**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of Emergency Department records, review of a facility investigation, and interview, the facility failed to notify the Physician in a timely manner for changes in residents' condition for 2 residents (#24, #61) of 29 residents reviewed. The facility's failure to notify the Physician timely resulted in a delay in treatment and placed Resident #24 and #61 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:05 PM in the Administrator's office. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated revealed .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .The resident is involved in any accident or incident; including injuries of an unknown source .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Cardiovascular Disease, Hypertension, Peripheral Vascular Disease, and Frequent Falls. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assistance of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (anatomically speaking the wound is located at the 11:00 position on the face of a clock). Continued review of the Nurses' Notes revealed Resident #24 went to the Wound Clinic weekly for treatment of the pressure ulcer. Review of a facility investigation dated [DATE] revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM for treatment of the pressure ulcer. Continued review revealed while Certified Nursing Assistant (CNA) #1 and CNA #17 were getting Resident #24 up and dressed for her appointment, she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 who assessed the resident but took no further action. Review of the facility investigation revealed upon return to the facility, CNA #3 observed the resident's knee appeared swollen with the knee cap leaned over and reported her observations to LPN #3. Continued review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Further review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Continued review of the facility investigation dated [DATE] revealed CNA #5 was showering the resident on [DATE] and noted the resident's .right knee was swollen and the knee was not sitting straight up the way it was on [DATE] . Continued review revealed CNA #3 informed LPN #5 of the swollen knee who agreed the knee was swollen and stated she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, painful and notified the Physician who gave an order for the resident to be transferred to the Emergency Department (ED). Continued review of the facility investigation revealed the ED Nurse called the facility to ask if the resident had fallen because she had a femur fracture (fracture of the long bone in the leg). Review of the ED record dated [DATE] at 12:02 AM revealed Resident #24 had a history of Dementia, non-ambulatory, and was to be evaluated for right knee edema and pain. Continued review of the ED records revealed a statement the Resident had no trauma and was non-ambulatory according to facility records. Review of the ED records revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur [long bone of thigh] into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weight bearing, swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment, pain level, or the status of the resident's knee by LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 5:39 PM revealed Resident #24 was noted to have a right swollen knee per LPN #5 and LPN #4 agreed the knee was swollen, warm, and painful to touch. Continued review revealed the Physician was notified and gave orders for the resident to be transferred to the hospital. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 returned from the Wound Clinic her knee was swollen. Continued interview revealed she notified the Charge Nurse (LPN #3) the resident's knee was swollen on [DATE]. Further interview revealed CNA #3 took Resident #24 to her room and assisted her to bed. Further interview revealed CNA #3, who initially saw the knee upon return from the Wound Clinic knew something was wrong and told LPN #3 but no action was taken. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was no documentation of observation of the resident's knee and no action was taken. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked the LPN #5 to look at the resident's legs. CNA #5 continued to state the knee was turned inward and the resident was in severe pain. Continued interview with CNA #5 revealed LPN #5 resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy (PT) if they could help with positioning. The therapist stated not to bother doing anything because the [Resident's] leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM and [CNA #1] asked a co-worker to assist the resident with getting dressed and into a wheelchair for pickup. Continued interview revealed the resident had no complaints or abnormalities. Further interview revealed about 2:00 PM Resident #24 complained of leg pain and LPN #3 assessed the leg but found no concerns. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a right heel pressure ulcer which was treated at the Wound Clinic and complained of foot pain regularly. Continued interview revealed CNA #9 notified LPN #1 of the knee swelling who thought a PT consult was needed. Further interview revealed when the swelling was reported a second time the resident was transferred to the ED and the femur fracture was diagnosed. Interview revealed Resident #24 returned to the facility in late 12/2017 from the hospital with a right above the knee amputation and gastric tube (feeding tube in stomach) and was in poor health at the time. Continued interview revealed a few days later the resident's blood pressure and blood glucose became elevated so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; her heart stopped on [DATE]; and died. Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, stated Resident #24 was transferred using a stand-pivot method. Interview with the DON confirmed there was a delay in notifying the Physician so medical treatment could be obtained for Resident #24 when she had pain and swelling of her knee. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting [Resident #24] in and out of the clinic. Continued interview revealed once inside the staff stood the resident up and eased her to the treatment bed using the stand-pivot method of transfer; eased her legs onto the bed; and propped her right leg on a pillow. Further interview with CNA #2 revealed she accompanied Resident #24 to and from the Wound Care Clinic in the van and offered to assist with the resident's transfer at the clinic but was not needed. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and Peripheral Vascular Disease. On [DATE] upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. LPN #3 assessed the knee; felt there was no significant swelling; and failed to document her assessment. CNA #3 stated she told the Nurse about Resident #24's swollen knee and pain but the Nurse failed to document any assessment of the resident's knee and failed to notify the Physician. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation the Physician was notified from [DATE]-[DATE] when CNAs stated they reported the resident had pain. Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident required surgical intervention with a right above the knee amputation and insertion of a feeding tube, by which she received her nutrition. The resident subsequently developed pneumonia and a systemic infection, her heart stopped, and died. The facility failed to notify the Physician timely of Resident #24's complaints of pain and change in condition and a delay of care resulting in Immediate Jeopardy for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with diagnoses including Type 2 Diabetes Mellitus, Dementia, Left Above the Knee Amputation, Peripheral Vascular Disease, Hypertension, Heart Failure, Depression and Anxiety. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional diagnosis of Right Femur Fracture (long bone in the thigh) was added on [DATE] when readmitted . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Continued review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .[Resident #61] was in the bed .This morning, [12-9-2017] she said her knee was hurting .As I was changing her she complain[ed] of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the Director of Nursing (DON) who documented .CNA reported that nurse on 11-7 [night shift] was made aware around 5 AM of resident's complaint of pain to right knee . Review of a witness statement signed by Licensed Practical Nurse (LPN) #9 dated [DATE] included in the facility investigation revealed, .When I went in resident's room to give pain med [medication] for rt [right] leg [CNA #10] told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM [night shift] on [DATE] . Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the resident's voiced pain, a man had dropped her, or any pain medication was given. Medical record review revealed a Physician's Telephone Order dated [DATE] at 12:30 PM Stat [immediately] right knee x-ray due to swelling and pain . signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain[ed] of R [right] knee pain stated she was drop[ped] by a man last night right knee noted to be swollen painful to touch or move MD [medical doctor] made aware order to have x-ray done and call him .will continue to monitor waiting on [mobile x-ray] to come to facility for x-ray . Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing's (ADON) office, confirmed the facility did not follow their policy on promptly notifying the resident's Physician when Resident #61 reported to LPN #9 around 5:30 AM to be in pain and someone had dropped her, resulting in a delay of treatment until it was reported to the Physician approximately 7 hours later. Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, regarding the delay in reporting of a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them (LPN #9, CNA #10). The surveyor verified the Allegation of Compliance by: 1. On [DATE] the on-call Nurse who failed to notify the DON of the incident for 3 days was in-serviced on timely reporting and quality of care. 2. On [DATE] all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On [DATE] all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 4. On [DATE] all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On [DATE] all staff were educated on Notification of Change and Condition. 6. On [DATE] staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, and Reporting all Resident Claims. 7. On [DATE] licensed staff were educated on Incomplete Data on the Medication Administration Records and Treatment Administration Records. 8. From [DATE] - [DATE] all staff were educated again on the Abuse Policy and Procedure, notification, and Reporting. 9. Review of daily audits on [DATE] and [DATE], of resident observations for change in pain, change or decline in condition, assessment as indicated with Physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Licensed Staff and CNAs assigned to each resident. 10. Interview with staff members on [DATE] regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims revealed they were able to discuss each of the topics. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility investigations, observation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention for 3 residents (#24,#61,#32) failed to prevent resident to resident abuse for 8 residents (#43, #62, #64, #67, #75, #81, #93, #167) reviewed for abuse of 48 sampled residents. The facility's failure to prevent neglect placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:05 PM in the Administrator's office. F-600 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Abuse Prevention Policy and Procedure, revised [DATE] revealed, The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any staff member, other residents .It is the policy of this facility .to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .A resident to resident altercation should be reviewed as a potential situation of abuse .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . Medical record review revealed Resident #24 was admitted to the facility on [DATE], readmitted on [DATE] and [DATE] with diagnoses including Atherosclerotic Cardiovascular Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, and Frequent Falls. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness wound where the wound extends below layers of healthy skin) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (using a face of a clock showing 11:00 anatomically). Continued review of Nurses' Notes revealed Resident #24 went to an off-site Wound Clinic once weekly for treatment of the pressure ulcer. Medical record review of Wound Clinic notes revealed Resident #24 had a pressure ulcer on her right heel which was necrotic and was debrided on [DATE] (prior to her admission to the facility). Continued review of the Wound Clinic notes dated [DATE] revealed the wound had deteriorated and the upper edges were necrotic. Further review of the Wound Clinic notes dated [DATE] revealed the wound had undermining; was debrided; and an x-ray was ordered to rule out osteomyelitis. Continued review of the Wound Clinic notes dated [DATE] revealed Resident #24 had a Stage III pressure ulcer on the right heel longer than 9 months and the facility had been using Medihoney with minimal improvement. Further review revealed the ulcer measures 0.9 cm x by 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record (MAR) for 11/2017 revealed Resident #24 was ordered Acetaminophen (Tylenol) 325 milligrams (mg), give 2 tablets every 4 hours as needed and Lortab 5/325 mg, give 0.5 tablet one hour before wound care. Medical record review of Nurses' Notes dated [DATE] at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by Licensed Practical Nurse (LPN) #9. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of a facility investigation dated [DATE] revealed Resident #24 went to the Wound Clinic weekly. Continued review revealed when Certified Nursing Assistant (CNA) #1 and CNA #17 were getting the resident ready for her appointment when she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 of the resident's pain and slight swelling and LPN #9 assessed Resident #24. Continued review revealed upon return from the wound care clinic the resident's knee appeared swollen with the knee cap leaned over. CNA #3 reported her observations to the nurse. Further review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment of the resident's knee by either LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 3:19 PM revealed Resident #24 had no complaints of pain or discomfort. Medical record review of Nurses' Notes dated [DATE] at 8:45 AM revealed Resident #24 had no complaint of pain voiced. Continued review of the Nurses' Notes revealed at 1:07 PM the resident had no complaint or indication of pain. Further review of the Nurses' Notes at 1:11 PM revealed the resident's right heel had deteriorated with the wound being smaller but the depth had increased. Medical record review of the Comprehensive Care Plan revealed an update on [DATE] with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Review of a PT evaluation dated [DATE] revealed Resident #24 was wheelchair bound prior to admission. Continued review revealed the resident required maximum assistance to go from supine to sitting as well as to roll from side to side for care. Further review revealed the resident required total assistance of 2 people to scoot up in bed. Review of a facility investigation dated [DATE] revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on [DATE]. Continued review revealed CNA #3 informed LPN #3 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful, notified the Physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated [DATE] at 12:02 AM, revealed Resident #24 had a history of Dementia and was to be evaluated for right knee edema and pain. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Further review od the ED record revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Review of the hospital record of a consult from the Infectious Diseases Physician dated [DATE], revealed the right heel wound was necrotic and had an odor suggesting infection. Continued review revealed the Physician documented would require further medical or surgical debridement or right below the knee amputation. Further review revealed the Physician documented Resident #24 had very poor nutritional intake which was a risk factor for poor healing of a wound or surgical site. Continued review revealed the resident was very frail with Dementia and was expected to have poor quality of life. Further review revealed the Physician hoped the amputation could be done within the next week to avoid prolonged use of antibiotics with their side effects. Review of hospital notes dated [DATE] revealed Resident #24 underwent an .above the knee amputation of the right leg due to non healing distal right femoral shaft fracture, peripheral vascular disease, non-healing right foot wound . Medical record review revealed Resident #24 returned to the facility on [DATE] with a right above the knee amputation, G-tube (used to instill feeding directly into the stomach) and tube feeding infusing, as well as a Stage III pressure ulcer on the coccyx. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was admitted to the hospital with blood pressure 181/101, pulse 128, temperature 101.3, and glucose 349. Continued review revealed Resident #24 was diagnosed with .healthcare associated pneumonia/hospital-acquired pneumonia/aspiration pneumonia . Review of a Physician's Note dated [DATE] revealed the resident had been doing poorly for the last few months and was expected to have poor quality of life. Continued review revealed the Hospitalist discussed the resident's medical condition with the family but they wanted aggressive measures. Further review of a Physician's Note dated [DATE] revealed .had long discussion with daughter and son. They want to continue full code and aggressive therapy. Patient is lethargic and encephalopathic . Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 had returned from the hospital. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was .found by a CNA and it looked as if she was not breathing . Further review revealed the Nurse was notified and Cardiopulmonary Resusitation (CPR) was begun. Continued review revealed Resident #24 was transferred to the hospital where she expired. Review of the Certificate of Death revealed the cause of death included Coronary Artery Disease, Diabetes Mellitus with Hyperglycemia, Peripheral Vascular Disease, and Hyperlipidemia. Telephone interview with LPN #9 on [DATE] at 10:35 AM revealed she had no idea Resident #24 had a fractured hip because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to find a cause for the fracture. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic on [DATE], her knee was swollen. Continued interview revealed she notified LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her in bed. Medical record review of the 11/2017 MAR revealed no documentation Tylenol was administered for the resident's pain. Medical record review of Nurses' Notes revealed no documentation LPN #9 or LPN #3 assessed the resident to determine her pain level or the status of the resident's knee. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked LPN #5 to look at the resident's legs and the knee was turned inward and the resident complained of severe pain. Continued interview revealed LPN #5 stated the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed LPN #5 asked PT if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the Nurse assessed the leg but found no concerns. Medical record review of the 11/2017 MAR revealed no documentation of Tylenol administration in spite of the resident complaining of severe pain. Medical record review of Nurses' Notes dated [DATE] revealed no documentation LPN #5 assessed the resident's knee. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the Nurse of the knee swelling who thought a PT consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hospital and the femur fracture was diagnosed. Interview revealed Resident #24 returned to the facility in late 12/2017 with a right above the knee amputation and a PEG tube and was unstable at the time. Continued interview revealed a few days later the resident's blood pressure and glucose became unstable so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; coded on [DATE]; and expired. Interview revealed there was no conclusion as to the cause of the fracture. Continued interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed the CNA who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Interview the DON confirmed there was a delay in obtaining medical treatment for Resident #24 when she had swelling of her knee; did not receive appropriate pain management; and was not assessed appropriately when she complained of leg pain. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the clinic the wound clinic staff stood the resident up; used a stand-pivot method to ease her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview revealed the CNA (#5) who initially saw the knee upon return from the Wound Clinic knew something was wrong and told both the Charge Nurse and the facility Wound Care Nurse but no action was taken. Further interview revealed the Charge Nurse assessed Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was little documentation of observation of the resident's knee and no treatment was provided. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and Peripheral Vascular Disease. On [DATE] upon return from the Wound Clinic, the CNA noted the resident's right knee was swollen. The LPN assessed the knee; saw no significant swelling; and failed to document her assessment. The resident was also complaining of pain in her legs; the LPN stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain but the Nurses failed to document any assessment of the resident's knee; Nurses failed to document administration of pain medication; and Nurses failed to notify the Physician of the resident's complaint of pain. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered when the resident was complaining of pain; the Physician was notified; Resident #24 was transferred to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident underwent a right above the knee amputation; insertion of G-tube Tuve inserted into the stomach); and enteral feedings. The resident subsequently developed pneumonia and sepsis; coded; and died. The failure to notify the Physician in a timely manner of the swollen knee; failure to administer pain medication when the CNAs notified the Nurses the resident was complaining of pain; and the failure of the Nurses to document assessments of the resident's knee constituted neglect for Resident #24 at an Immediate Jeopardy level. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with diagnoses including Type 2 Diabetes Mellitus, Dementia, Left Above the Knee Amputation, Peripheral Vascular Disease, Hypertension, Heart Failure, Depression and Anxiety. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional diagnosis for Right Femur Fracture was added on [DATE] when readmitted . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for poor nutritional status related to diagnosis of Diabetes Mellitus, Hypertension, Congestive Heart Failure, Left Above the Knee Amputation and was considered Obese. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Continued review of the Care Plan revealed the resident was at risk for falls related to decreased mobility, cognitive and physical function deficits. Further review revealed approaches for the Care Plan included bed in low position and safety mats at bedside. Continued review revealed Resident #61 required assistance with Activities of Daily Living (ADL's) due to decreased mobility, multiple chronic disease processes, generalized weakness and Above the Knee Amputation of the Left Leg. Further review revealed the resident had .Decreased vision related to: blind in left eye and poor vision in right eye. I do not wear glasses as they do not help me . Continued review revealed Resident #61 had cognitive loss present as evidenced by her short term memory loss. Medical record review of the MAR for [DATE] revealed Resident #61 had an order dated [DATE] for Hydrocodone/Acetaminophen (pain medication) 5/325 mg one tablet by mouth three times daily (TID) prn. Continued review revealed no hydrocodone pain medication was administered [DATE] through [DATE]. Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the voiced pain, that a man had dropped her, or that any pain medication was administered. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .[Resident #61] was in the bed .This morning, 12-9-2017 she complain[ed] that her knee was hurting .As I was changing her she complain[ed] of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the DON and documented .CNA reported that Nurse on 11-7 was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated [DATE] included in the facility investigation revealed, .When I went in [the] resident's room to give pain med [medication] for rt [right] leg that [CNA #10] told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on [DATE] . Review of an interview conducted by LPN #2/Unit Manager with Resident #61 on [DATE] at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on. 4. ' Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review of a Physician's Telephone Order dated [DATE] at 12:30 PM revealed Stat [immediately] right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain[ed] of R [right] knee pain stated she was drop[ped] by a man last night right knee noted to be swollen painful to touch or move MD [Medical Doctor] made aware order to have x-ray done and call him .will continue to monitor waiting on mobile x-ray to come to facility for x-ray . Medical record review of a Social Service Note dated [DATE] revealed .SSD (Social Services Director) met with resident in room. Resident resting in bed with eyes open .Is HOH [hard of hearing] and suffers with vision problems which can make communication difficult at time[s], even when getting down at resident's level . Medical record review of a Social Servise Note dated [DATE] revealed .SSD met with resident in room .Could be heard yelling out which is baseline for resident . An interview was attempted with Resident #61. Although she was able to speak at the time of the incident, she had been in the hospital in the interval and was now unable to speak. Interview with LPN #7 on [DATE] at 7:55 AM on the 200 hall revealed she was passing medications the morning of [DATE] and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed the LPN went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and the LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. The LPN stated she called the doctor and received an order for an x-ray. Further interview revealed it took a while for the mobile x-ray to get to her. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on [DATE]. Interview with LPN #9 on [DATE] at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on [DATE] and completed on the morning of [DATE]. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of [DATE] and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of the Physician's Orders for [DATE] revealed there was no order for Tylenol. Interview with CNA #10 on [DATE] at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on [DATE] and he notified LPN #9 and she went in to check on her. Interview with LPN #2 on [DATE] at 3:35 PM in the Restorative Nursing office revealed she came to the facility on [DATE] about dusk dark and assessed Resident #61 upon arrival. Continued interview revealed the resident told her that her leg was hurting. The Surveyor asked What medication did [LPN #9] give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing (ADON)'s office, confirmed the facility failed to follow their policy on administering pain medication. Continued interview with the DON confirmed the facility failed to promptly notify the resident's Physician when the resident had a change of status. These failures resulted in neglect, which is classified as abuse, due to Resident #61 not receiving pain medication and a delay in treatment of approximately 6 hours Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain with no pain medication given, and the neglect in the delay in reporting and a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9, CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Iron Deficiency Anemia, Barrett's Esophagus, Dysphagia, Pressure Ulcer of Left Heel Stage 3, Pain in Left Hip, Muscle Weakness, Heart Failure. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR dated 1/2018 revealed dates [DATE] thru [DATE] .Fentanyl [opioid] 12 MCG [Micrograms]/HR [Hour] Patch apply on epatch [one patch] every 3 days for apin [pain]. Rotate site . Was not documented as administered. Medical record review of the MAR for 1/2018 revealed on [DATE] at 3:00 PM the resident's scored 7/10, (pain level scored from 1 - 10 with 1 being the lowest pain level and 10 being the highest pain level); on [DATE] at 3:00 PM it was 8/10; on [DATE] it was 5/10, and on [DATE] it was 9/10. Observation of Resident #32 on [DATE] at 12:20 PM in his room with the DON present revealed she performed a skin assessment. Continued observation revealed no Fentanyl Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on [DATE] at 12:25 PM in Resident #32's room, revealed staff are notified to check placement of Fentanyl Patch, when it pops each shift on the computer . Interview with LPN #1 on [DATE] at 2:33 PM in the Medication Room at the back Nurses' Station revealed Resident #32 needed another written prescription to be faxed to the pharmacy. I don't believe he got a Fentanyl Patch on that day ([DATE]) Interview with LPN #2 on [DATE] at 3:15 PM revealed the Pharmacy was called regarding filling the Fenatyl patch. The original order was faxed on [DATE]. But mg was placed on the order instead of mcg. Continued interview revealed Resident #32 did not have a Fentanyl Patch on and the correct order was faxed on [DATE]. Interview with the DON on [DATE] at 3:30 PM at the back Nurses Station confirmed the facility failed to ensure Resident #32 received his Fentanyl Patch, which resulted in Resident #32 not receiving pain medication for 10 days and while experiencing pain. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Aphasia, Ataxia, Congestive Heart Failure, Atrial Fibrillation, and Dementia. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #43 scored 8 on the BIMS indicating she was moderately cognitively impaired. Medical record review revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Obsessive-Compulsive Disorder, Weight Loss, Atrial Fibrillation, Hypertension, and Femur Fracture. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #62 scored 12 on the BIMS, indicating she was mildly cognitively impaired. Review of the facility investigation revealed on [DATE] two residents (#43, #62) had an altercation. Continued review of a statement from the Activity Aide dated [DATE] revealed .At or around 4:05 PM while finishing up the movie matinees, I witnessed two residents [#43, #62] in a fist fight in the middle of the room. As I was trying to separate the two [#62] would not let go of [#43] arm and would not stop hitting her . Further review of the facility investigation on [DATE] revealed a statement from Resident #85 who stated she witnessed both residents hitting one another but [Resident #62] started it. Continued review of the facility investigation revealed a statement from another resident who stated .Resident #62] pinched [Resident #43] and [Resident #43] pinched back and they started fighting . Medical record review of Nurses' Notes dated [DATE] revealed LPN #2 was called to the dining room by the Activity Director and found Resident #62 in a physical altercation with Resident #43. Continued review revealed Resident #62 stated She hit me. Further review revealed the residents were separated but Resident #62 hit Resident #43 on the back of the shoulder. Continued review revealed Resident #62's son requested the resident be sent to the ED. Interview with the DON on [DATE] at 2:30 PM in the DON's office, confirmed Resident #43 and Resident #62 were involved in a resident-to-resident altercation. Medical record review revealed Resident #167 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Accident, Dementia, Psychotic disorder, Anxiety Disorder and Vascular Dementia with Behaviors. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #167 had a BIMS of 3 indicating the resident as severely cognitively impaired. Review of facility investigation dated [DATE] revealed Resident #43 was in the dining when she was hit with a coffee cup by Resident #167. Interview with Resident #43 on [DATE] at 8:15 AM in her room revealed Resident #167 hit Resident #43 on the head with a coffee cup and Resident #43 hit Resident #167 on the shoulder. Interview with the LPN #2 on [DATE] at 10:57 AM at the front Nurses Station revealed LPN #2/Unit Manager was called to the dining room because Resident #167 threw a coffee cup at Resident #43. When LPN #2/Unit Manager got to the dining room she observed Resident #167 was agitated and was slinging her arms and trying to self-propel. Resident #43 was seated at another table. Continued i[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility investigation, medical record review, and interview, the facility failed to correctly document residents' medical problems including assessments of residents with pain for 2 residents (#24, #61) of 48 residents reviewed. The facility's failure to provide accurate assessments placed Resident #24 and Resident #61 in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator was notified of the Immediate Jeopardy on 2/28/18 at 4:05 PM in the Administrator's office. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 3/2/18. The findings included: Review of facility policy, Pain Management, undated revealed .Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers .In the long-term care setting the comfort and well-being of the individual resident should always be paramount .Adequate pain management should be sought in each case .The same pain control measures that are used for residents who are able to communicate should be used for residents unable to communicate their pain due to dementia, aphasia or other causes . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Cardiovascular Disease, Hypertension, Peripheral Vascular Disease, and Frequent Falls. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Review of a facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic weekly for treatment to the right and left heels. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. Certified Nurse Aide (CNA) #3 reported her observations to the Nurse. Further review revealed Licensed Practical Nurse (LPN) #3 assessed the resident who complained of heel pain when questioned. Review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe swelling to the leg. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation of an assessment by LPN #3 or LPN #9. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Medical record review of Nurses' Notes on 11/23/17 at 1:11 PM revealed the resident's right heel had deteriorated with the wound being smaller but the depth had increased. Review of a facility investigation dated 11/24/17 revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on 11/21/17. Continued review revealed CNA #3 informed LPN #10 of the swollen knee who agreed the knee was swollen and stated she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, and warm to touch, and notified the Charge Nurse (LPN #4). Medical record review of Nurses' Notes dated 11/24/17 at 5:39 PM revealed Resident #24 was noted to have a right swollen knee per LPN #5 and LPN #4 agreed the knee was swollen, warm, and painful to touch. Continued review revealed the Physician was notified at 5:39 PM by LPN #4 and gave orders for the resident to be transferred to the hospital. Review of the facility investigation revealed the ED nurse called the facility to ask if the resident had fallen because she had a femur fracture. Interview with the Director of Nursing (DON) on 2/1/18 at 4:03 PM in her office revealed Resident #24 had a heel ulcer which was treated at the Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the nurse of the knee swelling who thought a PT consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the Emergency Department (ED) and the femur fracture was diagnosed. Further interview with the DON confirmed Nurses had failed to assess Resident #24 appropriately when the CNAs reported the resident was having leg pain. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with diagnoses including Type 2 Diabetes Mellitus, Dementia, Left Above the Knee Amputation, Peripheral Vascular Disease, Hypertension, Heart Failure, Depression and Anxiety. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional diagnosis for Right Femur Fracture was added on 12/12/17 when readmitted . Medical record of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was total dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides and was unable to ambulate. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated 12/29/16 revealed Resident #61 was at risk for poor nutritional status related to diagnosis of Diabetes Mellitus, Hypertension, Congestive Heart Failure, and Left Above the Knee Amputation. Medical record review of a Care Plan dated 1/4/17 revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Continued review of the Care Plan revealed the resident was a risk for falls related to decreased mobility, and cognitive and physical function deficits. Further review revealed approaches for the Care Plan included bed in low position and safety mats at bedside. Continued review revealed Resident #61 required assistance with Activities of Daily Living (ADLs) due to decreased mobility, multiple chronic disease processes, generalized weakness and Above the Knee Amputation (AKA) of the Left Leg. Further review revealed the resident had .Decreased vision related to: blind in left eye and poor vision in right eye. I do not wear glasses as they do not help me . Continued review revealed Resident #61 had cognitive loss present as evidenced by her short term memory loss. Medical record review of the Medication Administration Record, (MAR) for December 2017 revealed Resident #61 had an order dated 12/4/17 for Hydrocodone/Acetaminophen (pain medication) 5/325 milligrams (mg), one tablet by mouth three times daily (TID) as needed (PRN). Continued review revealed no hydrocodone pain medication was administered 12/4/17 through 12/9/17. Review of a witness statement signed by Certified Nurse Aide (CNA) #10 dated Saturday, 9, 2017 revealed .[Resident #61] was in the bed .This morning, 12-9-2017 she complain[ed] that her knee was hurting .As I was changing her she complain[ed] of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM and signed by the Director of Nursing [DON] and documented .CNA reported that nurse on 11 AM-7 PM shift was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med [medication] for rt [right] leg that [CNA #10] told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Medical record review of the Nurses' Notes for 12/9/17 revealed no documentation by LPN #9 regarding the voiced pain, a man had dropped her, any assessment of the resident for injuries, or any pain medication was administered. Review of a facility investigation and an interview conducted by LPN #2/Unit Manager with Resident #61 on 12/9/17 at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on.' 4. Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review revealed a Physician's Telephone Order dated 12/9/17 at 12:30 PM revealed Stat [immediately] right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain[ed] of R [right] knee pain stated she was drop[ped] by a man last night right knee noted to be swollen painful to touch or move MD [medical doctor] made aware order to have x-ray done and call him .will continue to monitor waiting on mobile x-ray to come to the facility for x-ray . Medical record review of a Social Service Note dated 12/13/17 revealed .SSD [Social Services Director] met with resident in room. Resident resting in bed with eyes open .Is HOH [Hard of Hearing] and suffers with vision problems which can make communication difficult at time, even when getting down at resident's level . Medical record review of a Social Service Note dated 12/13/17 revealed .SSD met with resident in room .Could be heard yelling out which is baseline for resident . Interview with LPN #7 on 1/31/18 at 7:55 AM on the 200 hall revealed she was passing medications the morning of 12/9/17 and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed the LPN went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and the LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to Resident #61's pain level. The LPN stated she called the doctor and received an order for an x-ray. Further interview revealed it took a while for the mobile x-ray service to get to her. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on 12/9/17. Telephone interview with LPN #9 on 1/31/18 at 10:18 AM revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. The Surveyor asked the LPN what she remembered about Resident #61 the morning of 12/9/17 and the LPN stated the resident complained of foot and leg pain frequently and then stated I gave her Tylenol that morning. Medical record review of Physician's Orders for December 2017 revealed there was no order for Tylenol. Medical record review of the hospital History and Physical dated 12/9/17 revealed Resident #61 .who was sent to ED [Emergency Department] this evening from her nursing facility for a suspicion of right femoral fracture . Continued review revealed Resident #61 had been admitted to this hospital in December 2016 for generalized weakness and again in November 2017 for an episode of coffee-ground emesis. Further review revealed .She is status post left AKA amputation presumably for peripheral vascular disease in the context of diabetes .She is immobile and is blind in the left eye and is significantly deaf .She seems reasonably comfortable, resting in bed, but does hurt when her left leg is manipulated .She has been apparently bed bound at the nursing home for at least the last year and it is not clear how she broke her right leg at this point . Telephone interview with CNA #10 on 1/31/18 at 11:08 AM revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed she went and assessed Resident #61. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on 2/1/18 at 3:50 PM in the Assistant Director of Nursing office confirmed the facility failed to promptly notify the resident's Physician when the resident had a change of status. Further interview the DON confirmed the resident was not assessed appropriately after telling the nurse she fell. These failures resulted in pain due to Resident #61 not receiving pain medication and due to a delay in treatment of approximately 7 hours. Interview with the Administrator on 2/1/18 at 5:08 PM in the Assistant Director of Nursing's office, after reviewing Resident #61's care regarding the reporting of pain and no pain medication given, and regarding the neglect in the delay in reporting of a change in status in resident condition, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9, CNA #10). The surveyor verified the Allegation of Compliance by: 1. On 12/4/18 - 12/5/18 pain assessments were completed on all residents with no further residents being affected. 2. On 11/27/17 all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On 11/29/17 all staff were educated on Notification of Change and Condition. 4. On 11/27/17 all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On 11/27/17 all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 6. On 12/9/17 staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, Reporting all Resident Claims. 7. On 2/2/18 licensed staff were educated on Incomplete Data on MAR and TAR, and Duragesic Patch and Verification. 8. From 2/5/18 - 2/23/18 all staff were educated again on Abuse Policy and Procedure, Notification, and Reporting. 9. On 2/28/18 review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Charge Nurse and CNA assigned to each resident. 10. On 3/1/18 - 3/2/18 interview with staff members regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims revealed they were able to discuss each topic. 11. On 3/2/18 observation of all residents with Fentanyl patches revealed all residents had patches in place with the date of application and dosage on each patch. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F-580 Refer to F-600 Substandard Qualtiy of Care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well being for 3 residents (#24, #61, #32) of 29 residents reviewed for pain. This failure to manage pain effectively placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy on 2/28/28 at 4:05 PM in the Administrator's office. F-697 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 3/2/18. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. The findings included: Review of facility policy, Pain Management, undated revealed .Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers .In the long-term care setting the comfort and well-being of the individual resident should always be paramount .Adequate pain management should be sought in each case .The same pain control measures that are used for residents who are able to communicate should be used for residents unable to communicate their pain due to dementia, aphasia or other causes . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Cardiovascular Disease, Hypertension, Peripheral Vascular Disease, and Frequent Falls. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes dated 11/21/17 revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss with extensive destruction) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (deep tissue damage) of 2 cm at 11:00 (using the 11:00 o'clock position on a clock). Continued review of Nurses' Notes revealed Resident #24 went off-site to the Wound Clinic weekly for treatment of the pressure ulcers . Medical record review of Wound Clinic notes dated 11/21/17 revealed Resident #24 had a Stage III ulcer (full thickness loss to tissue) on the right heel longer than 9 months and the facility had been using Medihoney (wound care mixture) with minimal improvement. Further review revealed the pressure ulcer measures 0.9 centimeters (cm) x (by) 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record (MAR) for 11/2017 revealed Resident #24 was ordered Acetaminophen (Tylenol) 325 milligrams (mg), give 2 tablets every 4 hours as needed. Medical record review of Nurses Notes dated 11/20/17 at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by LPN #3. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic. Continued review revealed when CNA #1 and CNA #17 were getting Resident #24 ready for her appointment, when she complained of leg pain. Further review revealed CNA #1 reported the resident's pain to LPN #9 who assessed the leg but took no action. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. Certified Nurse Aide (CNA) #3 reported her observations to the nurse. Further review revealed Licensed Practical Nurse (LPN) #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified a second time and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Review of facility investigation dated 11/27/17 revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on 11/21/17. Continued review revealed CNA #5 informed LPN #5 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, and warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful and notified the physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated 11/25/17 at 12:02 AM, revealed Resident #24 had a history of Dementia and was to be evaluated for right knee edema and pain. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Continued review revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint .(fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts) Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of the Comprehensive Care Plan revealed an update on 11/24/17 with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Telephone interview with LPN #9 on 1/31/18 at 10:35 AM revealed she had no idea Resident #24 had a fractured hip because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to determine the cause for the fracture. Interview with CNA #3 on 1/31/18 at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic her knee was swollen. Continued interview revealed she told the LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her into bed. Medical record review of the 11/2017 MAR revealed no documentation Tylenol was administered. Interview with CNA # 5 on 2/1/18 at 6:20 AM in the conference room revealed when Resident #24 came back from the Wound Clinic on 11/21/17, her legs looked different. Continued interview revealed she asked LPN #4 look at the resident's legs and the knee was turned inward and she complained of pain. Continued interview revealed LPN #5 said the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on 2/1/18 at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on 11/21/17 at 7:45 AM and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the LPN assessed the leg but found no concerns. Medical record review of the 11/2017 MAR revealed no documentation of Tylenol administration in spite of the resident complaining of pain. Interview with the Director of Nursing (DON) on 2/1/18 at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the off-site Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the nurse of the knee swelling who thought a physical therapy consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hopsital Emergency Department (ED) and the femur fracture was diagnosed. Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Continued interview with the DON confirmed Resident #24 did not receive appropriate pain management. Telephone interview with CNA #2 on 2/1/18 at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the (wound clinic) staff stood the resident up and eased her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview with CNA #3 saw the knee upon return from the Wound Clinic and knew something was wrong and told both LPN #3 and LPN #4. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong. Continued interview revealed from 11/21/17 - 11/23/17 there was little documentation of observation of the resident's knee. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had comorbidities of Diabetes Mellitus and Peripheral Vascular Disease. On 11/21/17 upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. The resident was complaining of pain in her legs; LPN #3 stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain however, the nurses failed to document any assessment of the resident's knee and failed to document administration of pain medication. On 11/24/17 Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered for the knee when the resident complained of pain. The Physician was notified on 11/24/17 and Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. The failure to administer pain medication when the CNAs notified the Nurses' the resident was complaining of pain constituted inadequate pain management for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with diagnoses including Type 2 Diabetes Mellitus, Dementia, Left Above the Knee Amputation, Peripheral Vascular Disease, Hypertension, Heart Failure, Depression and Anxiety. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional diagnosis of Right Femur Fracture was added on 12/12/17 when readmitted . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 had a Brief Interview of Mental Status (BIMS) score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was total dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated 12/29/16 revealed Resident #61 was at risk for poor nutritional status related to diagnosis of Diabetes Mellitus, Hypertension, Congestive heart Failure, Left Above the Knee Amputation and was considered Obese. Medical record review of a Care Plan dated 1/4/17 revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Medical record review of the Medication Administration Record, (MAR) for December 2017 revealed Resident #61 had an order dated 12/4/17 for Hydrocodone/Acetaminophen (pain medication) 5/325 milligrams, one tablet by mouth three times daily prn. Continued review revealed no hydrocodone pain medication was administered 12/4/17 through 12/9/17. Continued review revealed there was no order for Tylenol. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .(Resident #61) was in the bed .This morning, 12-9-2017 she complain[ed] her knee was hurting .As I was changing her she complain[ed] of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM and signed by the DON who documented .CNA reported that nurse on 11:00 PM-7:00 AM was made aware around 5:00 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN (Licensed Practical Nurse) #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med [medication] for rt [right] leg that [CNA #10] told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Review of a witness statement signed by LPN #7 dated 12/9/17 revealed .When passing AM [morning] meds [medications] resident was complaining her knee was hurting while they transferred her to her chair. After being in chair resident was calm. I ask her why she was yelling. She said that man drop[ped] her while putting her in bed. Resident then told [RN #2] the same thing about being drop[ped]. Resident calm and quiet while in chair, sleeping at intervals in chair. After lunch resident was put to bed and calm the rest of the shift waiting to be x-rayed . Medical record review of the Nurse Notes for 12/9/17 revealed no documentation by LPN #9 regarding voiced pain, that a man had dropped her, or that any pain medication was administered. Medical record review of a Physician's Telephone Order dated 12/9/17 at 12:30 PM revealed Stat [immediately] right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain of R [right] knee pain stated she was drop[ped] by a man last night right knee noted to be swollen painful to touch or move MD [medical doctor] made aware order to have x-ray done and call him .will continue to monitor waiting on mobil x-ray to come to facility for x-ray . Medical record review of the hospital History and Physical to which Resident #61 was transferred to dated 12/9/17 revealed .The patient is a [AGE] year old lady who was sent to ED [Emergency Department] this evening from her nursing facility for a suspicion of right femoral fracture . Continued review revealed Resident #61 had been admitted to this hospital in December 2016 for generalized weakness and again in November 2017 for an episode of coffee-ground emesis. Further review revealed .She is status post left AKA amputation presumably for peripheral vascular disease in the context of diabetes .She is immobile and is blind in the left eye and is significantly deaf .She seems reasonably comfortable, resting in bed, but does hurt when her left leg is manipulated .She has been apparently bed bound at the nursing home for at least the last year and it is not clear how she broke her right leg at this point . Interview with LPN #7 on 1/31/18 at 7:55 AM on the 200 hall revealed she was passing medications the morning of 12/9/17 and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed LPN #7 went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. LPN stated she called the doctor and received an order for an x-ray. Further interview revealed it took a while for the mobile x-ray to get to her. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on 12/9/17. Telephone interview with LPN #9 on 1/31/18 at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of 12/9/17 and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of Physician Orders for December 2017 revealed there was no order for Tylenol. Telephone interview with CNA #10 on 1/31/18 at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed on 12/9/17 she went and assessed Resident #61. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did [LPN #9] give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the Director of Nursing (DON) on 2/1/18 at 3:50 PM in the Assistant Director of Nursing's (ADON) office, after discussion of Resident #61's complaint of being dropped and of knee pain, confirmed the facility did not follow their policy on administering pain medication when a resident reported to be in pain. Interview with the Administrator on 2/1/18 at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain and no pain medication given, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9. CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Iron Deficiency Anemia, Barrett's Esophagus, Dysphagia, Pressure Ulcer of Left Heel Stage 3, Pain in Left Hip, Muscle Weakness, Heart Failure. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR dated 1/2018 revealed for dates 1/23/18 thru 1/26/18 .Fentanyl [opioid] 12 MCG [Micrograms]/HR [Hour] Patch apply on epatch [one patch] every 3 days for apin [pain]. Rotate site . Was not documented as administered. Observation of Resident #32 on 1/31/18 at 12:20 PM in his room with the DON present revealed she performed as skin assessment. Continued observation revealed no Fentanyl Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on 1/31/18 at 12:25 PM in Resident #32's room, was interviewed on how staff was notified when to check placement of Fentanyl Patch. LPN #1 responded .The computer has a reminder that pops each shift . Interview with LPN #1 on 2/1/18 at 2:33 PM in the Medication room at the back nurses' station revealed Resident #32 needed another hard script to be faxed to pharmacy. I don't believe he got a Fentanyl Patch on that day. Interview with LPN #2 on 2/1/18 at 3:15 PM revealed the pharmacy was called on 1/31/18. The original order was faxed on 1/23/18. But MG (Milligrams) was placed on the order instead of MCG (Micrograms). Continued interview revealed Resident #32 did not have a Fentanyl Patch on and the order was refaxed on 1/31/18. Interview with the DON on 2/1/18 at 3:30 PM at the back nurses station confirmed the facility failed to ensure Resident #32 received his Fentanyl Patch (pain patch), which resulted in Resident #32 not receiving the Fentanyl patch for 10 days and the resident complaining of pain. The surveyor verified the Allegation of Compliance by: 1. On 12/4/18 - 12/5/18 pain assessments were completed on all residents with no further residents being affected and reviewed on 3/1/18. 2. On 2/2/18 licensed staff were educated on Incomplete Data on MAR and TAR, and Duragesic Patch and Verification. 3. On 2/28/18 review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Charge Nurse and CNA assigned to each resident. 4. On 3/2/18 observation of all residents with Fentanyl patches revealed patches were in place; dated with the date of placement; and dosage. 5. On 3/1/18 review of audits comparing pain medication ordered and its presence in the medication cart. 6. On 3/2/18 review of pain assessments revealed they were current on all residents. 7. On 3/1/18 - 3/2/18 interview with licensed staff members regarding Duragesic patches, placement, verification of dosage, ordering patches, and how to handle Pharmacy issues revealed they were aware of the correct procedures. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F-580 Refer to F-600 Substandard Qualtiy of Care Refer F-641

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation, and interview, the facility failed to accurately document administered medication on the Medication Administration Record (MAR) for 3 Residents (#24, #61, #32) of 48 records reviewed. The facility's failure to accurately document and ensure medication was administered resulted in further pain and placed Resident #24, #61, and #32, in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 2/28/18 at 4:05 PM in the Administrator's office. The Immediate Jeopardy was effective from 11/21/17 - 2/23/18. An Acceptable Allegation of Compliance which removed the Immediacy of teh Jeopardy was received and corrective actions were validated through review of documents, observation, and staff interivews conducted onsite on 3/2/18. The findings included: Review of facility policy, Medication: Controlled Drugs, revised 6/16/16 revealed .Records must be accurate and include: Name of the resident, Prescription number and name of issuing pharmacy, Drug name and strength, Medication form, Route of administration, Strength and dose administered, Date and time of administration, Signature of the person administering the drug . Medical record review revealed Resident #24 was admitted to the facility on [DATE], 12/27/17, and 1/15/18, with diagnoses including Atherosclerotic Cardiovascular Disease, Hypertension, Peripheral Vascular Disease, Diabetes Mellitus, and Frequent Falls. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness wound (where the wound extends below layers of healthy skin) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (undermining is wound beneath healthy tissue) of 2 cm at 11:00 (using a face of a clock showing 11:00 anatomically). Continued review of Nurses' Notes revealed Resident #24 went to the off-site Wound Clinic once weekly for treatment of the pressure ulcer. Medical record review of the Medication Administration Record (MAR) for 11/2017 revealed Resident #24 was ordered Acetaminophen 325 milligram (mg), give 2 tablets every 4 hours as needed (PRN) and Lortab 5/325 mg, give 0.5 tablet one hour before wound care. Medical record review of Nurses' Notes dated 11/20/17 at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by LPN #9. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of a facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic for treatment to her heels. Continued review revealed when CNA (Certified Nursing Assistant) #1 and CNA #17 were getting the resident ready for her appointment she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 of the pain and slight swelling and LPN #9 assessed Resident #24. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. CNA #3 reported her observations to LPN #3. Further review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation of an assessment of the resident's knee by either LPN #9 or LPN #3. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Interview with CNA #1 on 2/1/18 at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on 11/21/17 and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the nurse assessed the leg but found no concerns. Medical record review of the 11/2017 MAR revealed no documentation of Tylenol administration in spite of the resident complaining of severe pain. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation LPN #5 assessed the resident's knee. Interview with the DON on 2/1/18 at 4:03 PM in her office revealed Resident #24 confirmed there was no documentation of any assessments by the LPNs regarding Resident #24's pain level and status of the knee. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with diagnoses including Type 2 Diabetes Mellitus, Dementia, Left Above the Knee Amputation, Peripheral Vascular Disease, Hypertension, Heart Failure, Depression and Anxiety. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional diagnoses for Right Femur Fracture was added on 12/12/17 when readmitted . Medical record of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was not cognitively intact. Continued review revealed the resident had clear speech with distinct intelligible words, made herself understood and understands with clear comprehension. Further review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of the MAR for December 2017 revealed Resident #61 had an order dated 12/4/17 for Hydrocodone/Acetaminophen 5/325 milligrams, one tablet by mouth three times daily prn (as needed). Continued review revealed no Hydrocodone/Acetaminophen pain medication was administered 12/4/17 through 12/9/17. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017, revealed .[Resident #61] was in the bed .This morning, 12-9-2017 she complained that her knee was hurting .As I was changing her she complained of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM signed by the DON and documented .CNA reported that nurse on 11-7 was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med [medication] for rt [right] leg that [CNA #10] told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Review of an interview conducted by LPN #2/Unit Manager with Resident #61 on 12/9/17 at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on.' Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review of the Nurses' Notes for 12/9/17 revealed no documentation by LPN #9 regarding the voiced pain, that a man had dropped her, or that any pain medication was administered. Medical record review revealed a Physician's Telephone Order dated 12/9/17 at 12:30 PM Stat [immediately] right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain[ed] of R [right] knee pain stated she was drop[ped] by a man last night right knee noted to be swollen painful to touch or move MD [Medical Doctor] made aware order to have x-ray done and call him .will continue to monitor waiting on mobileex [mobile x-ray] to come to facility for x-ray . Interview with LPN #9 on 1/31/18 at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. Surveyor asked LPN what she remembered about Resident #61 the morning of 12/9/17 and LPN stated the resident complained of foot/leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of the Physician's Orders for December 2017 revealed there was no order for Tylenol. Interview with CNA #10 on 1/31/18 at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed she came to the facility on [DATE] about dusk dark and she went and assessed Resident #61 upon arrival. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on 2/1/18 at 3:50 PM in the Assistant Director of Nursing office, after discussion of Resident #61's complaint of being dropped and of knee pain, confirmed the facility failed to follow their policy on administering and documenting pain medication. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Iron Deficiency Anemia, Barrett's Esophagus, Dysphagia, Pressure Ulcer of Left Heel Stage 3, Pain in Left Hip, Muscle Weakness, and Heart Failure. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview Mental Status (BIMS) of 14 indicating he was cognitively intact. Medical record review of the MAR dated 1/2018 revealed .Fentanyl [pain patch/opiod] 12 mcg [micrograms]/HR [Hour] apply one patch every 3 days for apin [pain]. Rotate site . Further review revealed the medication was not administered as ordered on 1/23/18, 1/26/18, and 1/29/18. Continued review revealed the medication placement was not checked as ordered on 1/23/18, 1/26/18, and 1/29/18. Interview with the resident in the resident's room revealed the resident stated no wonder I was hurting. Medical record review of the 1/2018 MAR revealed .Hydrocodon [Hydrocodone]-Acetaminophen 5-325 [opioid] - one tab PO [by mouth] every 8 hours for pain . Further review revealed the medication was not administered as ordered on 1/21/18, 1/22/18, and 1/23/18. Medical record review of the Controlled Drug Record dated 1/12/18 revealed .Hydrocod-Acetamin [sic] 5 mg- 325 mg 1 TAB by Mouth Three times Daily . Further review revealed the medication was signed out on the dates 1/21/18 at 9:00 PM, 1/22/18 at 2:00 PM, and 1/23/18 at 6:00 AM. Interview with Registered Nurse #2/Unit Manager on 2/1/18 at 3:47 PM in his office revealed there were some issues with the computer and the Electronic Medication Administration Record [EMAR] has to be checked for completion. Continued interview confirmed the documented medication was not given in order to clear the EMAR. Interview with Director of Nursing (DON) on 2/1/18 at 4:00 PM in her office revealed the computer screen would lock up for the incoming Nurse if the previous Nurse did not complete documentation for administration. Continued interview revealed RN #2 had management access and inaccurately documented the narcotics were not administered to Resident #32. This inaccuracy could result in a potential for Resident #32 to recieve the drug twice. The Surveyor verified the Allegation of Compliance by: 1. On 11/27/17 the on-call Nurse who failed to notify the DON of the incident for 3 days was in-serviced on timely reporting and quality of care. 2. On 11/27/17 all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On 11/27/17 all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 4. On 11/27/17 all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On 11/29/17 all staff were educated on Notification of Change and Condition. 6. On 12/9/17 staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, and Reporting all Resident Claims. 7. On 2/2/18 licensed staff were educated on Incomplete Data on the Medication Administration Records and Treatment Administration Records. 8. From 2/5/18 - 2/23/18 all staff were educated again on the Abuse Policy and Procedure, notification, and Reporting. 9. Review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with Physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Licensed Staff and CNAs assigned to each resident. 10. Interview with staff members regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims and they were able to discuss each. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F580 Refer to F-600 Substandard Quality of Care Refer to F-641 Refer to F-697 Substandard of Quality Care