight until 07/17/23 at 5:30 PM when Resident #1 was transferred to the hospital. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers and toileting. Supervision and set ups with locomotion on and off the unit. Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with family member revealed she visits almost daily at 3:00 PM, when she entered the facility on Monday the receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room LVN C followed expressing the same thing, (that Resident #1 had an injury), family member stated when she entered the room Resident #1 was moaning, groaning and grimacing from pain, both Resident #1 and roommate started to explain the cause of her pain, late Saturday night, early Sunday morning about midnight, that she was reaching for the call button, fell and the aide came in and threw her back in bed, Resident #1 stated to family member she fell on her bottom and hit her head. Family member stated she pulled the cover back and it was obvious there was a fracture to her right femur. Family member stated she was upset the facility had not contacted her prior to her entering the facility. Family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, roommate to Resident #2 revealed during the 7:00 PM-7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room [ROOM NUMBER] times throughout the night, 9:00 PM when she assisted me to bed for the evening, 12:30 AM when she requested a brief change and to be repositioned, Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was wakened by a loud noise, and Resident #1 complaining and moaning, and she saw Student Aide D leaving the room. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at this time different staff were working and was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nurses' station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall to put Resident #1 to bed around 3:00 PM-4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted the physician using the electronic communication app on Monday 07/17/23 at 10:45 AM due to right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. According to the Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident, however she stated it was expected that the facility immediately notify the physician using the electronic communication app when residents have a change in condition. Interview on 07/25/23 at 4:55 PM with DON revealed she was alerted during morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. According to DON Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. DON stated LVN C was alerted of Resident #1's pain and injury on Monday 07/17/23 morning, contacted the physician, followed orders for x-ray. DON stated following findings of the x-ray Resident #1 was transferred to the hospital on 07/17/23 with findings of fractured femur which resulted in surgery. According to DON it is facility policy for the charge nurse to contact the physician immediately when residents are complaining of pain or have a change of condition. The DON stated the charge nurse is also responsible for alerting family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents are exhibiting a change of condition or have been involved in an injury. The DON stated it was the responsibility of all staff to report any neglect or failure to treat residents to charge nurse, ADON, DON or to the abuse coordinator. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM - 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated she walked away and thought LVN A provided medication at that time. CNA stated she did not observe LVN A do any type of assessment. The next night I worked again, Resident #1 was already in the bed, sleeping, she slept the whole night and did not wet the whole night. When I attempted to wake her the next morning, she grabbed the covers and requested water, she refused to get up for the day. I then alerted LVN A Resident #1 had no incontinent care all night, refused to get up and her request for lots of water. CNA E stated she had completed training on resident abuse and neglect, that she understood to alert charge nurse when there is a change in condition with residents. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Physical/Occupational therapy evaluation and treatment as per orders. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM - 7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 PM copy of documentation signed by Physician reflected: Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 5:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Sacred cross called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by nurse reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 PM written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip and femur one time only for right leg pain for 1 day Record review of Final X-Ray Report revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on 07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered on 07/15/23, 07/16/23, 07/17/23 prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records dated 07/18/23 reflected the resident completed surgery on 07/18/23. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, During breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM - 7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM - 6:00 AM. LVN A stated when the CNA E went to get her up, she stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at this time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, who and how soon would they report suspected abuse? Ask 5 residents how staff is treating them. Document date/time, resident name, if there was any negative response. Document any corrective action if needed on the back of this form. During incident/event review in standup, was there any evidence of any potential neglect. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, completing full assessments and identifying source for pain and resident neglect and following facility policy.

Based on observation, interview and record review, the facility failed to ensure the 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 eleven residents reviewed for quality of care. LVN A and LVN B failed to address pain, complete an assessment, contact the physician, and provide effective pain treatment, for Resident #1 when she showed signs and symptoms of significant pain from midnight on 07/16/23 until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital after x-rays revealed the resident had a fracture to the right femur and hip at 3:30 PM on 07/17/23. An Immediate Jeopardy was identified on 07/25/23. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. MDS did not indicate any pain or shortness of breath. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing that Resident #1 had an injury. The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the cover back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The Family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM- 4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. During an observation and interview on 07/25/23 at 3:34 PM with Resident #1 revealed she was in bed resting, quiet, when she saw family member enter the room she started smiling and began talking. When asked about her knee she began speaking and pointing to the floor. Resident #1 stated she fell out of the bed and hurt her knee. Resident #1 patted on her right knee and stated, it hurt. According to Resident #1, she had been administered pain medication and was not in pain at this time. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted physician through electronic communication app (communication app with medical director) on Monday 07/17/23, 10:45 AM due to Resident #1 complaining of right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident, however she stated it was expected that the facility immediately notify electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting on 06/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated, she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 hall with Resident #1 which was whom Resident #1 was referring to as the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated at about 10:30 AM LVN C was alerted of Resident #1's pain and injury, contacted the physician, and followed orders for x-ray. The DON stated Resident #1 was transferred to the hospital on July 17th with findings of fractured femur which resulted in surgery. According to the DON it was the facility policy for the charge nurse to contact the physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator as the abuse coordinator when residents were exhibiting a change of condition or had been involved in an injury. Interview on 07/26/23 at 9:48 AM with CNA E revealed she worked on the 7:00 PM 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. The next night she worked again, Resident #1 was already in the bed, sleeping, she slept the whole night and did not wet the whole night. When she attempted to wake her the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up, and her request for lots of water Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with: even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 3. Resident #1 has osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis through review date. Interventions: Give analgesics as needed for pain, Resident may complain of pain, stiffness, or weakness. Document complaints. Give medications as ordered. Observe/document for side effects and effectiveness. Observe for risk of falls. Observe/document/report as needed for signs and symptoms or complications related to osteoporosis: Acute fracture, compression fractures, loss of height, pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 9:15 PM written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 1745 before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 08:35 written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's order revealed: Order date: 07/17/23 10:52 AM Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report, dated 07/17/23, revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered at any time from 07/15/23, 07/16/23, and 07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered at any time from 07/15/23-07/17/23 prior to resident being sent out to the hospital. Record review of hospital records dated 07/17/23 revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records date 07/18/23 reflected the resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping everyone and anyone trying to get their attention. CNA T stated Resident #1 was trying to say something, but because she did not work with her on a regular basis, she (CNA T) grabbed CNA G. CNA T stated Resident #1 was moaning, CNA T stated she thought Resident #1 said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and [Student Aide H] was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated after left Resident #1 in the dining room the resident wheeled herself back to the nurses' station, she refused breakfast, lunch, and dinner on that day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A stated she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM- 6:00 AM. LVN A stated when CNA E went to get the resident up, the resident stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, her legs were sideways, and her legs stiff. LVN A stated when she went to check Resident #1, the resident was dressed, in a wheelchair in the hallway. LVN A stated at that time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23, she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23, and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained the resident was in pain. LVN A stated she did not contact the Physician, DON, or the oncoming nurse that she was informed Resident #1 was in pain. According to LVN A not completing a full assessment or identifying a change of condition could place residents at risk of not receiving immediate care. Review of facility current Notifying the Physician of Change in Status policy, dated 03/11/13, reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention . 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. the nurse will gather medications, vital signs, signs and symptoms, and interventions that have currently been implemented. 3. the nurse is responsible for responding to a change of condition in a timely and effective manner. 4. If the situation is an emergency and the attempts to the physician was unsuccessful, the nurse will contact the nearest ambulance service for assistance. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. Record review of facility's Quality of Care revealed they did not have one however, provided Resident Rights policy revised 11/28/16 indicated The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must establish and maintain identical policies and practices regarding provision of services under the State plan for all residents regardless of payment source. This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified. an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 Resident #1 was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form beginning 07/26/23, titled Real Time Monitoring indicated log started with slots for date, new pain, MD notified, new order implemented/medication given, initials/comments. Record review of the facility plan of correction monitoring tool form titled Change of Condition Monitoring indicated log ask 10 nurses per week what would they do if a resident had a change of condition, or it was reported to them that a resident had a change of condition. Date/Nurse name, Did they respond correctly? Corrective action? The Director of Nursing was informed the Immediate Jeopardy was removed on 07/27/23 at 5:00 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eleven residents reviewed for pain. The facility failed to address when Resident #1 screamed out in pain when her leg was moved, complete assessment, contact physician, and provide effective pain treatment, for Resident #1 when she showed signs and symptoms of significant pain from midnight on 07/16/23 until 07/17/23 at 5:30 PM when Resident #1 was transported to the hospital after x-rays revealed the resident had a fracture to the right femur and hip at 3:30 PM on 07/17/23, which required surgical intervention. An Immediate Jeopardy was identified on 07/25/23. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. The MDS did not indicate any pain or shortness of breath. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at high risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 3. Resident #1 has osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis through review date. Interventions: Give analgesics as needed for pain, Resident may complain of pain, stiffness, or weakness. Document complaints. Give medications as ordered. Observe/document for side effects and effectiveness. Observe for risk of falls. Observe/document/report as needed for signs and symptoms or complications related to osteoporosis: Acute fracture, compression fractures, loss of height, pain. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing, (that Resident #1 had an injury). The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the cover back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 4:29 PM with CNA F revealed when she arrived to work on Sunday 07/16/23, 7:00 AM-7:00 PM shift, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated on this day she worked a different hall and was not sure what aides or nurses on 200 hall had done to treat her leg pain. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. CNA F stated she normally worked with her on 200 and noted the behavior was not normal so she advised the aides on 200 hall (CNA G and Student Aide H) to put Resident #1 to bed around 3:00 PM-4:00 PM. According to CNA F she was told by aides on 200 hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated the next morning 07/17/23, she returned to the 200 hall. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care, during this time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side, she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. During an observation and interview on 07/25/23 at 3:34 PM, with Resident #1 revealed she was in bed resting, quiet, when she saw family member enter the room she started smiling and began talking. When asked about her knee she began speaking and pointing to the floor. Resident #1 stated she fell out of the bed and hurt her knee. Resident #1 patted on her right knee and stated, it hurt. According to Resident #1, she had been administered pain medication and was not in pain at this time. Interview on 07/25/23 at 4:42 PM with the Nurse Practitioner revealed she was not on-call from 07/15/23-07/17/23; however, she was able to reveal on her phone that LVN C contacted physician through electronic communication app (communication app with medical director) on Monday 07/17/23, 10:45 AM due to Resident #1 complaining of right leg pain, Resident #1's leg was bent, and she was guarding, aide was completing care and felt movement in the leg with transferring. The Nurse Practitioner stated the doctor saw resident via video and was able to provide order for x-ray and tramadol for pain. The Nurse Practitioner stated the information she received about the injury was speculation so she could not speak on the risk for the resident; however, she stated it was expected that the facility immediately notify the physician via the electronic communication app when residents had a change in condition. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting on 07/17/23 that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON, Resident #1 stated, she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to as the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated at about 10:30 AM LVN C was alerted of Resident #1's pain and injury, contacted the physician, and followed orders for x-ray. The DON stated Resident #1 was transferred to the hospital on 07/17/23 with findings of fractured femur which resulted in surgery. According to the DON, it was the facility policy for the charge nurse to contact the physician immediately when residents were complaining of pain or had a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator (Abuse Coordinator) when residents were exhibiting a change of condition or had been involved in an injury. Interview on 07/26/23 at 9:48 AM, with CNA E revealed she worked on the 7:00 PM - 7:00AM overnight shift on 07/15/23. CNA E stated she saw Student Aide D enter Resident #1's room [ROOM NUMBER] times throughout the shift and abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone, she was not wet so she left her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated the next night when she worked again, Resident #1 was already in the bed, sleeping. CNA E stated the resident slept the whole night and did not wet the whole night. When she attempted to wake Resident #1 up the next morning, the resident grabbed the covers and requested water. CNA E stated the resident refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up, and her request for lots of water. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 AM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 09:15 written by LVN C reflected the following late entry: CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 1530, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5::54 PM written by the ADON reflected the following late entry: Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected: Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U reflected: Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 AM, written by LVN C reflected: Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review of Resident #1's order revealed: Order date: 07/17/23 at 10:52 AM, Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report, dated 07/17/23, revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. (bone broken at an angle that affected the knee and leg) 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's July 2023 MAR revealed: Tramadol HcL oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered at any time from 07/15/23-07/17/23 prior to resident being sent out to the hospital. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered at any time from July 15th - July 17th prior to resident being sent out to the hospital. Record review of hospital records, dated 07/17/23, revealed: Chief complaint: Right leg pain from a fall. Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Hospital records dated 07/18/23 reflected the resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/26/23 at 12:01 PM, with LVN C revealed she worked the 7:00 AM - 7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM, with CNA T revealed she worked the morning shift 7:00 AM - 7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping every and anyone trying to get their attention. CNA T stated Resident #1was trying to say something, but because she did not work with her on a regular basis, she grabbed CNA G. CNA T stated Resident #1 was moaning, she thought the resident said, Help me. According to CNA T because she worked on another hall, she did not see Resident #1 again. CNA T stated because she contacted the CNA that was working on her hall, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, During breakfast I was pushing Resident #1 down to the dining room and Student Aide H was telling her that Resident #1's leg was swinging, which she could not see because she was behind her and trying to get residents to breakfast. CNA G stated once she left Resident #1 in the dining room she wheeled herself back to the nursing station, she refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told him about it more than once. Interview on 07/26/23 at 2:03 PM, with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain, and this was not normal for her. According to Student Aide H when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/26/23 at 2:10 PM, with LVN B revealed he worked the morning shift 7:00 AM - 7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her keen was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow-up with Resident #1 throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner, he apologized for not being much help. Interview on 07/26/23 at 2:46 PM with LVN A revealed she worked on the overnight shift 7:00 PM-7:00 AM on 07/15/23 for 100 Hall and 200 Hall. LVN A she did not have any complaints of a fall. LVN A stated throughout the night Resident #1 rested fine, until she was getting out of bed between 5:30 AM-6:00 AM. LVN A stated when the CNA E went to get her up, she stated her knee was hurting and it was reported she was sleeping in a weird position. Her head was up really high, legs were sideways, and legs stiff, when she went to check Resident #1 was dressed, in wheelchair, in the hallway. LVN A stated at this time she did not think anything serious happened. LVN A stated she administered pain mediation prior to leaving on 07/16/23. (review of medication administration did not support LVN A administering any type of pain medication) LVN A stated when she returned the next day there were no complaints of pain, Resident #1 was in bed the entire shift. LVN A stated when she left on Monday morning 07/17/23 she got a call from the facility stating Resident #1 was injured. LVN A stated during the call she was informed Resident #1 complained of pain on Sunday 07/16/23 and the day nurse gave her pain medication. LVN A stated she did not complete an assessment to identify the source pain after CNA E and Resident #1 complained resident was in pain. LVN A stated she did not contact physician, DON, or the oncoming nurse she was informed Resident #1 was in pain. According to LVN A not completing full assessment or identifying a change of conditions could place residents at risk of not receiving immediate care. Record review of the facility's Pain Management, Assessment Scale Policy dated revised 05/25/16 indicated, complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . Assess resident's physical symptoms of pain, physical complaints, and daily activities, perform comfort measures to promote relaxation, .have the resident rate pain on a scale of one to ten .Talk with resident about pain and assess for pain relief after interventions . This was determined to be an Immediate Jeopardy on 07/26/23 at 4:49 PM. The Director of Nursing was notified. an Immediate Jeopardy had been identified. The Director of Nursing was provided with the Immediate Jeopardy on 07/26/23 at 5:38 PM. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 Resident #1was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM, revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility Plan of Removal monitoring tool form beginning 07/26/23, titled Real Time Monitoring indicated log started with slots for date, new pain, MD notified, new order implemented/medication given, initials/comments. Record review of the facility plan of correction monitoring tool form titled Change of Condition Monitoring indicated log ask 10 nurses per week what would they do if a resident had a change of condition, or it was reported to them that a resident had a change of condition. Date/Nurse name, Did they respond correctly? Corrective action? The Director of Nursing was informed the Immediate Jeopardy was removed on 07/27/23 at 5:00 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to have evidence that in response to alleged abuse/neglect a thorough investigation was conducted to prevent further potential abuse/neglect for 1 (Resident #1) of eleven residents reviewed for neglect. The facility failed to conduct a thorough investigation into an allegation of abuse/neglect after Resident #1 fell and was allegedly put back in bed by Student Aide D on 07/16/23 at midnight, and the resident complained of pain through 07/17/23 at 5:30 PM when she was transported to the hospital after x-rays revealed the resident sustained a fracture of the right femur and hip. An Immediate Jeopardy was identified on 07/25/23, The Immediate Jeopardy template was provided to the facility on [DATE] at 5:38 PM. While the Immediate Jeopardy was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of further injury or worsening of their conditions. Findings included: Record review of Resident #1's face sheet dated 07/25/23 revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, muscle weakness, reduced mobility, abnormal posture, repeated falls, foot drop, right foot (gait abnormality of the right foot). Record review of Resident #1's annual MDS assessment, dated 06/12/23 revealed her BIMS score was 99 indicating Resident #1 was unable to complete assessment. Her Functional Status for activities of daily living indicated she required extensive assistance with one person assist with bed mobility, dressing and personal hygiene. Extensive assistance with 2 person assist with eating, transfers, and toileting. Supervision and set ups with locomotion on and off the unit. Section J indicated Resident #1 had a recent fall with a major injury (bone fractures). Record review of Resident #1's BIMS assessment dated [DATE] revealed her BIMS score was 0 indicating severe impairment. Record review of Resident #1's care plan, last care conference 04/28/23, revealed: 1. Resident #1 at risk for falls related to muscle weakness, Goals: risks and injury potential will be minimized through the next review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The resident needs a safe environment with even floors free from spills and or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. 2. Resident #1 has an activities of daily living self-care performance deficit related to dementia, disease process. Goal: maintain current level of function in activities of daily living through the review date. Intervention: gather and provide needed supplies, observe/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Resident requires extensive assist by 1 staff to turn and reposition in bed. Resident requires extensive assist by 2 staff to move between surfaces. Resident requires extensive assist of 1 staff to dress. Resident requires extensive assistance by 2 staff for toileting. 3. Resident #1 has potential for pain related to right foot drop. Goal: Resident will not have an interruption in normal activities due to pain through review date. Intervention: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions ever shift. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observe/document for probable cause of each pain episode. Remove/limit causes where possible. Observe/document for side effects of pain medication. Observe/record/report to nurse any signs and symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling outs, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observe/record/report to nurse loss of appetite, refusal to eat and weight loss. Observe/record/report to nurse resident complaints of pain or requests for pain treatment. Provide non-pharmacological interventions. Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms of pain or discomfort. Therapy referral as indicated. 4. Resident #1 has Osteoporosis. Goal: Resident will remain free of injuries or complications related to osteoporosis. Interventions: Give analgesics PRN for pain. Resident may complain of pain, stiffness, or weakness. Document complaints. Observe for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Observe/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain. Record review of Resident #1's progress notes dated 06/25/23 - 07/17/23 revealed no mention or assessment of Resident #1 complaint of pain. Record review of Resident #1's progress notes dated 07/17/23 at 12:00 PM copy of documentation signed by Physician reflected, Follow up Physical exam, Elderly, frail female in some distress seen via video, Right lower extremity bent at ninety degrees, grimacing with palpation. Patient seen via telemedicine with nurse. 1. Pelvis and right femur x-ray. Concern for fracture status post transfer. 2. Tramadol 100mg po q6h PRN pain for 14 days if no allergies. 3. Follow up x-ray. Record review of Resident #1's progress notes dated 07/17/23 at 09:15 written by LVN C reflected, Late Entry CNA F reported that resident was complaining of pain during a brief change. I went and looked at her leg, and then messaged the doctor. The doctor video called, and we looked at the leg together. The doctor ordered x-rays and pain meds for resident. This nurse put in the orders. The x-ray techs showed up around 3:30 PM, and so did family member. X-ray showed femur break. This nurse reported that to doctor and called for transport to hospital. It was 5:45 PM before resident was transported to hospital due to ambulance being busy. Record review of Resident #1's progress notes dated 07/17/23 at 5:54 PM written by ADON reflected, Late Entry Resident reported leg pain to aide and aide notified nurse. Nurse assessed resident and did a telehealth video call and X-ray, and pain meds were ordered. Family member was at bedside during x-ray and when it was resulted. Right femur fracture. Upon further investigation, resident states she did fall out of bed last night onto her knees and a worker helped her up. Patient has good situational awareness. Emergency Transportation was called, and resident sent to hospital at 5:45 PM. Record review of Resident #1's progress notes dated 07/17/23 at 6:46 PM written by LVN C reflected, Resident #1 was transferred to a hospital on 07/17/2023 5:50 PM related to right femur fracture. Record review of Resident #1's progress notes dated 07/17/23 at 7:34 PM written by LVN U documented Resident #1 in hospital. Record review of Resident #1's progress notes dated 07/18/23 at 8:35 AM, written by LVN C reflected, Spoke to family member in regards to resident. Resident is going to have surgery for repair the femur fracture, remove old hardware that has come out, and run a rod from her knee to pelvis. Resident will be non-weight bearing post-operation and will no longer be able to walk. Record review of accident and incident reports dated 05/25/23 - 07/25/23 indicated Resident #1 had fracture incident on 07/17/23 3:30 PM. Record review Resident #1's of order revealed: Order date: 07/17/23 10:52 AM Order Summary: Xray of pelvis, Right hip, and femur one time only for right leg pain for 1 day Record review of Resident #1's Final X-Ray Report revealed: 1. Moderately displaced oblique fracture of distal diaphysis of femur of indeterminate age. 2. Dislocation of right hip is present 3. Internal fixation of right femoral neck. Record review of Resident #1's medication administration record revealed: 1.Tramadol HCI oral tablet 100 MG (give 1 tablet by mouth every 6 hours as needed for pain for 14 days) for the month of July was not administered on July 17th prior to resident being sent out to the hospital. 2. Tylenol Extra Strength Oral Tablet 500 MG (give 1 tablet by mouth every 6 hours as needed for pain) for the month of July was not administered on July 15th, 16th or 17th prior to resident being sent out to the hospital. Record review of Resident #1's hospital records revealed: Chief complaint: Right leg pain from a fall Emergency department work up included a right femur x-rays revealed a displaced, evaluated distal femoral diaphyseal fracture. Resident completed surgery on 07/18/23. Record review of Resident #2's face sheet dated 07/25/23 revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, muscle wasting, abnormal posture, lack of coordination. Record review of Resident #2's annual MDS assessment, dated 05/23/23 revealed her BIMS score was 15 indicating Resident #2's cognition was intact. Her Functional Status for activities of daily living indicated she required extensive assistance with two person assist with bed mobility, transfers, and toileting. Extensive assistance with 2 persons assist with eating, dressing, personal hygiene, locomotion on and off the unit. Always incontinent with bowel and bladder. Adequate hearing, vision, and ability to understand others. Interview on 07/25/23 at 2:57 PM with Resident#1's family member/responsible party revealed she visits almost daily at 3:00 PM. When she entered the facility on Monday, 07/17/23, the Receptionist stated there was something wrong with Resident #1. She stated on her way to Resident #1's room, LVN C followed expressing the same thing, (that Resident #1 had an injury). The family member stated when she entered the room, Resident #1 was moaning, groaning and grimacing from pain. Both Resident #1 and roommate, Resident #2, started to explain the cause of her pain, late Saturday night (07/15/23), early Sunday morning (07/16/23) about midnight, that she was reaching for the call button, fell and the Student Aide D came in and threw her back in bed. Resident #1 stated to family member she fell on her bottom and hit her head. The family member stated she pulled the covers back and it was obvious, the leg looked as if there was a fracture to her right femur. The family member stated she was upset the facility had not contacted her prior to her entering the facility. The family member stated in speaking with the Administrator he apologized and stated the facility should have contacted her immediately and he would complete an investigation. Interview on 07/25/23 at 3:22 PM with Resident #2, who was Resident #1's roommate, revealed on 07/15/23 during the 7:00 PM-7:00 AM shift she met Student Aide D. Resident #2 stated Student Aide D entered the room three times throughout the night. At 9:00 PM, when Student Aide D assisted the resident to bed for the evening and at 12:30 AM when the resident requested a brief change and to be repositioned. Resident #2 stated she heard Resident #1 requesting to have her bed lifted, which should not have been done. Resident #2 stated about 1:45 AM she was awakened by a loud noise, and she heard Resident #1 complaining and moaning. Resident #2 stated she saw Student Aide D leaving the room. According to Resident #2 she did not see Resident #1 fall or on the floor but heard a loud noise that woke her. Resident #2 stated Resident #1 liked to get up at 5:30 AM, at that time different staff were working, and she was told Student Aide D left the facility. Resident #2 stated Resident #1 complained of pain when CNA E got her out of bed and prepared her for breakfast. Interview on 07/25/23 at 4:29 PM, with CNA F revealed when she arrived to work on Sunday 07/16/23, she observed Resident #1 sitting out by the nursing station, complaining of pain, saying that her right leg was hurting. CNA F stated Resident #1 had complained of pain by tapping her right leg the whole time she was in the chair. According to CNA F she was told by aides on 200 Hall they had informed LVN B that Resident #1 was complaining about pain to her right leg. CNA F stated she was notified Resident #1 remained in bed throughout the night and breakfast due to her complaint of pain. CNA F stated she entered Resident #1's room to complete care around 10:00 AM, during that time she observed Resident #1's leg was bent and thought it was weird. CNA F stated she rolled Resident #1 to her right side, when she rolled her on her left side CNA F stated she noticed Resident #1's leg just fell to the side. CNA F stated at this point she went to alert LVN C for an assessment. Interview on 07/25/23 at 4:55 PM with the DON revealed she was alerted during morning clinical meeting that Resident #1 was complaining of pain and an x-ray had been ordered. According to the DON Resident #1 stated she fell out of bed and the night worker helped her back to bed. The DON stated Student Aide D was reassigned to the 200 Hall with Resident #1 which was whom Resident #1 was referring to the night worker. The DON stated after the fall Student Aide D did not notify anyone of Resident #1's fall or complaint of pain and left mid shift and had not returned to the facility. The DON stated LVN C was alerted of Resident #1's pain and injury, contacted the physician, followed orders for x-ray. DON stated following findings of the x-ray Resident #1 was transferred to the hospital on 07/17/23 with findings of fractured femur which resulted in surgery. The DON stated the charge nurse was responsible for assessing Resident #1 to identify where the pain was coming from and why resident was having a change of condition. According to the DON, it was facility policy for the charge nurse to contact the physician immediately when residents are complaining of pain or have a change of condition. The DON stated the charge nurse was also responsible for alerting family or responsible party and herself along with the Administrator as the abuse coordinator when residents are exhibiting a change of condition or have been involved in an injury. The DON stated it is not practice to neglect residents by not providing proper care. According to the DON it was discussed with the Administrator whether to investigate and report the incident during the morning clinical meeting on 07/17/23. The DON stated we were all on the same page to complete an investigation and report to the state agency. DON stated the Administrator was aware of the incident and began the investigation on how Resident #1 resulted in having a fracture. The DON stated she attempted to contact Student Aide D, however had not been successful. The DON stated the ball was left with the Administrator, he decided not to report the incident. Interview on 07/26/23 at 9:48 AM, with CNA E revealed she worked on the 7:00 PM-7:00 AM overnight shift on 07/15/23. CNA E stated Student Aide D abruptly left the facility about 2:17 AM. CNA E stated after Student Aide D left the facility, she did a round to Resident #1's room and observed her in bed sitting straight up sleeping, she left the room to prepare for a brief change, upon returning Resident #1 was making sounds of moaning and groaning which she thought was her normal communication to leave her alone. CNA E stated when she returned at 5:30 AM to get her up for the day she yelled out differently, her cry was deeper than her normal communication. CNA E stated her roommate commented that sound was different and that she thought Resident #1 was in pain. CNA E stated when she pushed Resident #1 to the Hall Resident #1 grabbed her shirt and patted her knee indicating she was in pain. CNA E stated she thought Resident #1 just wanted to fix her pant leg which needed to be pulled down, CNA E then lifted Resident #1's right leg and she screamed, when she stated when she lowered Resident #1's leg she screamed again patting her right knee. CNA E stated she then told LVN A that Resident #1 was in pain and may need Tylenol. CNA E stated the next night when she worked again, Resident #1 was already in the bed, sleeping. CNA E stated when she worked the next night, Resident #1 slept the whole night and did not wet the whole night. She stated when she attempted to wake Resident #1 up the next morning, the resident grabbed the covers and requested water. CNA E stated Resident #1 refused to get up for the day. CNA E stated she then alerted LVN A Resident #1 had not had care all night, refused to get up and her request for lots of water. Interview on 07/26/23 at 12:01 PM with LVN C revealed she worked the 7:00 AM-7:00 PM shift on 07/17/23, after breakfast she was notified by CNA F that something was wrong with Resident#1's leg. LVN C stated Resident #1's right leg was usually 90% straight and left leg bent, but at this time she was in a butterfly position, with both heels touching her brief. LVN C stated she immediately contacted physician via electronic communication app, video call within 2 minutes, and received an order for x-ray and Tramadol for pain. LVN C stated x-ray was completed within 4 hours indicating femur fracture of the right leg. LVN C stated at this time she prepared for Resident #1 to be sent out to the hospital. LVN C stated during her assessment Resident #1's leg was swollen, warm to touch, and she was guarding with palpations. According to LVN C when she asked Resident #1 and Resident #2 how the injury took place neither of them said anything until Resident #1's family member entered the room, it was not until then she heard Resident #1 say she fell out the bed. LVN C stated after the findings of the x-ray she was notified Resident #1 was not eating, had refused all 3 previous meals, not drinking, crying, and saying her knee was hurting. LVN C stated Resident #1 had not had any pain medications prior or while waiting to transfer to the hospital. LVN C stated Resident #1 did not exit the facility for the hospital until 5:30 PM. According to LVN C not contacting the physician immediately over the weekend placed Resident #1 at risk for further damage to her leg, infection, becoming septic and prolonged time in pain. LVN C stated she could not understand why Resident #1 was not already sent out prior to her shift. LVN C stated I followed protocol however, knowing what she knows now she should have used her nursing judgement and called 911 to send Resident #1 to the hospital immediately after observation and assessment of her leg. Interview on 07/26/23 at 12:59 PM, with CNA T revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA T stated she walked past Resident #1 as she was out in the hallway. CNA T stated Resident #1 was stopping every and anyone trying to get their attention. CNA T stated Resident #1 was moaning, she stated she thought the resident, Help me. According to CNA T, she did not contact the nurse to notify him that Resident #1 was complaining of pain. CNA T stated not notifying the nurse Resident #1 was expressing pain may have caused her prolonged pain. Interview on 07/26/23 at 1:13 PM with CNA G revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, CNA G stated when she arrived Resident #1 was already sitting in her spot near the nursing station. CNA G stated Resident #1 did tell her about her knee pain. CNA G stated when LVN B arrived she notified him of her pain. CNA G stated, during breakfast I was pushing Resident #1 down to the dining room and [Student Aide H] was telling me that Resident #1's leg was swinging, which I could not see because I was behind her and trying to get residents to breakfast. CNA G stated after she left Resident #1 in the dining room, the resident wheeled herself back to the nurses' station CNA G stated Resident #1 refused breakfast, lunch, and dinner on this day. CNA G stated Resident #1 continued pointing to her knee saying it was hurting. CNA G stated she and Student Aide H discussed amongst themselves that something was wrong with Resident #1's leg and that they both had told LVN B about it more than once. Interview on 07/26/23 at 2:03 PM with Student Aide H revealed she worked the morning shift 7:00 AM-7:00 PM on 07/16/23, Student Aide H stated when she arrived to work Resident #1 was in her usual spot near the nursing station. Student Aide H stated she saw CNA G pushing Resident #1 down the Hall and noticed her leg was swinging back and forth, she was crying, complaining of pain in her leg that was swinging. Student Aide H stated she expressed to LVN B what she observed. Student Aide H stated she later put Resident #1 down for bed, completed care, and when she rolled her on her right side she screamed so loud. Student Aide H stated she then went to alert LVN B that she was screaming in pain. According to Student Aide H, when she returned to put Resident #2 down for bed, she asked Resident #1 what happened, Resident #1 would agree to having a fall after she was asked a series of questions. Student Aide H stated she then returned to LVN B and shared that Resident #1 indicated she had a fall. Interview on 07/16/23 at 2:10 PM, with LVN B revealed he worked the morning shift 7:00 AM-7:00 PM on 07/16/23. He stated Resident #1 was already up in her wheelchair and near the nursing station when he arrived. LVN B stated Resident #1 appeared normal to him and he did not recognize anything out of the normal with her. LVN B stated she did return from the dining room refusing breakfast stating her knee was hurting. LVN B stated he did not observe any bruising or redness after being told by staff Resident #1 was in pain. LVN B stated he did not administer a full assessment for pain and stated he did not administer any pain medication for Resident #1's pain. LVN B stated he could not recall doing anything to assist Resident #1's pain. LVN B also stated he did not follow up with her throughout the day to see how she was feeling or to see if he needed to alert the physician that she was indicating pain, change of condition, or her refusal to eat. When LVN B was asked about risk to Resident #1's fractured femur not being assessed in a timely manner he apologized for not being much help. Interview on 08/01/23 at 2:50 PM with the Administrator revealed he was alerted to Resident #1's right femur fracture after the results of her x-ray. The Administrator stated after interviews with staff, Resident #2, and family member it was confirmed that Resident #1 had a fall. The Administrator stated although Resident #1's cognitive status was zero, Resident #1 was able to accurately explain what happened. Resident #1 was able to recall and state that she had a fall. According to the Administrator, he did not complete an investigation and he then decided the incident was not reportable to state agency based on his interview with Resident #1 and her ability to recount the incident. The Administrator stated he was not able to interview Student Aide D because she had avoided his phone calls and had not returned to the facility. Record review of facility's current Abuse/Neglect policy, dated 03/29/18, reflected: The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged neglect and situations that may constitute neglect to any resident in the facility. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse will be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from neglect must report this to the DON, administrator, stated and/or adult protective services. Facility employees must report all allegations of abuse, neglect, mistreatment of residents, exploitation, injury of unknown source to the facility administrator. The facility administrator or designee will report to Health and Human Service Commission all incidents that meet the criteria, if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. On 07/26/23 at 5:38 PM the DON was notified an Immediate Jeopardy had been identified. The facility's Plan of Removal was accepted on 07/27/23 at 1:18 PM. The Plan of Removal reflected the following: o As of 7/26/23 [Resident #1] was assessed for pain. Orders received as of 7/26/23 for scheduled and PRN pain meds. o All residents in the facility were assessed for any increased pain by the DON, ADON and Charge Nurses as of 7/26/23. No additional issues were found. Education: All charge nurses were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced by 7/26/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. o Implementation of physician orders immediately upon receipt including the administration of pain medications. o A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. All nursing staff were in-serviced on 7/26/23 by the Compliance Nurse/DON/ADON. All staff not in-serviced on 7/26/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. o Notify the charge nurse immediately if a resident is found on the floor. The resident will not be moved until assessed by a nurse. o Notification of change of condition to the physician immediately including falls, injuries, increased pain, decreased mobility, or a change in eating habits. o Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching Medical Director was notified by the DON on 7/26/23 at 8:18 PM about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 7/27/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 7/26/2023 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 7/26/23 and will continue x 4 weeks. Interview on 07/27/23 at 2:14 PM with ADON revealed in-services had been started to identify change of condition, charge nurse to complete full assessments, understanding signs and symptoms of pain both verbal and nonverbal, contacting the physician and implementing physician orders immediately. The ADON stated she completed in-services with aides regarding neglect and not moving resident after a fall, contacting the charge nurse when resident had a change in condition or expressed pain. The ADON stated during morning shift with LVN A on 07/16/23 was the beginning of Resident #1 expressing pain. The ADON stated LVN B was notified by staff that Resident #1 expressed pain and he should have done a complete assessment for pain, administered pain medication and communicated the history of the day with the oncoming nurse for the next shift. The ADON stated when LVN A returned to the facility on [DATE] at 7:00 PM Resident #1 was in bed, and nobody notified LVN A that Resident #1 was in pain. The ADON stated if LVN B communicated the history of the day, LVN A could have completed proper care and follow up. The ADON stated LVN B not communicating that Resident #1 expressed pain throughout the day put her at risk of not receiving proper pain management and treatment. The ADON stated it was her expectation to address resident needs, follow up with the doctor, DON, family and depending on the situation the Administrator. Further monitoring on 07/27/23 during interviews consisting of both day and night shifts revealed the following: Interviews on 07/27/23 from 2:15 PM through 07/27/23 4:30 PM with the DON, ADON, LVN A, LVN B, LVN C, CNA E, CNA F, CNA G, Student Aide H, LVN I, LVN J, LVN K, LVN L, LVN M, Student Aide N, CNA O, CNA P, Student Aide Q, CNA R, LVN S who worked the shifts of 7:00 AM-7:00 PM, 7:00 PM-7:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of residents complaining of pain, what to do and who to contact. The nursing staff expressed understanding of the importance of completing assessments and identify the source of pain and how that plays in part to resident safety. During observations on 07/27/23 between 8:00 AM-5:00 PM revealed staff assessing residents who were exhibiting pain, residents who requested and were administered pain medications. Staff were observed engaging with residents, preforming full assessments, and interviewing residents to determine the source of pain, contacting the physician, documenting, and notifying resident's responsible party of change of condition. Record review of the facility plan of correction monitoring tool form undated titled Actual/Alleged Abuse Monitoring Ask 8-10 staff members per week, situational questions related to the neglectful action document any corrective actions on the back of the form .indicated log started on 07/24/23 with slots for date, time, staff name, responded correctly, who and how soon would they report suspected abuse? Ask 5 residents how staff is treating them. Document date/time, resident name, if there was any negative response. Document any corrective action if needed on the back of this form. During incident/event review in standup, was there any evidence of any potential neglect. While the IJ was removed on 07/27/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, completing full assessments and identifying source for pain and resident neglect and following facility policy.

Based on observation, record review and interview the facility failed to ensure sufficient nursing staff to provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 6 residents reviewed for care. The facility failed to have sufficient staff to adequately supervise residents on the facility's secured unit during an overnight shift. Resident #1 had a fall on 05/07/23 that resulted in her fracturing her right clavicle (collar bone), and a nurse was not readily available to assess her. Resident #1 had to wait approximately 15 minutes before being assessed. This failure could affect all residents in the facility by increasing the risk of injury Findings included: Review of Resident #1's Admission Record dated 05/18/23 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (decline in memory and cognition), Type 2 diabetes, history of falling, abnormal gait, and muscle weakness. Review of Resident #1's quarterly MDS Assessment, dated 05/06/23, revealed Resident #1 had a BIMS of 03 indicating severe cognitive impairment. Her functional status scores indicated she needed supervision and setup help only with all ADLs, including bed mobility, transfer, walking in room and corridor, locomotion on and off unit. Resident #1 used a walker as a mobility device. Review of Resident #1's significant change in status MDS Assessment, dated 05/09/23, revealed Resident #1 had a BIMS of 03 indicating severe cognitive impairment. Her functional status scores indicated she needed supervision and one-person physical assist with walking in room and in corridor. Resident #1 needed supervision and setup assistance with locomotion on and off unit, and limited assistance and one-person assist with bed mobility and transfer. Resident #1 used a walker as a mobility device. Review of Resident #1's care plan, dated 05/10/23, revealed she had and ADL self-care deficit and needed supervision as needed for bed mobility, toileting, walking, and transfer. Record review of incident report completed by RN B, dated 05/07/23, revealed in part the following: Incident description: Nursing description-Pt was found sitting on the floor in her room, by the door this morning. Pt has a large area that is swollen, on her right clavicle/neck area that is painful to palpation, and she has a skin tear to her right elbow. Resident description-Resident states that she does not remember how she came to be sitting on the floor. Immediate Action Taken: Description- This nurse and CNA helped pt. to stand up and sit on the bed, vital signs taken, assessed pt. for any injuries or pain, provider on Spruce was notified of pt status, pt is resting quietly, alert but confused, no change in mental status or distress noted at this time. Mental Status: -Impulsive -Forgetful -Oriented to person -Lack of safety awareness Level of Pain-9 on scale of 1-10 Predisposing Environmental Factors: -Poor lighting Predisposing Physiological Factors: -Confused -Incontinent -Gait imbalance -Impaired memory -Weakness/fainted Review of the facility's Provider Investigation Report, dated 05/15/23, reflected the following: .Investigation Summary & Facility Response [Resident #1] was first observed on the floor by aide [Hospitality Aide]. During her last round on her shift she reported seeing [Resident #1] awake and sitting on the side of her bed. As [Resident #1] can use the toilet independently, [Hospitality Aide] continued down the hall to get another resident up for the day, which she said took about 30 minutes. After assisting the other resident [Hospitality Aide] said she was coming back up the hall and observed [Resident #1] sitting on the floor outside her bathroom door. [Hospitality Aide] said that she looked for the charge nurse, [LVN D], LVN, but did not find her. She said that she went to the secure doors for the unit, opened them and asked the aide at the 300-nursing station where [LVN D] was. [CNA E], the aide by the desk, responded that she did not know where [LVN D] was at that time. [Hospitality Aide] did not ask [CNA E] for assistance with [Resident #1]. [LVN D]was on the 300-hall doing her morning blood sugar checks and morning meds. The best timeline we have constructed through interviews with the staff is that [Resident #1] was sitting on the floor from sometime before 6:30am to about 7:15am when the day shift arrived and received a report that [Resident #1] was on the floor. [Hospitality Aide] was suspended pending the outcome of our investigation due to her inaction in getting assistance for [Resident #1] from the charge nurse or another aide. While [Hospitality Aide] checked on [Resident #1] repeatedly, she did not stay with her, and she did not exhaust all her resources to get assistance. Our investigation did not determine that [Hospitality Aide]'s inaction caused the physical injury to [Resident #1], but her inaction showed neglect in not doing more in a timely manner to address the situation. Upon assessment by the charge nurse, [RN B], [Resident #1] was found to be alert, but confused, at her normal baseline without increased confusion or decrease in mental status. The charge nurse and aide, [CNA A], CNA, got [Resident #1] up and returned her to her bed. [CNA A] cleaned [Resident #1] and put clean clothing on her. [RN B] tended to the skin tear on [Resident #1]'s right elbow. As a result of the assessment, the physician ordered [Resident #1] to be sent to .hospital for further evaluation and treatment. It was at the hospital that the x-ray and CT scans were conducted. The radiology results have been attached to this report. [Resident #1] returned from [hospital] the same day she was sent out, Sunday 5/7/23, with a sling on her right arm. Due to her Alzheimer's, she continues to remove the sling each time the staff place it on her. She does not understand why she should wear it and takes it off. When asked by the staff what had happened, [Resident #1]'s response was that she was going to the bathroom. When interviewed the next day, [Resident #1]'s answer was nonsensical. [Resident #1] ambulates independently, though often forgets to use her walker. [Resident #1] has not had a fall since being admitted to Longmeadow Healthcare until this incident. She walks a lot each day throughout the SecureCare unit. In-services on Abuse & Neglect and Fall Prevention were conducted with staff. Investigation Findings The investigation confirmed that [Resident #1] did sustain a fracture to her right clavicle as the result of an unwitnessed fall in her room. Observation on the secured unit and interview with Resident #1 on 05/17/23 at 11:14 AM, was unsuccessful due to her cognitive deficits. Resident #1 was unable to state how she fell and how long it took staff to help her. Resident #1's right clavicle was swollen. There were no other visible injuries, marks, or bruises. Resident #1's bed was in the lowest position and there was a fall mat on the floor next to the bed. There were no safety hazards or clutter observed in the room. Interview on 05/17/23 at 11:52 AM with CNA A revealed she had worked at the facility for about a year. She stated she worked weekdays 7:00 AM-7:00 PM on the secured unit. CNA A stated she worked on 05/07/23, the day Resident #1 had a fall. CNA A stated when she arrived at work at approximately 7:00 AM she found Hospitality Aide C, who worked the overnight shift and found Resident #1 on the floor, sitting at the nurse's station on the 300 hall, outside of the secured unit. CNA A stated she entered the secured unit and was immediately informed by RN B, who had also just made it onto the unit, that Resident #1 had fallen and was still on the floor. CNA A stated they went to Resident #1's room to assist her. CNA A stated Hospitality Aide C stated she was unable to move Resident #1 alone and was unable to find the nurse to assist her. CNA A stated she felt there was enough staff working on the secured unit during the day shift to properly supervise and care for all residents. Interview on 05/17/23 at 12:35 PM was conducted with the Administrator, ADON and Interim DON. The Interim DON stated it was reported that Resident #1 had a fall on 05/07/23 at approximately 6:45 AM, that resulted in a fractured clavicle bone. The ADON stated Resident #1 was diagnosed as having a history of falling but had never had a documented fall at the facility, although her gait was unsteady. The Interim DON stated that Hospitality Aide C was scheduled to work on the secured unit with LVN D, who was working between two halls, overnight on 05/06/23-05/07/23. The Interim DON stated it was reported that Hospitality Aide C was seen by oncoming morning shift staff sitting at a nurse's station outside of the secured unit while Resident #1 was still on the floor. The Administrator stated that during the facility's investigation, it was determined that Hospitality Aide C did not exhaust all of her resources to get immediate help for Resident #1 by not using a phone to call other staff, and she had been suspended pending the investigation. He stated the decision to terminate Hospitality Aide C due to neglect had since been made. He stated that LVN D was also pending termination for an unrelated reason. Interview on 05/17/23 at 1:38 PM with RN B revealed she had worked at the facility for about 2 months. She stated she worked 7 AM-7 PM on the secured unit. RN B stated when she arrived at work on the morning of 05/07/23, she was met by Hospitality Aide C, who was sitting at a nurse's station outside of the secured unit. She stated she was informed by her that Resident #1 had fallen and was still on the floor because she was unable to move her alone and LVN D was not around. RN B stated LVN D was working two halls, which was typical for the overnight shift, and was on a different hall checking blood sugars when she arrived at approximately 7:00 AM. RN B stated she and CNA A immediately went to Resident #1's room to assist her. RN B stated she assessed Resident #1 and found that her clavicle looked swollen. RN B stated that Resident #1 was upset and in pain. RN B stated the physician was notified and Resident #1 was sent out to the hospital. Attempted interview on 05/17/23 at 1:48 PM with LVD D was unsuccessful due to no response to phone call. Interview on 05/17/23 at 2:20 PM with Hospitality Aide C revealed she had worked at the facility for five months. She stated she worked 7:00 PM-7:00 AM on the 400 hall (secured unit), and worked on 05/06/23-05/07/23 when the incident with Resident #1 occurred. Hospitality Aide C stated she started doing her end of shift rounds at approximately 5:30 AM and found Resident #1 sitting on her bed. She stated she went back down the hall around 6:45 AM and found Resident #1 on the floor of her room. Hospitality Aide C states she did not hear Resident #1 yell for help when she fell . Hospitality Aide C stated Resident #1 informed her that she had fallen hard and did not want Hospitality Aide C to move her alone. Hospitality Aide C stated she was alone on the secured unit and had not seen LVN D since 10:00 PM. She stated that was her first time working overnight with LVN D and that she did not have this problem with other nurses. Hospitality Aide C stated she went to the end of the hall to open the door and told CNA E to find LVN D because she needed help. She stated she did not have her personal cell phone to call for help and had not been trained to use the unit phone to page for help over the intercom. Hospitality Aide C stated that by the time she went to tell Resident #1 that help was coming, there was another resident yelling for help that she had to assist. Hospitality Aide C stated there was a lot going on with the residents on the secured unit and she did not have any help. She stated after she assisted the other resident and was making her way back to Resident #1, CNA A and RN B were coming on the unit to start their shift. Hospitality Aide C stated she informed them of what had happened with Resident #1, and they went to assist her. Hospitality Aide C denied sitting at the nurses' station outside of the secured unit and stated that she remained on the secured unit the entire time. She denied that LVN D ever came to assist her. Hospitality Aide C stated the overnight shift was always staffed with one aide on the secured unit and they needed more staff due to the behaviors and needs of residents on that unit. She stated she had reported her concerns about staffing to management, but nothing changed. Hospitality Aide C stated she did not normally work with LVN D and had never experienced not having a nurse available until that day, which made it even harder on her. Interview on 05/17/23 at 4:40 PM with CNA E revealed she had worked at the facility for 3 months. She stated she worked 7 PM-7 AM on the 300 hall, which was directly across from the secured unit, and worked on 05/06/23-05/07/23 when the incident with Resident #1 occurred. CNA E stated she was unaware that Resident #1 had fallen until after she had left the facility when the Interim DON called her to get a statement. CNA E denied that Hospitality Aide C ever opened the doors to tell her she needed help on the secured unit because she would have helped her. CNA E stated that at the time it was reported that Resident #1 fell , she would have been busy getting residents on her hall dressed for the day and not sitting at the nurse's station. However, CNA E stated she would have heard someone yelling for help had Hospitality Aide C done so. CNA E stated LVN D was also assisting residents on the 300 hall at the time and would have also been available to help Hospitality Aide C. CNA E stated there was always one aide scheduled to work on the secured unit overnight, and she felt that was not sufficient to properly care for the residents. Interview on 05/18/23 at 1:40 PM with the Administrator revealed the facility's current resident to staff ratio was sufficient and was adjusted based on acuity level. He stated that one aide and one nurse floating between two halls was sufficient on the secured unit overnight with the current census of 22 residents. The Administrator stated if the secured unit was at its maximum capacity of 28 residents, they would consider adding an additional aide. He stated that during the overnight shift, although the nurse worked between two units, the expectation was for the nurse to be available to assist the aides when needed and make rounds at least every 2 hours. He stated the overnight shift was staffed lower due to the decreased ADL care requirements, such as showers and feedings. The Administrator stated the risk of not having sufficient staff available could be a delay in services which could lead to harm and injuries to the residents. Interview on 05/24/23 at 6:34 AM with LVN F revealed she had worked at the facility for 3 years. She stated she worked weekdays, overnight 7:00 PM-7:00 AM, on different halls. LVN F stated she worked on the 300 hall and 400 hall (secured unit) on this date. She stated she was the only nurse for both halls and this was common for the overnight shift. LVN F stated she felt that one nurse was sufficient for the nurse duties; however, two aides were needed for the secured unit, but it was usually staffed with one aide. LVN F stated that she remained available between both halls as they were across from each other. She stated she sat at the nurses' station on the 300 hall, which was in a central location and had a call light board that monitored lights for both halls. LVN F stated the aide assigned to the 300 hall would also do rounds and assist the aide on the secured unit when needed. Interview on 05/24/23 at 9:45 AM was conducted with the ADON revealed that Hospitality Aide C was hired under the COVID-19 waiver and had received the same trainings as all CNAs, and was prepared to test for certification; however, testing had not been scheduled. The ADON stated that Hospitality Aide C worked with a [NAME] for approximately 4 months and had to demonstrate acquired skills before being able to work alone. She stated Hospitality Aide C had only worked alone for about a month. The ADON stated she was confident in Hospitality Aide C's skills and abilities; however, she did sometimes show a lack in initiative and motivation. Record review of the facility's census, dated 05/07/23, revealed there were 18 residents on the secured unit on that date. Record review of the facility's staffing schedule for 7:00 AM-7:00 PM, dated 05/07/23, revealed there was one CNA scheduled to work the secured unit (Hall 400) and one LVN was scheduled to work between two halls (300 and 400 hall). Record review of an in-service titled Abuse & Neglect, dated 05/09/23, revealed staff were in-serviced on abuse/neglect. Record review of an in-service titled Fall Prevention, dated 05/09/23, revealed staff were in-serviced on fall prevention. Record review of facility's monitoring form revealed that alleged/actual abuse monitoring was conducted at the facility on 05/08/23-05/12/23. Record review of an in-service titled Nursing Dept. staff meeting, dated 05/16/23, revealed staff were informed to not attempt to move a resident who had fallen and to notify a nurse as soon as possible. The in-service also informed staff to never leave a resident who had fallen unattended and to stay by their side until a nurse arrived and could assess them. Record review of an in-service titled What to do when you have an emergency, dated 05/17/23, and as a result of the investigation, revealed staff were informed to immediately find assistance, use the unit phone to page overhead for assistance, or call 911 if no one responded. Record review of an in-service titled Rounding on your assigned hall, dated 05/17/23, revealed staff were informed to never leave the secured unit unattended. Review of Hospitality Aide C's training records, dated 12/21/22-02/23/23, revealed she had been trained on the following: - General Topics (included safety/emergency procedures) - Basic Nursing Skills (included recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor) - Personal Care Skills - Mental Health and Social Service Needs - Care of Cognitively Impaired Residents - Basic Restorative Services - Residents' Rights On 05/18/23 at 2:00 PM, a facility staffing policy was requested from the Administrator, and he stated the facility did not have one.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for care provided. The facility failed to assess and document Resident #1's injuring her left leg on 12/13/22, after having an emergency transfer during a tornado warning. On 12/16/22 (3 days later) it was noticed Resident #1 had bruising and swelling to her left foot and an X-ray was order and indicated a tibia (shin bone) /fibula (calf bone) fracture. This failure could place residents at risk for a delay in treatment or diagnosis of new symptoms, a decline in the resident's condition, and the need for hospitalization . Findings included: Review of Resident #1's facesheet, dated 01/05/23, reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke) due to unspecified occlusion (blocking) or stenosis (narrowing) of unspecified cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (paralysis to the left side), contracture of muscle, unspecified joint (muscle/joints tighten), other reduced mobility, muscle wasting and atrophy, muscle weakness, and swan-neck deformity of left finger/s and right fingers. Review of Resident #1's MDS Quarterly Assessment, dated 11/17/22, reflected Resident #1 was cognitively intact with a BIMs score of 15. The MDS reflected Resident #1 needed the extensive assistance of two or more people for transfers from the bed, chair, wheelchair, and standing position, and she used a wheelchair for mobility. Review of Resident #1's Care Plan, dated 12/17/22, reflected: Focus: Resident #1 has left-sided hemiparesis r/t CVA. Goal: Resident #1 will remain free of complications or discomfort related to hemiparesis through review date. Interventions: Give medications as ordered. Obtain and observed lab/diagnostic work as ordered. Pain management as needed. - Focus: Resident #1 has limited physical mobility r/t Weakness, CVA. Goal: Resident #1 will demonstrate the appropriate use of wheelchair to increase mobility through the review date. Interventions: Resident #1 requires (extensive assistance) by (1) staff for locomotion using (wheelchair). - Focus: Resident has potential for pain r/t disease process. Goal: Resident #1 will not have an interruption in normal activities due to pain through the review date. Interventions: Administer Tylenol #3 and tramadol prior to treatments and therapy, as ordered. Anticipate the resident's need for pain relief and respond immediately to any complaint pain. Evaluate the effectiveness of pain interventions every shift and PRN. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident past-experience of pain. Observe/record/report to Nurse resident complaints of pain or request for pain treatment. - Focus: Alteration in musculoskeletal status r/t fracture of the left tibia. Goal: Resident #1 injury will heal and progress without complications through the review date. Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all request for assistance. Give analgesics as ordered by the physician. Monitor skin at top and bottom of cast for breakdown and check temperature of toes and monitor for edema each shift. Review of Resident #1's Injury Nurses' Note 12 hr , effective date 12/14/22, assessment completed by the ADON on 12/16/22, reflected: .Pain A.) Does the resident appear or state to be in pain: Yes B.) Is the resident verbal or non-verbal: Verbal C.) Rate the resident's pain: 3.3, D.) Location of resident pain: Left lateral [outside part] leg E.) Resident description of pain: Dull. Review of Resident #1's Injury Nurses' Note 12 hr, effective date 12/15/22, assessment completed by the ADON, reflected: .Section 4. Injury .C.) Bruise .Section 6. Bruise A.) Location of injury: left lateral leg, B.) Size (cm) of bruise: 3.0 x 3.0, Description C.) Check all that apply - 2. Blue/Purple .Section 11. ADL: A. Has the resident had a decline in ADLs as a result of the injury: No. Section 12: Pain: A.) Does the resident appear or state to be in pain: Yes B.) Is the resident verbal or non-verbal: Verbal C.) Rate the resident's pain: 3.3 D.) Location of resident pain: Left lateral leg, E.) Resident description of pain: Dull. .Section 16: Notification: Were there any changes that required physician notification: No Review of Resident #1's Weekly Skin Assessment, dated 12/16/22, reflected: Section Weekly Skin Assessment: 1) Skin Color: Normal, 2) Temperature of skin: Warm, 3) a.) Bruise, aa.) Note location, measurement of any bruise: Left lateral leg 20 x 11 cm. Review of Resident #1's Final X-Ray Report, dated 12/16/22, reflected: Examination: Left Knee, Clinical Indication: Pain, Findings: Age-indeterminate (not known), transverse, non-displaced fracture at proximal tibial metaphysis (lower part of the shin bone) is noted. Age-indeterminate (not known), minimally displaced fracture at head of fibula (calf bone) is noted. There is no other acute fracture or dislocation. Moderate osteoarthritic (arthritis) predominantly involving the knee. Review of Resident #1's Emergency Visit, dated 12/16/22, reflected: [Resident #1] presents with leg injury, patient left leg got caught in a wheelchair on Tuesday and the staff twisted her leg to get it out. X-ray shows fracture [Resident #1's] x-ray indicated the presence of a proximal tibia/fibula fracture of unknown age Review: Musculoskeletal: Positive for arthralgias (pain in a joint) .Physical Exam: Musculoskeletal: General: Swelling and tenderness present. No edema (swelling). Normal range of motion. Left lower leg: Swelling and tenderness present Final Result: Narrative: Diffuse bone demineralization (osteoporosis) is seen. There is a proximal tibial metaphyseal fracture with mild valgus angulation. No significant displacement. Mild impaction is seen. Severe tricompartmental degenerative disease (knee arthritis) is seen with small joint effusion. Suboptimal imaging positioning but there is a suspected proximal fibular (calf bone) fracture as well. Review of Resident #1's undated Incident Statement reflected: On Tuesday Nurses got me up and tried to put me in the chair and my leg went under me. That is all I remember. My leg was not that bad and was not hurting then later when I got into bed, I had some pain. The nurse ADON told me I had a bruise later and that's it. Review of Resident #1's TAR for December 2022 revealed on 12/13/22 Resident #1's pain level was an 8 and she was given Tramadol. On 12/14/22, no pain level was recorded for the resident. On 12/15/22, the resident's pain level was recorded as 0, and she received Tylenol Tablet 325 mg. On 12/16/22, the resident's pain level was 5, and she received Tylenol Tablet 325 mg. Observation and interview on 01/05/23 at 12:22 PM of Resident #1 lying in bed with a blue cast on her left leg. Resident #1 stated she could not recall the date, but during a tornado warning she was being transferred from her bed to her wheelchair by three staff. She stated she was normally transferred using a Hoyer lift, but that day the Hoyer lift was being used by another resident and staff were rushing so she was transferred by ADON and LVN B. Resident #1 could not recall who the third nurse was that assisted. She stated the nurses used the bed sheets to transfer her. Resident #1 stated she had one nurse at her back, another nurse holding her bottom, and another nurse holding her legs. Resident #1 stated when she was placed her in the wheelchair her left leg got caught underneath the wheelchair, and she notified the nurse. Resident #1 stated the nurse repositioned her left leg, and she then was moved in her wheelchair outside the room with the other residents. Resident #1 stated when she was placed back in bed by CNA E and another staff, whose name she did not recall, she informed CNA E and the other staff that her leg was hurting. Resident #1 stated she also told other staff, but she could not recall their names. She stated she also notified her family. Resident #1 stated she could not recall the date when she notified her family, but it was before she went to the hospital. Resident #1 stated the facility ordered x-rays and sent her to the hospital three days after the tornado warning. Resident #1 stated she was in pain; however, she was always battling pain due to her contractures. Interview on 01/05/23 at 12:54 PM with the ADON revealed on 12/13/22 the city was under a tornado warning, and they were instructed to get all the residents in the hallway. The ADON stated Resident #1 was a Hoyer lift transfer; however, the Hoyer machine was being used on another resident at the time. She stated Resident #1 did not want to wait and was yelling at her asking her to get her out of the room immediately, so she made the decision to transfer Resident #1 by using bedsheets. The ADON stated she asked LVN C to assist with the transfer, the ADON stated she could not recall who the third staff was who assisted them. The ADON stated the three of them transferred Resident #1. The ADON stated once the transfer with Resident #1 from the bed to the wheelchair was completed, they heard Resident #1 say my leg at which time the ADON readjusted Resident #1's left leg right away. The ADON denied hearing any pop or the resident complain of pain. The ADON stated she was not sure how Resident #1's left leg got caught underneath the wheelchair. She stated for the rest of the day Resident #1 was by the nurses' station hanging out and Resident #1 never complained of pain. Interview on 01/05/23 at 1:07 PM with CNA A revealed she came in to work after the tornado warning was over. CNA A stated she transferred Resident #1 back to bed with the assistance of CNA B. CNA A stated they used a Hoyer lift to transfer Resident #1 from the wheelchair to her bed. She stated when they placed Resident #1 back to bed Resident #1 complained of pain to her left leg. CNA A stated Resident #1 informed her that earlier that morning, during her transfer from her bed to her wheelchair she got hurt. CNA A stated earlier the same day before transferring Resident #1 back to her bed, Resident #1 was at the nurses' station where she observed another resident bump into Resident #1 left leg. CNA A stated Resident #1 yelled out in pain, and she asked the resident to back off her leg. CNA A stated she did not observe any bruising on the resident's left leg. CNA A stated she notified LVN C about Resident #1 having pain in her left leg on 12/13/22. CNA A stated the only other time Resident #1 complained of pain was when Resident #1 was placed in her bed. Interview on 01/05/23 at 1:34 PM with CNA B revealed she assisted CNA A with transferring Resident #1 back to bed around 5:00 PM. CNA B stated they used a Hoyer lift to transfer Resident #1. When they placed Resident #1 back in bed, Resident #1 complained of pain to the left leg. CNA B stated she assumed Resident #1 had a cramp to the left leg since she is always in pain. However, Resident #1 told them that earlier that morning during the tornado warning she was transferred to the wheelchair and got hurt. CNA B stated they notified LVN C of resident being in pain on 12/13/22. Interview on 01/05/23 at 1:45 PM with LVN C revealed she worked the day of the tornado warning; however, she had arrived at the facility after the tornado warning was done. LVN C stated she was the nurse for Resident #1 that day and not once was she informed that Resident #1 was in pain. LVN C stated Resident #1 never complained of pain to her. LVN C stated Resident #1 is verbal and can notify them if she is having any pain. LVN C stated the only time she observed a concern with Resident #1 was on 12/16 when Resident #1 was sent to the hospital. Interview on 01/05/23 at 2:45 PM with CNA D revealed she worked with Resident #1 on 12/14/22. She stated when she provided Resident #1 with her ADL's Resident #1 complained of pain to her left leg. She stated she notified the nurse on 12/14/22; however, due to her being employed through an agency she could not recall the name of the nurse that she informed, she was not familiar with staff names. CNA D stated she did not observe any bruising to Resident #1 left leg on 12/14/22. Interview on 01/05/23 at 3:04 PM with LVN E by phone revealed she worked with Resident #1 the day of the tornado warning. LVN E stated she helped the ADON and another staff transfer Resident #1 from her bed to her wheelchair. LVN E stated the Hoyer lift was being used on another resident and Resident #1 was getting upset and did not want to wait for the Hoyer lift. She stated Resident #1 wanted to get out of the room. LVN E stated when they set Resident #1 down in her wheelchair, Resident #1 stated her leg was stuck. She stated the ADON got down and adjusted her left leg. LVN E stated Resident #1 did not complain of any pain after transferred or the entire day when she was at the nurses' station. LVN E stated Resident #1 is verbal and can notify them if she is having any pain. Interview on 01/05/23 at 3:14 PM with Resident #1 family member revealed Resident #1 had contacted her via phone to notify her that she was in pain and no one was helping her. Family member could not recall which day Resident #1 had called her. She stated she contacted the facility immediately about Resident #1 being in pain; however, she could not recall who she spoke to. Family member stated just two days ago (01/03/23) Resident #1 informed her that she had x-rays completed and was sent to the hospital. The Family member stated Resident #1 went a lot of days being in pain. Once again family member could not recall who the staff she had spoken with. Interview on 01/05/23 at 4:09 PM with LVN F revealed she worked with Resident #1 the following day after the tornado warning. LVN F stated she was never notified that Resident #1 was having pain to the left leg. LVN F stated Resident #1 never complained of pain to her. LVN F stated Resident #1 does ask for pain medication when she is in pain. LVN F stated if Resident #1 had pain they would have followed up with the doctor. Interview on 01/05/23 at 4:21 PM with the Treatment Nurse revealed she worked the day of the tornado warning. She stated she also completed a skin assessment on Resident #1 and Resident #1 never complained of pain. The Treatment Nurse could not recall when the skin assessment was completed. The Treatment Nurse stated Resident #1 would always be at the nurse's station during the day which is located outside her office and not once did Resident #1 complain of pain. Interview on 01/05/23 at 5:21 PM with the DON revealed she was on off the day of the tornado warning and did not return to work until 12/15. She stated on 12/16 she was notified that an x-ray had been ordered for Resident #1 and after reviewing the x-results it was determined that Resident #1 had a fracture of unknown age and was sent to the emergency room . The DON stated after conducting her investigation she was informed that during the tornado warning on 12/13/22 Resident #1 was being transferred and Resident #1's left leg got stuck underneath the wheelchair. The DON stated she obtained Resident #1's statement when Resident #1 returned to the facility from the hospital. The DON stated Resident #1 was happy with her care when she interviewed her; however, when Resident #1 spoke with a family member later on Resident #1 became upset. The DON stated after obtaining her staff statements it was determined that Resident #1 did not complain of pain until Friday 12/16/22 and her staff order x-rays. Follow-up interview on 01/05/23 at 5:41 PM with the ADON revealed she was notified by LVN G the morning of Friday (12/16/22) of Resident #1 complaint of pain to the left leg. The ADON stated she completed a head-to-toe assessment and noticed a bruise on her leg and it was swollen. The ADON stated she contacted the doctor and order an x-ray. The ADON stated she did not complete a head-to-assessment on 12/13/22 because Resident #1 did not complain of pain and no injuries were noted. The ADON stated she did not follow-up with Resident #1 on 12/13/22 after knowing her leg got stuck underneath the wheelchair to make sure she was okay. The ADON stated after noticing the bruise on 12/16/22 she went back and completed the incident report regarding Resident #1's left leg injury. The ADON stated she does not believe there was a risk in the delay in Resident #1's treatment due to Resident #1 being capable of verbalizing pain. The ADON stated the failure was her not following up with Resident #1 after the incident on 12/13/22. Interview on 01/05/23 at 5:46 PM with LVN G by phone revealed he was the nurse for 200 Hall during the night shift from 7:00 PM- 7:00AM. LVN G stated Resident #1 is always in pain due to her contractures; however, the morning of 12/16/22 Resident #1 complained of pain. LVN G stated he was aware of the incident that Resident #1 had during the transfer; however, Resident #1 did not notify him of where the pain was coming from. LVN G stated he provided Resident #1 with her pain medication and he noticed the bruise on Resident #1 left leg and notified the incoming nurse who was the ADON the morning of 12/16/22. LVN G stated other than on 12/16/22 Resident #1 did not complain of pain. Interview on 01/05/23 at 6:21 PM with CNA H revealed she works the night shift from 7:00 PM to 7:00 AM on the 200 Hall. She stated she does not recall the dates but Resident #1 had complained to her about pain and she notified the night nurse who was LVN G. CNA H stated LVN G provided Resident #1 with pain medications. CNA H stated Resident #1 informed her about hurting her leg while being transferred during the tornado warning. CNA H stated Resident #1 never mentioned if she ever told any nurses about her pain. Follow-up interview on 01/05/23 at 7:29 PM with the DON revealed during her investigation it was revealed there was no incident report done initially and no documentation of the incident. The DON stated her expectations of when an incident occurs is for her staff to follow up with the resident and complete and assessment if the resident reports any pain. The DON stated the risk of not following up with Resident #1 resulted in injury of known origin. A quality-of-care policy was requested; however, it was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accidents. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent the resident from spilling hot coffee on herself twice. On 10/08/22, Resident #1 spilled hot coffee on herself resulting in raised, reddened areas on her abdomen. On 11/27/22, Resident #1 spilled hot coffee on herself, and she sustained blistering burns on her abdomen, which required wound care. 2. The facility failed to ensure Resident #1 did not have access to hot coffee after her second time being burned (scalded). 3. The facility failed to ensure coffee was maintained at a safe temperature to prevent scalding. An Immediate Jeopardy was identified on 12/02/22. While the Immediate Jeopardy was removed on 12/03/22, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures put residents at risk for serious injury and pain. Findings included: Review of Resident #1's quarterly MDS assessment, dated 11/20/22, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: cerebral palsy, Parkinson's disease, moderate intellectual disabilities, and abnormalities of gait and mobility. The assessment reflected Resident #1 had moderately impaired cognition with a BIMS score of 10, she sometimes understood others, and she responded adequately to simple direct communication only. Resident #1 required supervision and the physical assistance of one person for eating. Review of Resident #1's current undated care plan reflected the following: - Resident #1 had an ADL self-care performance deficit related to limited mobility, confusion, and lack of coordination. Interventions included supervision assistance from one staff with eating. - The resident had a burn/blister related to a coffee spill. Interventions included assessing the reason for the burn/blister, notifying staff of the cause, determining measures to prevent further skin injuries, and performing any wound care as ordered. - Risk of burns due to hot liquids due to getting coffee independently without assistance. Interventions included assisting the resident with hot liquids. Resident #1 was to drink hot liquids while sitting at a table. Resident #1 was to use cups with a lid, wear clothing/lap protector when drinking hot liquids, and staff will assist with pouring drinks into correct cup if/when resident get her own drink. - The resident had a behavior problem related to cerebral palsy. Resident #1 sometimes got coffee without asking for help, without wearing a clothing protector, and without using a specialty cup with handles. Interventions included discussing the resident's behavior, explaining and reinforcing why the behavior was unsafe, and anticipating and meeting the resident's needs. Review of Resident #1's incident report, dated 10/08/22, reflected the following: .Resident noted with redness to abdomen and right upper thigh. No blistering noted at time of redness noted resident likely spilled coffee or hot chocolate on her, but staff did not witness Interventions initiated by nurse: encourage resident to ask staff for assistance with getting coffee or hot chocolate so an appropriate cup with lid can be utilized Gait and Mobility: 1. Unsteady gait 2. Leans to the side Cognition/Behavior at Time of Event: cognitive impairment; refuses to call for assistance Notes: Conclusion: Resident believed to have spilled coffee or hot chocolate on herself. She is able to get her own coffee without staff assistance and has to be redirected/assisted with changing clothing several times a day due to spilling liquids on herself. Intervention: Educate staff to get resident coffee when she gets up, in a cup with a lid to prevent spills. Hot liquid apron to be worn in the mornings when drinking coffee Review of Resident #1's nurses' notes dated 10/08/22 entered by LVN A revealed the following: The aide notified me of burn marks on the resident. I went to go look at it. She has red burn marks that are slightly raised. There are a few areas that are peeling off. I applied anasept gel to the area. This morning we asked if they knew anything about her spilling coffee on herself. The kitchen staff said they remember that yesterday at breakfast time she did spill coffee on herself. Review of Resident #1's nurses' notes, dated 10/08/22, entered by the Wound Care Nurse revealed the following: Resident has 14.0 cm x 14.0 cm pink raised area to abdomen, 0.5 cm x 2.0 cm area at the bottom of pinkened area. Resident has 11.0 cm x 16.0 cm raised pink area to right upper thigh. Notified family and Dr. Rec[eived] new order to cleanse with wound cleanser and apply Silvadene cream daily Review of Resident #1's incident report, dated 11/27/22, reflected the following: Event: Resident brought to nursing station by CNA who noticed resident had blister to abdomen. Dr. notified and family notified with wound care orders in place Resident Statement: resident stated she was drinking coffee Interventions initiate by nurse: moisture proof apron to be worn Skin Findings: resident has fluid filled blister to abdomen with red periwound of 7.0 cm x 4.5 cm Review of Resident #1's nurses' notes, dated 12/01/22, entered by the Wound Care Nurse revealed the following: Wound Care Dr. here this shift to see resident. Abdomen 22 cm x 18 cm x 0.1 cm, moderate serous drainage (clear drainage), 40% slough and 40% viable tissue and 20% skin. Rec orders to cleanse area with normal saline or wound cleaner, pat dry, cover with ABD [abdomen] pads and secure with tape, twice a day. Left proximal anterior thigh 6 cm x 20 cm x 0.1 cm, light serous drainage, 50% viable tissue, 50% skin, rec new order to cleanse wound with normal saline, pat dry cover with dry dressing twice a day An observation on 12/01/22 at 10:21 AM revealed Resident #1 was in the dining room sitting at a dining table in her wheelchair. The resident was leaning to the left side of her wheelchair drinking coffee out of a regular cup, without a lid, and had a coffee stirrer inside. Resident #1 was wearing a large gray apron which covered the entire front of her body. At that time, a staff member (name unknown), poured her coffee into a cup with a lid and handles and upon touching the outside of the cup with the covered lid, the coffee felt warm, not hot. Resident #1's arms/hands appeared to be very shaky as she was drinking the coffee. She was seated approximately 20 feet from the coffee urns in the dining room. An observation of the dining room on 12/01/22 at 10:25 PM revealed there were two large coffee urns on the counter next to the kitchen. Styrofoam cups were placed next to the coffee urns within resident reach and available for all residents to self-serve. An observation on 12/01/22 at 1:25 PM revealed Resident #1 was in bed being changed after her shower. There was redness from one side of the resident's abdomen to the other side. There were two spots with noted slough and some of the other area still had a blister to it. The resident was asked what happened to her stomach and the resident said coffee. Resident #1 was also asked if that area hurt, and she nodded her head yes. An interview on 12/01/22 at 1:33 PM with CNA B revealed on 11/27/22 she saw Resident #1 heading towards the dining room around 7:00 AM, and she told the resident not to get coffee but to get some tea instead. CNA B stated the resident got tea at that time and around 10:30 AM, she noticed the resident's shirt was wet, so she took Resident #1 back to her room to change her. As she removed Resident #1's shirt, she noticed a blister on the resident's stomach and reported it to the nurse. CNA B further stated the staff had been in-serviced to monitor Resident #1 after the first time she burned herself with coffee (10/08/22), but CNA B said they could not be around the resident at all times to prevent her from getting coffee on her own. CNA B said after the second burn, Resident #1 was given a gray apron that covered the front of her body that better protected her. An interview on 12/01/22 at 4:19 PM with ADON C revealed she was working the day Resident #1 was found with a blister on her abdomen on 11/27/22. ADON C said a CNA took the resident to the nurses' station, and she noticed a fluid-filled blister in the middle of her abdomen. The CNA asked the resident if she had spilled coffee, and Resident #1 said yes coffee. The resident was not wearing any protection over her shirt because they usually tried to put them on the resident prior to her meals in the dining room. ADON C further stated they continued to monitor Resident #1 and redirected her from trying to get her own coffee, but they could not be with the resident 24 hours a day to prevent that. The ADON said after the last burn, 11/27/22, they decided to keep clothing protectors on Resident #1 at all times to keep her from burning herself with coffee. An interview on 12/01/22 at 2:16 PM with CNA C revealed Resident #1 would seek coffee all the time, and they tried to monitor the resident as best they could to keep her from getting coffee herself or they tried to make sure the coffee cooled before it is given to the resident in her special cup. CNA C further stated Resident #1 understood what she was being told, and acknowledged she did not need to get coffee on her own, but she continued to do so. An interview on 12/02/22 at 10:06 AM with Resident #1's family revealed Resident #1 really liked coffee. The family members stated even though they did not want her getting it herself, she continued to do it and would not listen to staff because it appeared she wanted to be more independent. Resident #1's hand had some contractures and tremors, but she would not ask the staff for assistance and would try and get coffee when no one was looking. The resident's family said, after the first burn, she purchased long bibs to give Resident #1 extra protection with spills during meals. The resident's family also stated they spoke with Resident #1 and told her she could not go into the dining room unless it was mealtime, and she appeared to get upset. But the resident liked to get up early in the morning, and she could probably go the dining room while the staff were getting other residents up. An interview on 12/02/22 at 2:36 PM with the DON revealed after Resident #1 had her first coffee burn, 10/08/22. After this incident, the DON stated they ordered some spill resistant bibs for the resident to have during meals. After the first incident, dietary began to check the temperature of the coffee and keep a log. Staff were in-serviced to monitor Resident #1 to keep her from getting her own coffee and to redirect her as needed. After the second burn (11/27/22), they in-serviced staff to make sure Resident #1 was wearing an apron at all times, while she was out of bed. The DON further stated Resident #1 was probably not safe to get her own coffee, but said it was the resident's right to continue drinking coffee, and the resident understood she was not supposed to get it herself. An interview on 12/02/22 at 9:28 PM with the Administrator revealed he was only aware of Resident #1 having two coffee burns as she was able to get coffee safely in the past. After the first burn, 10/08/22, they educated staff to make sure the resident was wearing her aprons at mealtimes and redirect Resident #1 if she was seen trying to make her own coffee. At that time, staff were to get the resident's specialty cup to pour the coffee into for safety. After the second burn, 11/27/22, staff began putting aprons on Resident #1, at all times, while she was up, to keep her from burning herself. Other than doing one-on-one care with the resident, staff were again in-serviced to monitor, intervene, and redirect Resident #1 when she was out of bed to prevent her from getting her own coffee. The Administrator also stated the dietary staff were in-serviced on taking the temperature of the coffee after it was made, and the temperatures were being kept in a log to keep track of them. An observation on 12/02/22 at 9:42 AM with the Dietary Manager revealed coffee from the urns in the dining room was poured into a cup to check the temperature. The Dietary Manager first used a digital thermometer in the first cup of coffee from one the urns, and the temperature reading was 154 degrees. The Dietary Manager then got a stem thermometer to verify the temperature of the coffee, and the temperature reading was 160 degrees. The Dietary Manager then got another cup and poured coffee from the second urn to check the temperature, and the reading was the exact same as the first cup of coffee. An interview on 12/02/22 at 10:00 AM with the Dietary Manager revealed she made the coffee that morning, 12/02/22, and she poured ice in the urns to cool the coffee. The Dietary Manager said she thought the coffee temperatures were so high because the ice had not been mixed well; therefore, the bottom part of the urn contained the hotter coffee. She further stated the appropriate temperature of the coffee should have been at 140 degrees or less per their policy. The Dietary Manager said the coffee temperatures were being checked once at breakfast, lunch, and dinner and not each time a new pot of coffee was brewed. An interview on 12/02/22 at 3:08 PM with the Dietitian revealed there was no state or federal regulation to the temperature of coffee, but ideally, it should have been served between 120 to 140 degrees for the safety of the residents. She stated the temperature of the coffee should be taken after it was brewed to make sure it was not too hot and coffee temperatures could be changed at the discretion of the residents. An Interview on 12/02/22 at 2:09 PM with the Wound Care Physician revealed this was the second time she treated Resident #1 for a coffee burn to her abdomen. She said the first time the resident's burn healed quickly because it was more superficial, but the most recent burn was much worse. She was contacted to treat Resident #1, and she assessed her the day prior, 12/01/22, and there was some dead tissue and there were still some blisters noted. The Wound Care Physician said she was not able to stage Resident #1's burn because it was her first visit seeing the current burn, and burns usually evolved as time passed. She said she would possibly be able to stage the resident's burn after her second visit. Review of the facility's signed in-service records, dated 10/10/22, reflected the following: New Skin Condition/Reporting/Administering Care . - All staff will be responsible for making sure appropriate residents are receiving the necessary help when retrieving drinks, especially if the drink is a warm beverage - Staff will be responsible for insuring the appropriate cup is available to residents who need special utensils. - If a special apron or clothing protector is needed, all staff will be responsible for making sure the resident has help putting on said special protector. 11/28/22 Hot Liquids/Food Spills and Protective Clothing/Apron/Special Drinking Cups - Any resident that needs special clothing or apron must be assisted with help putting on said apron prior to going to dining room. Nurse is responsible for insuring [sic] resident has on protective clothing and special cup provided for safety when drinking hot liquids Review of the coffee temperature for November 2022 revealed the temperature of the coffee at breakfast on 11/27/22 was 129 degrees and 130 degrees at lunch. The temperature of the coffee was being checked during each meal at breakfast, lunch, and dinner. Review of the facility's undated Guidelines on Serving Coffee in the Nursing Facility provided by the Dietary Manager on 12/01/22 reflected the following: .2. The standard for coffee service will be 140 degrees, unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additionally safety measures have been implemented, or the safety of residents warrants a lower temperature. If coffee is served at 140 degrees, it will cool to 138 degrees when dispensed into a room temperature coffee cup or mug, and per Time and Temperature Relationship to Serious Burns from the American Burn Association 5. An investigation and evaluation will be performed for any resident who receives a coffee burn, and a plan to reduce this resident's risk of receiving future burns will be developed and implemented Review of The American Burn Association Scald Injury Prevention Educator's Guide, https://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf reflected the following: .Time and Temperature Relationship to Severe Burns Water Temperature Time for a third degree burn to occur 155 degree F 1 second 140 degrees F 5 seconds An Immediate Jeopardy was identified on 12/02/22. The Administrator was notified of the Immediate Jeopardy on 12/02/22 at 12:37 PM . The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 12/02/22 at 5:26 PM and reflected the following: - Resident #1's attending physician was notified on November 17, 2022 and received new order for Silvadene to abdomen twice a day. Resident #1 was seen by in-house wound care physician on December 1, 2022 with no new order received. On November 29, 2022 additional moisture proof aprons were ordered for resident #1 to always wear. On October 8, 2022, resident #1 was provided with cup with handles with coffee. - A 100% audit is being initiated and completed on December 2, 2022 on all resident burns in the last 3 months to ensure appropriate interventions are in place to minimize risk of re-occurrence. - Residents who consume coffee were assessed for the need of assistive devices on December 2, 2022, and will be repeated quarterly as needed. Facility identified 3 residents with coffee mugs with lids. - In-service all dietary staff regarding checking the liquid temperature to ensure temperatures are not above 140 degrees prior to serving to the residents. This in-service will be initiated by the administrator on December 2, 2022. Any dietary staff not present or in-serviced will not be allowed to assume their duties unit this in-service had been completed. - A coffee temperature log was initiated December 2, 2022. Coffee temperature will be checked and logged prior to serving/making coffee available residents. Coffee will not be served until the temperature is 140 degrees or less. - Starting on December 2, 2022, coffee dispensers will delivered to each nurses' station for resident to access with nursing assistance to eliminate any risk of hot spilled burn for residents that require higher level of supervision or assistance. - [Medical Director], was notified of the Immediate Jeopardy on December 2, 2022 at 1:11 PM. - Ad Hoc Quality Assurance Performance Improvement Committee meeting will be held December 2, 2022, to review and discuss Immediate Jeopardy. - Administrator or designee will monitor this corrective actions. Any identified issues will be immediately addressed by the administrator or designee. - Administrator will report progress of this plan to the Quality Assurance Performance Improvement Committee meeting monthly. The facility administrator will monitor plan and make changes until issues are resolved. Monitoring of the facility's Plan of Removal included the following: Observations on 12/03/22 from 8:42 AM to 8:55 AM revealed additional residents identified as an increased burn risk, Resident #2 and #3, both had coffee in cups with lids to prevent coffee burns at breakfast. Resident #1 was at the dining table with two cups, and each cup had a lid and handles. She was drinking milk from one cup and the other cup contained warm coffee. Resident #1 was wearing a clothing protector during and after breakfast. Observation on 12/03/22 at 9:55 AM revealed there was a coffee carafe on a rolling cart next to the nurses' station of the 100 and 200 hall, and there were no cups within resident reach. The temperature of the coffee in the carafe was 118 degrees. Observation on 12/03/22 at 9:57 AM revealed the coffee carafe was behind the nurses' station of the 300 and 400 [NAME], and was not accessible to residents. The temperature of the coffee was 138 degrees. Interviews on 12/03/22 from 9:00 AM to 11:16 AM with the Dietary Staff S, T, U, V, and W revealed they had all been in-serviced on how to make and cool coffee to 140 degrees or below before serving. They were also educated on which residents had been assessed and found to be unsafe with hot beverages. Residents #1, #2, and #3 were to have special cups with lids and were to have assistance in getting their coffee. They were also told Resident #1 should always be wearing a clothing protector to prevent spills. The Dietary Staff were knowledgeable in recording the coffee temperature on the temperature logs after each new coffee brew. Interviews were conducted on 12/03/22 starting at 9:00 AM and continued through 11:16 AM with 17 staff members from various shifts regarding in-services which included hot liquids and food spills and the new location of the coffee carafe's at the nurses' station. The staff members were able to identify the three residents that required cups with lids when drinking hot liquids and assist other residents that required help getting coffee. They were to make sure Resident #1 was always wearing a clothing protector and her hot beverages were in a cup with a lid. The staff interviewed from various shifts were as follows: CNA G, CNA H, CNA K, CNA L, CNA P, CNA R, CNA X, CNA Y; LVN A, LVN F, LVN I, LVN M, LVN O, RN J, RN Q; Medicatoin Aide N; Housekeeper E; and the Floor Tech. The Administrator was notified on 12/03/22 at 11:25 AM, the Immediate Jeopardy was removed. While the immediacy was removed on 12/03/22, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 3 of 27 residents reviewed for supervision. (Residents #1, #2 and #3) The facility did not adequately supervise Resident 1 who had a history of [REDACTED].#2 and #3 on 11/01/19, which resulted in Resident #3 sustaining lacerations to his face. This failure could place other residents requiring supervision at risk for accidents and injuries. Findings included: 1. An undated admission record, printed on 11/11/19 indicated Resident #1 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A psychiatric note dated 7/31/19 indicated the psychiatrist recommended Resident #1 for psychiatric visits once a week. There was no documentation of any psychiatric visits for Resident #1. A nurse's note dated 9/20/19 indicated Resident #1 was yelling at another resident, and punched LVN A in the face when LVN A attempted to redirect Resident #1. The MDS dated [DATE], indicated Resident #1 had severe cognitive deficits, memory problems, severely impaired decision-making skills, inattention and disorganized thinking. She was easily annoyed, had delusions, and had physical and verbal behaviors directed at others 1 to 3 days a week. She required the assistance of 1 staff member for transfers and bed mobility and did not require any mobility devices. The care plan with a review date of 10/17/19 indicated Resident #1 was a wander risk, had a behavior problem and believed another resident was her husband, was physically and verbally aggressive, and had impaired cognitive function. Interventions listed were to redirect the resident, modify the environment and administer medications. A nurse's note from 10/20/19 indicated Resident #1 followed Resident #3's roommate into his room, and when staff attempted to redirect Resident #1, she became verbally and physically aggressive with staff. She began cursing at and scratching the aides who were attempting to assist her out of the room. During an observation and interview on 11/12/19 at 1:26 p.m. CNA D had approximately 5 scars to her right arm and 1 scar on her left arm that she said were caused on 10/20/19 when she attempted to redirect Resident #1 when she found the resident in Resident #3's room. She said Resident #1 was physically aggressive. CNA D said Resident #1 was confused and began scratching her. She said CNA C tried to help her, but he received worse injuries than hers. During an observation and interview on 11/12/19 at 1:38 p.m. CNA C had approximately 10 scratches to his bilateral arms. He said the DON knew Resident #1 scratched his arms on 10/20/19 while he was providing care. He said the DON's exact words were damn or dang, and she did not do anything about the physical abuse. During an interview on 11/12/19 at 1:51 p.m., the DON said she knew Resident #1 had aggressive behaviors toward staff and residents. She said they did not notify the physician. She said she did not learn about the Resident #1's physical attacks on CNA C and CNA D until a few days after they occurred. She said she did not call anyone or follow up on the incidents and said the CNAs knew to call their doctor if they were hurt. She said she was not sure if she should have anticipated Resident #1 becoming aggressive with other residents, because she said the staff were working with the resident and attempting to redirect her. During an interview on 11/11/19 at 2:10 p.m., LVN A said Resident #1 had aggressive behaviors. She said on 11/01/19, Resident #3's roommate reported to LVN A that Resident #3 was lying in the floor of their room. The nurse practitioner and LVN A found Resident #3 on the floor of his room in a pool of blood. Resident #1 was in Resident #3's room and had blood on her hands. Resident #3 said she hit me, she hit me. LVN A said the incident with Resident #3 was the second resident-to-resident altercation Resident #1 was involved in that same day; there had been an altercation with Resident #2 that morning. LVN A said Resident #1 had numerous physical altercations with staff and had never been out of the facility for treatment related to those behaviors. LVN A said it seemed the facility did not like to send residents out. LVN A said she reported Resident #1's aggressive behaviors for at least two months, in the morning meetings. She said she was told Resident #1 had a referral with the psychiatric nurse practitioner, but the psychiatric nurse practitioner never came. LVN A said on 10/20/19, Resident #1 physically attacked and injured CNAs C and D. LVN A said after Resident #1 injured the CNAs, there was a one-time order for [MEDICATION NAME], an antipsychotic, and no other medication changes were made. LVN A said Resident #1 had delusions that Resident #3's roommate was her husband and when staff would attempt to redirect her, she would become physically and verbally aggressive. LVN A said the social worker contacted the behavioral hospital after Resident #3 was found on the floor in a pool of blood on 11/01/19, and Resident #1 was then transferred out. During a phone interview on 11/12/19 at 1:14 p.m., LVN B said Resident #1 was verbally aggressive with anyone she believed was interfering with Resident #3 because she believed Resident #3's roommate was her husband. LVN B said Resident #1 would yell and became angry with other residents and staff. LVN B said the facility administration realized Resident #1 had aggressive behaviors. She said the only interventions put in place were to separate Resident #1 and Resident #3's roommate, redirecting them, and taking each resident to their own room. She said she had personally notified the facility administration of the resident's behaviors and aggression. An updated care plan dated 11/01/19 and revised on 11/07/19 indicated Resident #1 had two resident-to-resident altercations and sustained no injury from either. Interventions listed were to redirect the resident when she became aggressive, modify the environment and administer medications. The undated medication review report, printed on 11/11/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed an antipsychotic, and a drug used to treat dementia. The undated order summary report, printed on 11/12/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed anti-anxiety, and antipsychotic medications. 2. An undated admission record, printed on 11/11/19, indicated Resident #3 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #3 had severe cognition deficits, rarely understood others or had others understand him, and had severely impaired decision-making skills. He was easily annoyed and had physical behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a walker for mobility. The care plan with a review date of 9/18/19 indicated Resident #3 was a wander risk, had the potential to be physically aggressive, and had impaired cognitive function. A nurse's note dated 11/1/19 indicated Resident #3 was found on the floor of his room that morning with a pool of blood behind his head. He told staff that a woman had hit him multiple times. His right eye was red and swollen shut, with a bleeding laceration to his upper right eye. His right lower lip was cut open and bleeding, his nose was asymmetrical , (larger on one side) and he had scratches to his face and neck. He was sent to the ER for evaluation and treatment. The undated medication review report, printed on 11/11/19, indicated Resident #3 was located on the secure unit, was referred to psychiatric services, and was prescribed a drug to treat [MEDICAL CONDITION]. A SBAR (situation, background, assessment, recommendation) form dated 11/01/19 indicated Resident #1 was placed on 1:1 monitoring after her altercation with Resident #3. An incident report dated 11/01/19 indicated Resident #1 was removed from unit after she hit Resident #3 because he was trying to hurt her daughter. A copy of physician's telephone orders dated 11/1/19 indicate Resident #1's [MEDICATION NAME] was increased from once a day to twice a day and she was prescribed Donepezil, a drug used to treat dementia after her altercation with Resident #3. 3 An undated admission record, printed on 11/12/19, indicated Resident #2 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #2 had intact cognition with fluctuating inattention. He had delusions and verbal behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a wheelchair for mobility. The care plan with a review date of 6/27/19 indicated Resident #2 was a wander risk, had the potential to be physically and verbally aggressive and had impaired cognitive function. A nurse's note dated 11/1/19 at 11:00 a.m. indicated Resident #1 repeatedly punched Resident #2 in the face when Resident #2 wandered into Resident #1's room. When staff attempted to separate the residents, Resident #1 became physically and verbally aggressive with staff. The residents were then separated, and no injuries were noted to either resident. In an interview on 11/11/19 at 2:45 p.m., the administrator was unaware of the incident when Resident #1 was found in her room punching Resident #2 in the head, on 11/1/19 and said it was a verbal altercation between Resident #1 and Resident #2. He said the psychiatric nurse practitioner was scheduled to see Resident #1 on the afternoon of 11/1/19. He said Resident #1 could be argumentative with staff was unaware of any previous aggressive behaviors. The administrator said he was never notified in the facility's morning meetings of Resident #1's aggressive behaviors. He indicated Resident #1 had psychiatric challenges. During an interview on 11/12/19 at 9:43 a.m., LVN A said the administrator did not normally attend the morning meetings. She said she notified the DON repeatedly Resident #1 was aggressive with staff but the DON did nothing. LVN A indicated she was unaware of any weekly visits with Resident #1 conducted by the psychiatrist or psychiatric nurse practitioner. Psychiatric notes provided by the facility from 9/20/19 and 11/1/19, indicated the psychiatric nurse practitioner recommended that Resident #1 be seen 2 times a month for 6 months. The facility was unable to provide further notes documenting twice monthly visits. During an interview on 11/12/19 at 1:50 p.m., the ADON indicated she was aware of Resident #1's aggressive behavior. She said Resident #1 was violent and had a history of [REDACTED]. During an interview 11/12/19 at 1:54 p.m., the administrator said he became aware Resident #1 had slapped an employee on 11/12/19, the day she was transferred out of the facility. He said the DON did not tell him that CNA C and D were injured by Resident #1. He said a resident having physical behaviors with staff was concerning and would indicate aggression with other residents as well. During an interview on 11/12/19 at 1:55 p.m., CNA [NAME] indicated she had been slapped by Resident #1. During an interview on 11/12/19 at 2:00 p.m., the activity director indicated Resident #1 could be aggressive if staff or residents were in her space. During an interview on 11/12/19 at 2:02 p.m., LVN F indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:04 p.m., LVN [NAME] indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:49 p.m., the DON indicated her expectation regarding resident to resident altercations was for staff to break up the fight and notify her. During an interview on 11/12/19 at 3:38 p.m., the facility was asked for additional information at exit. No additional information was provided.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 3 of 27 residents reviewed for abuse. (Residents #1, #2 and #3) The facility did not prevent Resident #1, who had a history of [REDACTED].#2 and #3. Resident #1 knocked Resident #3 to the floor resulting in lacerations to Resident #3's lip and eye. Resident #1 hit Resident #2 repeatedly in the face, and was physically agressive with staff. This failure could place other vulnerable residents at risk for abuse. Findings included: 1. An undated admission record, printed on 11/11/19 indicated Resident #1 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A psychiatric note dated 7/31/19 indicated the psychiatrist recommended Resident #1 for psychiatric visits once a week. There was no documentation of any psychiatric visits for Resident #1. A nurse's note dated 9/20/19 indicated Resident #1 was yelling at another resident, and punched LVN A in the face when LVN A attempted to redirect Resident #1. The MDS dated [DATE], indicated Resident #1 had severe cognitive deficits, memory problems, severely impaired decision-making skills, inattention and disorganized thinking. She was easily annoyed, had delusions, and had physical and verbal behaviors directed at others 1 to 3 days a week. She required the assistance of 1 staff member for transfers and bed mobility and did not require any mobility devices. The care plan with a review date of 10/17/19 indicated Resident #1 was a wander risk, had a behavior problem and believed another resident was her husband, was physically and verbally aggressive, and had impaired cognitive function. Interventions listed were to redirect the resident, modify the environment and administer medications. A nurse's note dated 10/20/19 indicated Resident #1 followed Resident #3's roommate into his room, and when staff attempted to redirect Resident #1, she became verbally and physically aggressive with staff. She began cursing at and scratching the aides who were attempting to assist her out of the room. During an observation and interview on 11/12/19 at 1:26 p.m. CNA D had approximately 5 scars to her right arm and 1 scar on her left arm that she said were caused on 10/20/19 when she attempted to redirect Resident #1 when she found the resident in Resident #3's room. She said Resident #1 was physically aggressive. CNA D said Resident #1 was confused and began scratching her. She said CNA C tried to help her, but he received worse injuries than her. During an observation and interview on 11/12/19 at 1:38 p.m. CNA C had approximately 10 scratches to his bilateral arms. He said the DON knew Resident #1 scratched his arms on 10/20/19 while he was providing care. He said the DON's exact words were damn or dang, and she did not do anything about the physical abuse. During an interview on 11/12/19 at 1:51 p.m., the DON said she knew Resident #1 had aggressive behaviors toward staff and residents. She said they did not notify the physician. She said she did not learn about the Resident #1's physical attacks on CNA C and CNA D until a few days after they occurred. She said she did not call anyone or follow up on the incidents and said the CNAs knew to call their doctor if they were hurt. She said she was not sure if she should have anticipated Resident #1 becoming aggressive with other residents, because she said the staff were working with the resident and attempting to redirect her. During an interview on 11/11/19 at 2:10 p.m., LVN A said Resident #1 had aggressive behaviors. She said on 11/01/19, Resident #3's roommate reported to LVN A that Resident #3 was lying in the floor of their room. The nurse practitioner and LVN A found Resident #3 on the floor of his room in a pool of blood. Resident #1 was in Resident #3's room and had blood on her hands. Resident #3 said she hit me, she hit me. LVN A said the incident with Resident #3 was the second resident-to-resident altercation Resident #1 was involved in that same day; there had been an altercation with Resident #2 that morning. LVN A said Resident #1 had numerous physical altercations with staff and had never been out of the facility for treatment related to those behaviors. LVN A said it seemed the facility did not like to send residents out. LVN A said she reported Resident #1's aggressive behaviors for at least two months, in the morning meetings. She said she was told Resident #1 had a referral with the psychiatric nurse practitioner, but the psychiatric nurse practitioner never came. LVN A said on 10/20/19, Resident #1 physically attacked and injured CNAs C and D. LVN A said after Resident #1 injured the CNAs, there was a one-time order for [MEDICATION NAME], an antipsychotic, and no other medication changes were made. LVN A said Resident #1 had delusions that Resident #3's roommate was her husband and when staff would attempt to redirect her, she would become physically and verbally aggressive. LVN A said the social worker contacted the behavioral hospital after Resident #3 was found on the floor in a pool of blood on 11/01/19, and Resident #1 was then transferred out. During a phone interview on 11/12/19 at 1:14 p.m., LVN B said Resident #1 was verbally aggressive with anyone she believed was interfering with Resident #3 because she believed Resident #3's roommate was her husband. LVN B said Resident #1 would yell and became angry with other residents and staff. LVN B said the facility administration realized Resident #1 had aggressive behaviors. She said the only interventions put in place were to separate Resident #1 and Resident #3's roommate, redirecting them, and taking each resident to their own room. She said she had personally notified the facility administration of the resident's behaviors and aggression. An updated care plan dated 11/01/19 and revised on 11/07/19 indicated Resident #1 had two resident-to-resident altercations and sustained no injury from either. Interventions listed were to redirect the resident when she became aggressive, modify the environment and administer medications. The undated medication review report, printed on 11/11/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed an antipsychotic, and a drug used to treat dementia. The undated order summary report, printed on 11/12/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed anti-anxiety, and antipsychotic medications. 2. An undated admission record, printed on 11/11/19, indicated Resident #3 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #3 had severe cognition deficits, rarely understood others or had others understand him, and had severely impaired decision-making skills. He was easily annoyed and had physical behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a walker for mobility. The care plan with a review date of 9/18/19 indicated Resident #3 was a wander risk, had the potential to be physically aggressive, and had impaired cognitive function. A nurse's note dated 11/1/19 indicated Resident #3 was found on the floor of his room that morning with a pool of blood behind his head. He told staff that a woman had hit him multiple times. His right eye was red and swollen shut, with a bleeding laceration to his upper right eye. His right lower lip was cut open and bleeding, his nose was asymmetrical , (larger on one side) and he had scratches to his face and neck. He was sent to the ER for evaluation and treatment. The undated medication review report, printed on 11/11/19, indicated Resident #3 was located on the secure unit, was referred to psychiatric services, and was prescribed a drug to treat [MEDICAL CONDITION]. A SBAR (situation, background, assessment, recommendation) form dated 11/01/19 indicated Resident #1 was placed on 1:1 monitoring after her altercation with Resident #3. An incident report dated 11/01/19 indicated Resident #1 was removed from unit after she hit Resident #3 because he was trying to hurt her daughter. A copy of physician's telephone orders dated 11/1/19 indicate Resident #1's [MEDICATION NAME] was increased from once a day to twice a day and she was prescribed Donepezil, a drug used to treat dementia after her altercation with Resident #3. 3 An undated admission record, printed on 11/12/19, indicated Resident #2 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #2 had intact cognition with fluctuating inattention. He had delusions and verbal behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a wheelchair for mobility. The care plan with a review date of 6/27/19 indicated Resident #2 was a wander risk, had the potential to be physically and verbally aggressive and had impaired cognitive function. A nurse's note dated 11/1/19 at 11:00 a.m. indicated Resident #1 repeatedly punched Resident #2 in the face when Resident #2 wandered into Resident #1's room. When staff attempted to separate the residents, Resident #1 became physically and verbally aggressive with staff. The residents were then separated, and no injuries were noted to either resident. In an interview on 11/11/19 at 2:45 p.m., the administrator was unaware of the incident when Resident #1 was found in her room punching Resident #2 in the head, on 11/1/19 and said it was a verbal altercation between Resident #1 and Resident #2. He said the psychiatric nurse practitioner was scheduled to see Resident #1 on the afternoon of 11/1/19. He said Resident #1 could be argumentative with staff was unaware of any previous aggressive behaviors. The administrator said he was never notified in the facility's morning meetings of Resident #1's aggressive behaviors. He indicated Resident #1 had psychiatric challenges. During an interview on 11/12/19 at 9:43 a.m., LVN A said the administrator did not normally attend the morning meetings. She said she notified the DON repeatedly Resident #1 was aggressive with staff but the DON did nothing. LVN A indicated she was unaware of any weekly visits with Resident #1 conducted by the psychiatrist or psychiatric nurse practitioner. Psychiatric notes provided by the facility from 9/20/19 and 11/1/19, indicated the psychiatric nurse practitioner recommended that Resident #1 be seen 2 times a month for 6 months. The facility was unable to provide further notes documenting twice monthly visits. During an interview on 11/12/19 at 1:50 p.m., the ADON indicated she was aware of Resident #1's aggressive behavior. She said Resident #1 was violent and had a history of [REDACTED]. During an interview 11/12/19 at 1:54 p.m., the administrator said he became aware Resident #1 had slapped an employee on 11/12/19, the day she was transferred out of the facility. He said the DON did not tell him that CNA C and D were injured by Resident #1. He said a resident having physical behaviors with staff was concerning and would indicate aggression with other residents as well. During an interview on 11/12/19 at 1:55 p.m., CNA [NAME] indicated she had been slapped by Resident #1. During an interview on 11/12/19 at 2:00 p.m., the activity director indicated Resident #1 could be aggressive if staff or residents were in her space. During an interview on 11/12/19 at 2:02 p.m., LVN F indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:04 p.m., LVN [NAME] indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:49 p.m., the DON indicated her expectation regarding resident to resident altercations was for staff to break up the fight and notify her. A facility Abuse and Neglect Prohibition policy, with a revision date of 8/17, indicates Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes .physical abuse. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. The policy goes on to say that in the prevention of abuse, Facility supervisors will immediately investigate and correct reported or identified situations in which abuse .is at risk for occurring. During an interview on 11/12/19 at 3:38 p.m., the facility was asked for additional information at exit. No additional information was provided.

Based on observation , interview and record review, the facility failed to implement their written policies and procedures to prevent abuse for 3 of 27 residents reviewed for abuse. (Residents #1, #2 and #3) The facility did not prevent Resident #1, who had a history of [REDACTED].#2 and #3. Resident #1 knocked Resident #3 to the floor resulting in lacerations to Resident #3's lip and eye. Resident #1 hit Resident #2 repeatedly in the face and was physically aggressive with staff. This failure could place other vulnerable residents at risk for abuse. Findings included: A facility Abuse and Neglect Prohibition policy, with a revision date of 8/17, indicates Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes .physical abuse. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. The policy said in the prevention of abuse, Facility supervisors will immediately investigate and correct reported or identified situations in which abuse .is at risk for occurring. 1. An undated admission record, printed on 11/11/19 indicated Resident #1 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A psychiatric note dated 7/31/19 indicated the psychiatrist recommended Resident #1 for psychiatric visits once a week. There was no documentation of any psychiatric visits for Resident #1. A nurse's note dated 9/20/19 indicated Resident #1 was yelling at another resident, and punched LVN A in the face when LVN A attempted to redirect Resident #1. The MDS dated [DATE], indicated Resident #1 had severe cognitive deficits, memory problems, severely impaired decision-making skills, inattention and disorganized thinking. She was easily annoyed, had delusions, and had physical and verbal behaviors directed at others 1 to 3 days a week. She required the assistance of 1 staff member for transfers and bed mobility and did not require any mobility devices. The care plan with a review date of 10/17/19 indicated Resident #1 was a wander risk, had a behavior problem and believed another resident was her husband, was physically and verbally aggressive, and had impaired cognitive function. Interventions listed were to redirect the resident, modify the environment and administer medications. A nurse's note from 10/20/19 indicated Resident #1 followed Resident #3's roommate into his room, and when staff attempted to redirect Resident #1, she became verbally and physically aggressive with staff. She began cursing at and scratching the aides who were attempting to assist her out of the room. During an observation and interview on 11/12/19 at 1:26 p.m. CNA D had approximately 5 scars to her right arm and 1 scar on her left arm that she said were caused on 10/20/19 when she attempted to redirect Resident #1 when she found the resident in Resident #3's room. She said Resident #1 was physically aggressive. CNA D said Resident #1 was confused and began scratching her. She said CNA C tried to help her, but he received worse injuries than her. During an observation and interview on 11/12/19 at 1:38 p.m. CNA C had approximately 10 scratches to his bilateral arms. He said the DON knew Resident #1 scratched his arms on 10/20/19 while he was providing care. He said the DON's exact words were damn or dang, and she did not do anything about the physical abuse. During an interview on 11/12/19 at 1:51 p.m., the DON said she knew Resident #1 had aggressive behaviors toward staff and residents. She said they did not notify the physician. She said she did not learn about the Resident #1's physical attacks on CNA C and CNA D until a few days after they occurred. She said she did not call anyone or follow up on the incidents and said the CNAs knew to call their doctor if they were hurt. She said she was not sure if she should have anticipated Resident #1 becoming aggressive with other residents, because she said the staff were working with the resident and attempting to redirect her. During an interview on 11/11/19 at 2:10 p.m., LVN A said Resident #1 had aggressive behaviors. She said on 11/01/19, Resident #3's roommate reported to LVN A that Resident #3 was lying in the floor of their room. The nurse practitioner and LVN A found Resident #3 on the floor of his room in a pool of blood. Resident #1 was in Resident #3's room and had blood on her hands. Resident #3 said she hit me, she hit me. LVN A said the incident with Resident #3 was the second resident-to-resident altercation Resident #1 was involved in that same day; there had been an altercation with Resident #2 that morning. LVN A said Resident #1 had numerous physical altercations with staff and had never been out of the facility for treatment related to those behaviors. LVN A said it seemed the facility did not like to send residents out. LVN A said she reported Resident #1's aggressive behaviors for at least two months, in the morning meetings. She said she was told Resident #1 had a referral with the psychiatric nurse practitioner, but the psychiatric nurse practitioner never came. LVN A said on 10/20/19, Resident #1 physically attacked and injured CNAs C and D. LVN A said after Resident #1 injured the CNAs, there was a one-time order for [MEDICATION NAME], an antipsychotic, and no other medication changes were made. LVN A said Resident #1 had delusions that Resident #3's roommate was her husband and when staff would attempt to redirect her, she would become physically and verbally aggressive. LVN A said the social worker contacted the behavioral hospital after Resident #3 was found on the floor in a pool of blood on 11/01/19, and Resident #1 was then transferred out. During a phone interview on 11/12/19 at 1:14 p.m., LVN B said Resident #1 was verbally aggressive with anyone she believed was interfering with Resident #3 because she believed Resident #3's roommate was her husband. LVN B said Resident #1 would yell and became angry with other residents and staff. LVN B said the facility administration realized Resident #1 had aggressive behaviors. She said the only interventions put in place were to separate Resident #1 and Resident #3's roommate, redirecting them, and taking each resident to their own room. She said she had personally notified the facility administration of the resident's behaviors and aggression. An updated care plan dated 11/01/19 and revised on 11/07/19 indicated Resident #1 had two resident-to-resident altercations and sustained no injury from either. Interventions listed were to redirect the resident when she became aggressive, modify the environment and administer medications. The undated medication review report, printed on 11/11/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed an antipsychotic, and a drug used to treat dementia. The undated order summary report, printed on 11/12/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed anti-anxiety, and antipsychotic medications. 2. An undated admission record, printed on 11/11/19, indicated Resident #3 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #3 had severe cognition deficits, rarely understood others or had others understand him, and had severely impaired decision-making skills. He was easily annoyed and had physical behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a walker for mobility. The care plan with a review date of 9/18/19 indicated Resident #3 was a wander risk, had the potential to be physically aggressive, and had impaired cognitive function. A nurse's note dated 11/1/19 indicated Resident #3 was found on the floor of his room that morning with a pool of blood behind his head. He told staff that a woman had hit him multiple times. His right eye was red and swollen shut, with a bleeding laceration to his upper right eye. His right lower lip was cut open and bleeding, his nose was asymmetrical , (larger on one side) and he had scratches to his face and neck. He was sent to the ER for evaluation and treatment. The undated medication review report, printed on 11/11/19, indicated Resident #3 was located on the secure unit, was referred to psychiatric services, and was prescribed a drug to treat [MEDICAL CONDITION]. A SBAR (situation, background, assessment, recommendation) form dated 11/01/19 indicated Resident #1 was placed on 1:1 monitoring after her altercation with Resident #3. An incident report dated 11/01/19 indicated Resident #1 was removed from unit after she hit Resident #3 because he was trying to hurt her daughter. A copy of physician's telephone orders dated 11/1/19 indicate Resident #1's [MEDICATION NAME] was increased from once a day to twice a day and she was prescribed Donepezil, a drug used to treat dementia after her altercation with Resident #3. 3 An undated admission record, printed on 11/12/19, indicated Resident #2 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #2 had intact cognition with fluctuating inattention. He had delusions and verbal behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a wheelchair for mobility. The care plan with a review date of 6/27/19 indicated Resident #2 was a wander risk, had the potential to be physically and verbally aggressive and had impaired cognitive function. A nurse's note dated 11/1/19 at 11:00 a.m. indicated Resident #1 repeatedly punched Resident #2 in the face when Resident #2 wandered into Resident #1's room. When staff attempted to separate the residents, Resident #1 became physically and verbally aggressive with staff. The residents were then separated, and no injuries were noted to either resident. In an interview on 11/11/19 at 2:45 p.m., the administrator was unaware of the incident when Resident #1 was found in her room punching Resident #2 in the head, on 11/1/19 and said it was a verbal altercation between Resident #1 and Resident #2. He said the psychiatric nurse practitioner was scheduled to see Resident #1 on the afternoon of 11/1/19. He said Resident #1 could be argumentative with staff was unaware of any previous aggressive behaviors. The administrator said he was never notified in the facility's morning meetings of Resident #1's aggressive behaviors. He indicated Resident #1 had psychiatric challenges. During an interview on 11/12/19 at 9:43 a.m., LVN A said the administrator did not normally attend the morning meetings. She said she notified the DON repeatedly Resident #1 was aggressive with staff but the DON did nothing. LVN A indicated she was unaware of any weekly visits with Resident #1 conducted by the psychiatrist or psychiatric nurse practitioner. Psychiatric notes provided by the facility from 9/20/19 and 11/1/19, indicated the psychiatric nurse practitioner recommended that Resident #1 be seen 2 times a month for 6 months. The facility was unable to provide further notes documenting twice monthly visits. During an interview on 11/12/19 at 1:50 p.m., the ADON indicated she was aware of Resident #1's aggressive behavior. She said Resident #1 was violent and had a history of [REDACTED]. During an interview 11/12/19 at 1:54 p.m., the administrator said he became aware Resident #1 had slapped an employee on 11/12/19, the day she was transferred out of the facility. He said the DON did not tell him that CNA C and D were injured by Resident #1. He said a resident having physical behaviors with staff was concerning and would indicate aggression with other residents as well. During an interview on 11/12/19 at 1:55 p.m., CNA [NAME] indicated she had been slapped by Resident #1. During an interview on 11/12/19 at 2:00 p.m., the activity director indicated Resident #1 could be aggressive if staff or residents were in her space. During an interview on 11/12/19 at 2:02 p.m., LVN F indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:04 p.m., LVN [NAME] indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:49 p.m., the DON indicated her expectation regarding resident to resident altercations was for staff to break up the fight and notify her. During an interview on 11/12/19 at 3:38 p.m., the facility was asked for additional information at exit. No additional information was provided.

Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse to prevent further abuse to residents for 3 of 27 residents reviewed for abuse. (Resident #'s 1, 2 and 3) The facility did not thoroughly investigate when Resident #1, who had a history of [REDACTED].#2 and #3. Resident #1 knocked Resident #3 to the floor resulting in lacerations to Resident #3's lip and eye. Resident #1 hit Resident #2 repeatedly in the face and was physically aggressive with staff. This failure could place other vulnerable residents at risk for further abuse. Findings included: 1. An undated admission record, printed on 11/11/19 indicated Resident #1 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. A psychiatric note dated 7/31/19 indicated the psychiatrist recommended Resident #1 for psychiatric visits once a week. There was no documentation of any psychiatric visits for Resident #1. A nurse's note dated 9/20/19 indicated Resident #1 was yelling at another resident, and punched LVN A in the face when LVN A attempted to redirect Resident #1. The MDS dated [DATE], indicated Resident #1 had severe cognitive deficits, memory problems, severely impaired decision-making skills, inattention and disorganized thinking. She was easily annoyed, had delusions, and had physical and verbal behaviors directed at others 1 to 3 days a week. She required the assistance of 1 staff member for transfers and bed mobility and did not require any mobility devices. The care plan with a review date of 10/17/19 indicated Resident #1 was a wander risk, had a behavior problem and believed another resident was her husband, was physically and verbally aggressive, and had impaired cognitive function. Interventions listed were to redirect the resident, modify the environment and administer medications. A nurse's note from 10/20/19 indicated Resident #1 followed Resident #3's roommate into his room, and when staff attempted to redirect Resident #1, she became verbally and physically aggressive with staff. She began cursing at and scratching the aides who were attempting to assist her out of the room. During an observation and interview on 11/12/19 at 1:26 p.m. CNA D had approximately 5 scars to her right arm and 1 scar on her left arm that she said were caused on 10/20/19 when she attempted to redirect Resident #1 when she found the resident in Resident #3's room. She said Resident #1 was physically aggressive. CNA D said Resident #1 was confused and began scratching her. She said CNA C tried to help her, but he received worse injuries than hers. During an observation and interview on 11/12/19 at 1:38 p.m. CNA C had approximately 10 scratches to his bilateral arms. He said the DON knew Resident #1 scratched his arms on 10/20/19 while he was providing care. He said the DON's exact words were damn or dang, and she did not do anything about the physical abuse. During an interview on 11/12/19 at 1:51 p.m., the DON said she knew Resident #1 had aggressive behaviors toward staff and residents. She said they did not notify the physician. She said she did not learn about the Resident #1's physical attacks on CNA C and CNA D until a few days after they occurred. She said she did not call anyone or follow up on the incidents and said the CNAs knew to call their doctor if they were hurt. She said she was not sure if she should have anticipated Resident #1 becoming aggressive with other residents, because she said the staff were working with the resident and attempting to redirect her. During an interview on 11/11/19 at 2:10 p.m., LVN A said Resident #1 had aggressive behaviors. She said on 11/01/19, Resident #3's roommate reported to LVN A that Resident #3 was lying in the floor of their room. The nurse practitioner and LVN A found Resident #3 on the floor of his room in a pool of blood. Resident #1 was in Resident #3's room and had blood on her hands. Resident #3 said she hit me, she hit me. LVN A said the incident with Resident #3 was the second resident-to-resident altercation Resident #1 was involved in that same day; there had been an altercation with Resident #2 that morning. LVN A said Resident #1 had numerous physical altercations with staff and had never been out of the facility for treatment related to those behaviors. LVN A said it seemed the facility did not like to send residents out. LVN A said she reported Resident #1's aggressive behaviors for at least two months, in the morning meetings. She said she was told Resident #1 had a referral with the psychiatric nurse practitioner, but the psychiatric nurse practitioner never came. LVN A said on 10/20/19, Resident #1 physically attacked and injured CNAs C and D. LVN A said after Resident #1 injured the CNAs, there was a one-time order for [MEDICATION NAME], an antipsychotic, and no other medication changes were made. LVN A said Resident #1 had delusions that Resident #3's roommate was her husband and when staff would attempt to redirect her, she would become physically and verbally aggressive. LVN A said the social worker contacted the behavioral hospital after Resident #3 was found on the floor in a pool of blood on 11/01/19, and Resident #1 was then transferred out. During a phone interview on 11/12/19 at 1:14 p.m., LVN B said Resident #1 was verbally aggressive with anyone she believed was interfering with Resident #3 because she believed Resident #3's roommate was her husband. LVN B said Resident #1 would yell and became angry with other residents and staff. LVN B said the facility administration realized Resident #1 had aggressive behaviors. She said the only interventions put in place were to separate Resident #1 and Resident #3's roommate, redirecting them, and taking each resident to their own room. She said she had personally notified the facility administration of the resident's behaviors and aggression. An updated care plan dated 11/01/19 and revised on 11/07/19 indicated Resident #1 had two resident-to-resident altercations and sustained no injury from either. Interventions listed were to redirect the resident when she became aggressive, modify the environment and administer medications. The undated medication review report, printed on 11/11/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed an antipsychotic, and a drug used to treat dementia. The undated order summary report, printed on 11/12/19 indicated Resident #1 was located on the secure unit, was referred to psychiatric services, and was prescribed anti-anxiety, and antipsychotic medications. 2. An undated admission record, printed on 11/11/19, indicated Resident #3 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #3 had severe cognition deficits, rarely understood others or had others understand him, and had severely impaired decision-making skills. He was easily annoyed and had physical behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a walker for mobility. The care plan with a review date of 9/18/19 indicated Resident #3 was a wander risk, had the potential to be physically aggressive, and had impaired cognitive function. A nurse's note dated 11/1/19 indicated Resident #3 was found on the floor of his room that morning with a pool of blood behind his head. He told staff that a woman had hit him multiple times. His right eye was red and swollen shut, with a bleeding laceration to his upper right eye. His right lower lip was cut open and bleeding, his nose was asymmetrical , (larger on one side) and he had scratches to his face and neck. He was sent to the ER for evaluation and treatment. The undated medication review report, printed on 11/11/19, indicated Resident #3 was located on the secure unit, was referred to psychiatric services, and was prescribed a drug to treat [MEDICAL CONDITION]. A SBAR (situation, background, assessment, recommendation) form dated 11/01/19 indicated Resident #1 was placed on 1:1 monitoring after her altercation with Resident #3. An incident report dated 11/01/19 indicated Resident #1 was removed from unit after she hit Resident #3 because he was trying to hurt her daughter. A copy of physician's telephone orders dated 11/1/19 indicate Resident #1's [MEDICATION NAME] was increased from once a day to twice a day and she was prescribed Donepezil, a drug used to treat dementia after her altercation with Resident #3. 3 An undated admission record, printed on 11/12/19, indicated Resident #2 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated Resident #2 had intact cognition with fluctuating inattention. He had delusions and verbal behaviors directed at others 1 to 3 days a week. He required extensive assistance of 1 staff member for bed mobility and transfers and required a wheelchair for mobility. The care plan with a review date of 6/27/19 indicated Resident #2 was a wander risk, had the potential to be physically and verbally aggressive and had impaired cognitive function. A nurse's note dated 11/1/19 at 11:00 a.m. indicated Resident #1 repeatedly punched Resident #2 in the face when Resident #2 wandered into Resident #1's room. When staff attempted to separate the residents, Resident #1 became physically and verbally aggressive with staff. The residents were then separated, and no injuries were noted to either resident. In an interview on 11/11/19 at 2:45 p.m., the administrator was unaware of the incident when Resident #1 was found in her room punching Resident #2 in the head, on 11/1/19 and said it was a verbal altercation between Resident #1 and Resident #2. He said the psychiatric nurse practitioner was scheduled to see Resident #1 on the afternoon of 11/1/19. He said Resident #1 could be argumentative with staff was unaware of any previous aggressive behaviors. The administrator said he was never notified in the facility's morning meetings of Resident #1's aggressive behaviors. He indicated Resident #1 had psychiatric challenges. During an interview on 11/12/19 at 9:43 a.m., LVN A said the administrator did not normally attend the morning meetings. She said she notified the DON repeatedly Resident #1 was aggressive with staff but the DON did nothing. LVN A indicated she was unaware of any weekly visits with Resident #1 conducted by the psychiatrist or psychiatric nurse practitioner. Psychiatric notes provided by the facility from 9/20/19 and 11/1/19, indicated the psychiatric nurse practitioner recommended that Resident #1 be seen 2 times a month for 6 months. The facility was unable to provide further notes documenting twice monthly visits. During an interview on 11/12/19 at 1:50 p.m., the ADON indicated she was aware of Resident #1's aggressive behavior. She said Resident #1 was violent and had a history of [REDACTED]. During an interview 11/12/19 at 1:54 p.m., the administrator said he became aware Resident #1 had slapped an employee on 11/12/19, the day she was transferred out of the facility. He said the DON did not tell him that CNA C and D were injured by Resident #1. He said a resident having physical behaviors with staff was concerning and would indicate aggression with other residents as well. During an interview on 11/12/19 at 1:55 p.m., CNA [NAME] indicated she had been slapped by Resident #1. During an interview on 11/12/19 at 2:00 p.m., the activity director indicated Resident #1 could be aggressive if staff or residents were in her space. During an interview on 11/12/19 at 2:02 p.m., LVN F indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:04 p.m., LVN [NAME] indicated she was aware of Resident #1's aggressive behaviors. During an interview on 11/12/19 at 2:49 p.m., the DON indicated her expectation regarding resident to resident altercations was for staff to break up the fight and notify her. During an interview on 11/12/19 at 3:38 p.m., the facility was asked for additional information at exit. No additional information was provided. A facility Abuse and Neglect Prohibition policy, with a revision date of 8/17, indicates Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes .physical abuse. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. The policy goes on to say that in the prevention of abuse, Facility supervisors will immediately investigate and correct reported or identified situations in which abuse .is at risk for occurring.

Based on observation, interview, and record review, it was determined the facility failed to provide each resident with adequate supervision and assistance devices to prevent accidents for two (Residents #1 and #2) of five residents reviewed for falls. 1. CNA E failed to supervise Resident #1 while showering the resident and the resident fell out of the shower chair. This failure resulted in Resident #1 sustaining multiple lacerations and an Acute Subdural Hematoma, which contributed to her death. 2. CNAs H and G failed to transfer Resident #2 with a Hoyer lift, as care planned, from the shower chair to a wheelchair. 3. Facility staff failed to include the correct assistance with showers, transfers, and special needs for residents on the residents' profiles to alert the CNAs. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect all 100 residents, including Resident #2, by placing them at risk for falls, bruising, lacerations, hematomas, fractures, and death. Findings included: 1. The MDS assessment, dated [DATE], reflected Resident #1 was an [AGE] year-old female, who was admitted to the facility on [DATE], and her [DIAGNOSES REDACTED]. The assessment also reflected Resident #1 was totally dependent on the assistance of two staff for bathing and transfers. Further review of the MDS assessment revealed Resident #1 had limitations in ROM with impairment of both lower extremities. Resident #1's Care Plan, dated [DATE], reflected a Problem Start Date of [DATE], and, "Resident requires a Broda Chair (wheelchair which reclines/tilts to assist residents with positioning) to increase quality of life. Medical symptoms that warrant its use unable to sit upright in a w/c falls forward." The plan also reflected, "Resident required assistance with ADL's - Transfer: Assist of one." The plan reflected the resident required the assistance of one person for bathing. Review of Resident #1's Physician order [REDACTED]. Resident #1's Point of Care ADL Report dated [DATE] reflected she was showered with the assistance of two CNAs twice that day. Resident #1's Point of Care ADL Report dated [DATE] and [DATE] reflected she was showered by one CNA each day. The facility's Incident/Accident Reports from [DATE] through [DATE] reflected no Reports regarding Resident #1 falling. The facility's Incident/Accident Report, dated [DATE], reflected Resident #1 fell in the shower on [DATE] at 6:45 AM. RN C authored the Report, which reflected, "Describe Exactly What Happened: call to shower room by CNA & observed resident on floor in front of shower chair lying on Right side. Awake & mumbling, moving arms - contractures in legs. Laceration right side of head approx. 4.3 cm x .5 cm red areas on right shoulder - skin tear right elbow-red area on right hip, moaning with movement. Wounds cleaned - steri stripped & ice applied. (Physician I) & (family member) notified. Transport called to take to hospital for evaluation & tx." The Investigation Findings,signed by the DON and Administrator on [DATE], revealed, "Findings and Analysis: Resident in shower, (sic) aide turned back to resident to dispose of dirty linens & resident fell from shower chair sustaining an injury. Aide was not aware resident had ability to propel self from chair. Describe patient's or resident's health condition at the conclusion of the investigation: resident in room with hospice nurse receiving crisis care at this time. Resident appears to be free from pain & distress at this time. Family member at bedside. Will continue to monitor." Resident #1's Nurse's Notes dated [DATE] at 6:45 AM and written by RN C reflected CNA E called her to the shower room, and she saw Resident #1 on the floor on her right side in front of the shower chair. The Notes indicated CNA E said she (CNA E) turned to put a towel in the linen barrel, the resident leaned forward in the chair, and fell forward to the floor. The Notes reflected another CNA was asked to assist in turning Resident #1 for observation, and the resident had a laceration on the right side of her forehead approximately 4.3 cm in size and a laceration on her right elbow approximately 2.3 cm in size. Further review of the Nurse's Notes revealed Resident #1 had reddened areas on her right shoulder and right hip, was awake and alert, moaned with movement, and had contractures to her legs and arms. The Notes further reflected the laceration and skin tear were cleaned and steri-strips applied, and ice was applied to her head wound and first aid was given by the Weekend Supervisor. Review of the Nurse's Notes revealed Physician I and Resident #1's family member were notified, neuro checks continued, and at 7:30 AM, Resident #1 was transported to the hospital via ambulance. Resident #1's Emergency Department Notes dated [DATE] reflected she arrived in the Emergency Department on [DATE] at 8:06 AM due to a fall. The Notes also reflected the chief complaint was the resident slipped out of a chair during a shower, and had a laceration to right her forehead and right elbow. Further review of the Emergency Department Notes revealed Resident #1 was discharged from the Emergency Department on [DATE] at 3:35 PM with orders for Hospice. Resident #1's hospital CT Scan report, dated [DATE], reflected: "Final Result: Acute right subdural hematoma (Subdural hematomas are usually the result of a serious head injury. When one occurs in this way, it is called an "acute" subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death) with mass effect on the right cerebral hemisphere and mild developing edema of the right cerebral hemisphere. Shift of midline (midline shift of the brain occurs when either side of the brain halves goes over the center line. A midline shift of the brain can have dire consequences, as it may cause abnormal pressure on the [DIAGNOSES REDACTED] or other sensitive parts of the brain) to the left with compression of the right lateral ventricle. Mild to moderate diffuse cerebral atrophy with moderate chronic ischemic changes. This critical finding was relayed to (Physician J) at the time of dictation." Repair was done to right forehead laceration and right elbow laceration. Resident #1's Nurse's Notes dated [DATE] at 4:15 PM reflected she returned to the facility via ambulance. Resident #1's Care Plan, dated [DATE], reflected a Problem Start Date of [DATE], and "Resident has history of falling R/T a fall with injury - Intracranial Bleed. Goal: Resident will remain free from further injuries. Approach: Keep bed in lowest position with brakes locked. Place resident in a fall prevention program. Provide resident with safety device/appliance High/Lo bed. Treat injured areas per md orders" The plan also included: "Resident required hospice R/T a [DIAGNOSES REDACTED]. Goal: Resident will experience death with dignity and physical comfort. Advanced directive wishes will be honored. Resident to be repositioned Q frequently to prevent skin problems." The new Care Plan did not address showering the resident. Resident #1's Nurse's Notes dated [DATE] reflected the facility's Medical Director, who was not her attending physician, examined Resident #1 and discussed Hospice Care for the resident. The Notes also reflected Hospice Care was started on [DATE]. Resident #1's Nurse's Notes dated [DATE] at 8:03 PM reflected she expired with the Hospice Nurse and a family member at her bedside. The Notes also reflected Physician I was notified. The facility's "Provider Investigation Report" dated [DATE] reflected, "CNA completing shower, Resident sitting in shower chair. CNA turned to deposit wet towel in dirty laundry barrel. CNA heard loud crash/turned back around/saw resident on floor...Cerebral bleed/Laceration Subdural hematoma diagnosed post-CT scan...Resident was assessed per chg (charge) nurse (name of nurse). Resident had significant laceration on her head/R (right) frontal - 5.5 cm. Resident was transferred per EMS to hospital for further eval/tx...DON//weekend Supervisor performed interview with CNA, (CNA E). Resident's injuries were assessed/tx. Supervisor review of incident/findings were conducted...1) CNA (CNA E) suspended until investigation completed. 2) Staff (Nursing) have received re-education on Fall Prevention/Bath Safety. 3) Staff have demonstrated competent performance of skills as per organizational competency checklist - Bath Safety." The Report was signed by the DON on [DATE]. There were no witness statements or interviews attached to the Report. An interview with the DON on [DATE] at 10:29 AM revealed Resident #1 required maximum assistance with ADLs prior to the fall. The DON stated Resident #1 did not have any recent falls prior to her fall on [DATE]. The DON stated CNA E gave Resident #1 a shower, and CNA E turned to put a towel in the laundry bin, when Resident #1 fell forward out of the shower chair. The DON stated she was not aware Resident #1 could pull herself up from the chair. She stated, "Everything was a work in progress." The DON stated Resident #1 expired after returning from the hospital. The facility's Phone List dated [DATE] reflected the DON's hire date was [DATE]. A telephone interview with Resident #1's family member on [DATE] at 1:00 PM revealed the facility notified him/her of the resident's fall on [DATE]. He/She stated he/she was told by the DON the fall was an accident. He/She stated the DON said an aide, after giving the resident a shower, went to put towels in a bin and Resident #1 fell forward and hit her head and side. He/She stated he/she was unaware of the severity of the head injury until the ER called and told him/her Resident #1 was unresponsive. He/She also stated he/she did not understand how Resident #1 fell , if she had been correctly positioned in the shower chair. He/She stated, "(CNA F) was very upset and told (him/her) she (Resident #1) must have been unattended when she (Resident #1) fell ." A telephone interview with CNA E on [DATE] at 1:45 PM revealed she gave Resident #1 a shower the day she fell , [DATE]. She stated she turned to throw a towel in the barrel. CNA E revealed she did not see Resident #1 fall, but heard her fall, and turned back around and saw Resident #1 on the floor. When asked how Resident #1 was positioned in the shower chair, CNA E replied the resident had her back against the back of the shower chair. CNA E revealed she was the only one in the shower room when showering Resident #1 due to short staffing on the weekends. CNA E stated she was not aware Resident #1 required the assistance of two people with showers. CNA E revealed she had only worked the 300 Hall for a month. CNA E stated CNA Q, who was familiar with Resident #1, assisted her (CNA E) in transferring the resident with the Hoyer lift to the shower chair. CNA E said CNA Q told her to go shower the resident, so she (CNA E) assumed the resident only needed the assistance of one person in the shower. An interview with CNA F on [DATE] at 2:16 PM revealed she worked the 2:00 PM to 10:00 PM shift on Monday though Friday. CNA F stated she was aware of Resident #1's fall, and "It must had been in the shower!" CNA F revealed she knew Resident #1 had a tendency to lean forward, and the resident had the ability to pull herself up from the shower chair. CNA F also stated when showering Resident #1, the shower chair should be reclined. A telephone interview with RN C on [DATE] at 3:29 PM revealed she was working the day Resident #1 fell , [DATE]. RN C stated she was the Charge Nurse on the weekends for the 300 Hall. She revealed CNA E came out of the shower room and yelled Resident #1 had fallen. RN C stated she notified the Weekend Supervisor, assisted with first aid, and notified Physician I and the resident's family. RN C revealed CNA E turned around to get a towel when Resident #1 fell out of the shower chair. She said she was aware Resident #1 leaned forward, and that was why Resident #1 was placed in a Broda Chair. RN C stated CNA E was new to the hall and may not have been as quick to respond. RN C also stated Resident #1 needed the assistance of two persons for transfers and the assistance of one person for showers. A telephone interview with the Weekend Supervisor on [DATE] at 5:11 PM revealed she worked double shifts on Saturdays and Sundays from 6:00 AM to 10:00 PM. She stated she was notified of Resident #1's fall on [DATE] by RN C, and RN C had already started assessing Resident #1. She revealed Resident #1 was a two-person transfer via Hoyer lift and required the assistance of one person for showering. The Weekend Supervisor stated Resident #1 was able to raise her back off a chair. When asked how the facility communicated with the CNAs regarding the type of care each resident required, the Weekend Supervisor replied the information was on the Residents' Profiles that were entered into the kiosks. She stated the kiosks were located on each hall. She also stated the CNAs documented in the kiosk the "Point of Care" for each resident, which indicated the care they provided for that resident. The Weekend Supervisor revealed she was aware of Resident #1's tendency to lean forward due to her contractures. On [DATE] at 3:37 PM, the DON was asked for a copy of Resident #1's Resident Profile, and the DON stated she no longer had one in the computer, because the resident had been discharged . An interview with LVN D on [DATE] at 11:37 AM revealed Resident #1 was in a Broda Chair, because of her tendency to lean forward. LVN D stated Resident #1 was usually showered on the weekdays on the 2:00 PM to 10:00 PM shift, and she was not aware of the weekend shower schedule for Resident #1. When asked if the shower chair could be reclined, LVN D stated she was not sure. At this time, LVN D and the surveyor went to the 300 Hall shower room to observe the shower chair. LVN D stated the chair would not recline. CNA G came in the shower room at this time and she was asked if the shower chair could recline. CNA G demonstrated that the shower chair did recline. CNA G had to forcefully pull the lever to recline the chair. The surveyor asked CNA G if she ever reclined the shower chair when giving Resident #1 a shower, and CNA G stated, "No. You can see how hard it was to recline that chair!" CNA G also stated Resident #1 could pull herself up from the shower chair. An interview with ADON B on [DATE] at 12:01 PM revealed the residents' MDS assessments generated their care plans. ADON B stated the Charge Nurse, who completed the admission assessment, put the information in the Resident Profile. ADON B revealed there was no area on the Resident Profile to input specific instructions for the resident. ADON B stated all residents should only require a one-person assist with showers, unless the resident was combative. An interview with ADON A on [DATE] at 12:39 PM revealed two weeks ago, she was generating all the care plans for the whole facility based on the residents' MDS assessments. She stated within the last two weeks, the system was changed and that task was now divided among the ADONs. ADON A stated the Resident Profile was started approximately six months ago. ADON A stated the Resident Profile was only completed at the time of admission and had been recently changed to include quarterly and change of condition updates. ADON A stated any changes in condition were not updated on the Resident Profile unless the Charge Nurse completed a new Profile POC Form. She stated this system was being changed. ADON A stated she could not explain why Resident #1's Care Plan dated [DATE] identified Resident #1 as a one-person transfer when Resident #1 was actually a two-person transfer via Hoyer lift. ADON A stated she was aware Resident #1 had a tendency to lean forward. An interview with the DON and Corporate Nurse on [DATE] at 3:45 PM revealed no residents were currently in the facility who required the assistance of two people with bathing. They stated the MDS Coordinator completed the MDS assessment for Resident #1 incorrectly. 2) The MDS assessment, dated [DATE], reflected Resident #2 was an [AGE] year-old male, who was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. The assessment reflected the resident needed extensive assistance of two people with transfers and was totally dependent requiring the assistance of two people for bathing/showering. The assessment also reflected Resident #2 had functional limitations in ROM with impairment in his arm and leg on one side of his body. Resident #2's Resident Profile reflected, "Transfer with assist of 1." This entry was dated [DATE]. Review of Resident #2's Fall Risk Evaluation, dated [DATE], revealed a score of 28, which indicated the resident was at a high risk for falls. Resident #2's Care Plan, dated [DATE], reflected a problem start date of [DATE], and he required assistance with ADLs R/T CVA, was at risk for falls, and a Hoyer lift was to be used for transfers. His Care Plan also reflected he needed the assistance of two staff for transfers and the assistance one staff for bathing. Resident #2's "Point of Care ADL Report dated [DATE] reflected he was showered with the assistance of two staff members. Resident #2's "Point of Care ADL Report," dated [DATE], [DATE], [DATE] and [DATE] reflected he was showered with the assistance of one staff member. Resident #2's "Point of Care ADL Report dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] reflected the resident was transferred with the assistance of two staff members. Resident #2's "Point of Care ADL Report dated [DATE], [DATE], [DATE], and [DATE] reflected he was transferred with the assistance of one person. An observation on [DATE] at 10:29 AM revealed CNA H showering Resident #2 without assistance. After completion of the shower, CNA H was assisted by CNA G with dressing and transferring the resident from the shower chair to the wheelchair using a gait belt. CNAs H and G were observed putting socks and shoes on Resident #2. The shower room floor was wet, and Resident #2 asked CNA H to put a towel on the floor before he tried to transfer him. Resident #2 asked the CNAs to bring his shower chair over to the wall where he could grab the rail when standing to have his incontinent brief and pants put on him. CNA H placed the gait belt around Resident #2 and assisted the resident to a standing position. (Resident #2 was not able to use his left arm or leg due to S/P CVA.) While CNA H was holding Resident #2 up in a standing position using a gait belt, CNA G was securing the incontinent brief and trying to pull up the resident's pants. Resident #2 was trying to keep hold of the side rail yelling, "Don't drop me," fearful he was going to fall. Resident #2 was then transferred to the wheelchair via gait belt. 3. The facility's current Policy and Procedure on Fall Management, dated 2011, reflected: 1. The facility would identify each resident, who was at risk for falls and would plan care and implement interventions to manage falls. 2. Qualified staff would complete the Fall Risk Evaluation to determine if the resident was a fall risk. 3. A resident fall management program would be implemented, which educated staff in creative, functional strategies while recognizing residents' right and their need to maintain the highest practical level of function. Interventions to Include in Staff Education for Intrinsic and Extrinsic Risk Factors:Early identification and assessment of specific risk factors for each resident. Reassessment with any acute illness, change in functional or cognitive status. Documentation of specific interventions in interdisciplinary care plan. Reassessment at regular intervals to determine if interventions were effective. Importance of communication on any new potential risk factors. Team conference and root cause analysis of any fall, even no injurious ones. 4. An IJ was identified on [DATE]. On [DATE] at 2:46 PM, the Administrator, DON and Corporate Nurse were notified of the IJ and a Plan of Removal was requested at that time. 5. The facility's Plan of Removal, accepted on [DATE], reflected: Residents identified during the survey as having inconsistent Resident Profiles compared to Care Plans would be re-assessed for fall risk, care plan would be updated and Resident Profiles would be reflective for care giver instructions for that resident. All residents would be reassessed for falls by licensed nurses by [DATE] at 2:00 PM. The DON/ADON/Unit Managers would review the resident roster to determine if there were any residents who required additional supervision or specific equipment during the bathing process and would care plan and update the Resident Rosters to reflect those identified residents by [DATE] at 2:00 PM. Residents identified as fall risk would be placed on the Falling Star Program and a visual identifier would be placed on their door. Care plans would be reviewed by the Interdisciplinary Team for appropriate interventions and updates completed by [DATE] at 2:00 PM. New admissions and re-admissions would be assessed for Fall Risk upon admission/re-admission. A Care Plan would be developed and reviewed by the Interdisciplinary Team for appropriate interventions and updates on an ongoing basis. Unit Managers would monitor Care Plan updates Monday through Friday, and Weekend RN would monitor Care Plan updates Saturday and Sunday. The DON/ADON/Unit Managers would place any new interventions on the 24 Hour Report by [DATE] at 2:00 PM and update Resident Profiles. This would serve as communications to staff on care plan changes. This would be monitored by the DON or designee daily by review of 24 Hour Report, resident's medical record and Resident Profile. CNAs would be instructed by the Charge Nurse to check their Resident Profile upon reporting to work for any updates. Monday through Friday Unit Managers would check the 24 Hour Report for any new interventions and make observations of the resident to validate that the interventions remained in place. Saturday and Sunday, the Weekend RN would check the 24 Hour Report for any new interventions and make observations of the resident to validate that the interventions remained in place. Staff Development Coordinator/DON/designee will re-educate Certified Nurse Assistants, Medication Aides and Licensed Nurses on all shifts. A demonstration would be provided regarding the proper use of the reclining shower chair. A post test would validate staff understanding. This re-education and post test would be completed by [DATE] by 2:00 PM. Facility staff not receiving this education would not be permitted to work until education was completed. The DON/designee would place a list of residents at risk for falls at the Nurses' Stations by [DATE] by 2: 00 PM. The DON/designee would be responsible for updating this list on an ongoing basis. The list of residents at risk for falls would be reviewed weekly/revised by the Standard of Care meeting. If changes were made, a revised list would be placed at the Nurses' Station and an update to the Resident Profile by the DON/designee. The facility would establish a Fall Risk committee, which would include the DON, Unit Managers, Therapy Representative, and Social Services by [DATE]. The committee would meet weekly and would review all interventions from the previous week's falls for the effectiveness of interventions. If interventions were not effective the team would update the care plan and implement additional interventions. Any new interventions would be added to the 24 Hour Report and Resident Profiles on an ongoing basis. CNAs would be instructed by the Charge Nurse to check their Resident Profiles upon reporting to work for any updates. All incidents would be reviewed by the nursing management team daily. The DON or designee would review all incidents and investigations for appropriate follow-up interventions. Guardian Angel rounds would include any new interventions for follow-up by the management team. Guardian Angels were facility staff. The Guardian Angels would be given a current list of residents at risk for falls weekly. As they made their rounds, they would be confirming the visual identifiers were in place. Any concerns would be brought to the attention of the DON/designee. Incidents and accidents would be tracked and trended for patterns. This would be reviewed by the Performance Improvement Committee on a monthly basis and changes would be implemented at the time of discovery. The DON would be responsible for compliance. Overall monitoring of the Performance Improvement Committee was the responsibility of the Administrator. The Medical Director was notified on [DATE] by the Administrator about the IJ. Performance Improvement Committee meetings were scheduled every second Wednesday of each month at 12:00 PM. The Medical Director attended the Quality Assurance meetings and would discuss deficiencies cited in the area of fall management and the plan of correction. Residents with falls would be assessed each shift for any evidence of injuries from the fall for a minimum of 72 hours post incident. If any symptoms developed from the shift assessments during that period, assessments would be continued until resolved. In addition to documenting any findings in the resident's record, an entry would be made in the 24 Hour Report of any findings. Unit Managers would check the 24 Hour Report and observe residents on follow-up Monday through Friday, and the Weekend RN would check the 24 Hour Report and observe residents Saturday and Sunday. Resident #2's Resident Profile, dated [DATE], reflected he required transfer assistance by two people with a Hoyer Lift, and bed mobility with assistance of one. The Resident Profile Form reflected there was an area for "Alerts" and "Face Sheet Notes," but both areas reflected: "Not Displayed." This indicated no information had been inserted into those areas. A revised Fall Risk Evaluation, Care Plan and Resident Profile was completed for Resident #2 on [DATE]. The Fall Risk Evaluation, dated [DATE], reflected Resident #2 scored a 22, which indicated a high risk of falls. The Comprehensive Plan of Care, dated [DATE], reflected Resident #2 was at risk for falls as evidenced by a decline in his functional status. The plan of care approaches included the Falling Star Program and use of a Hoyer lift. The Resident Profile, updated [DATE], reflected Resident #2 required transfer assistance of two and required a Hoyer lift. 6. Further interview with CNA E on [DATE] at approximately 2:30 PM revealed Resident #1 had a tendency to lean forward and the shower chair was reclined at approximately a 45-degree angle. She stated she was in-serviced the day of the incident. 7. Observation of the 300 Hall shower room on [DATE] at 2:13 PM, while accompanied by RN C, revealed a different shower chair than was observed on [DATE] and this chair was not able to recline. RN C stated she was not sure if CNA E knew the facility had a shower chair that reclined. RN C stated she was not sure if the shower chair that was used for Resident #1 was able to be reclined or not. When asked how staff communicated when there were concerns or changes in a resident's condition, RN C stated changes in condition or concerns were written on the 24 Hour Log and it was the responsibility of the Charge Nurse to verbally relay the information to the oncoming shift. She stated the Charge Nurse was responsible for informing the CNAs of any changes in care or new safety concerns. 8. An interview with the DON and Corporate Nurse on [DATE] at 10:00 AM revealed the facility only had one shower chair that reclined. The Corporate Nurse stated the facility had two other shower chairs that reclined, but on Saturday ([DATE]), when they checked all the shower chairs, the other reclining shower chair was broken. The DON stated the facility had a total of four shower chairs, one for each shower room.9. Interviews conducted from [DATE] through [DATE] from 2:26 PM through 9:30 AM with LVN N, CNA O, RN C, CNA E, and CNA P revealed they were in-serviced regarding showers, abuse/neglect, the computer system and the resident profiles. 10. On [DATE] the IJ was removed. On [DATE] at 12:03 PM the Administrator, DON, and the Corporate Nurse were informed of the removal of the IJ. While the IJ was removed, on [DATE], the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. 4) The facility's Form CMS-672, Resident Census and Condition of Residents, dated [DATE], reflected 100 residents residing in the facility.