**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly for one (Resident #1) of four residents reviewed for change in condition. The facility failed to notify the NP in a timely manner when Resident #1 voiced pain to her left knee, swelling, and heat to the touch was observed by LVN B. LVN B noted swelling and warm to touch on Resident #1's knee at approximately 4:00 PM. LVN B noted they contacted the NP when Resident #1's family was present at approximately 10:00 PM. Resident #1 was sent to the hospital and found to have a fractured left patella (kneecap). The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm, injuries, and hospitalization. Findings included: Review of Resident #1's face sheet, dated 09/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 also had diagnoses including displaced transverse fracture (the pieces of an individual's bone moved so much that a gap formed around the fracture when the individual's bone broke) of the left patella, multiple fractures of the ribs on the left side, unspecified fracture of the shaft (the main part of a cylindrical body) of the left femur (thigh bone), and an encounter for other orthopedic aftercare. Review of Resident #1's comprehensive MDS assessment, dated 07/25/24, reflected there was no BIMS score documented. Resident #1 also required partial/moderate assistance with most ADLs except transfers, in which she was dependent on staff assistance. Review of Resident #1's BIMS assessment, dated 09/02/24, reflected a 5 BIMS score, which indicated she had severe cognitive impairment. Review of Resident #1's care plan, revised on 09/09/24, reflected staff noted on 07/19/24 that Resident #1 had an ADL deficit related to her cognitive and physical limitations. Staff were required to notify Resident #1's RP and MD of significant change in condition/function as needed as an intervention that started on 08/12/24. Staff also included revisions that reflected Resident #1 had a left patella fracture without surgical intervention, had the potential for pain and limited joint movement complications, and that staff were required to notify the RP and MD of any significant change in condition. Review of LVN A's statement, dated 09/06/24, reflected on 09/05/24, she received a report that Resident #1 complained of pain, she reached out to the NP, and the NP requested an x-ray of Resident #1's knee. Review of LVN B's statement, undated, reflected on 09/05/24, revealed she was giving a shift change report to the 10 PM-6 AM nurse, went to Resident #1's room to say goodnight, and a family member told her that Resident #1 was saying something was wrong with her leg on the inside and she needed to see an orthopedic doctor. Resident #1 had no complaint of pain, but she had an ice pack on her left knee that she gave to Resident #1. LVN B called the NP and explained the situation and the NP told her to send Resident #1 to the ED for an x-ray. LVN B notified Resident #1's family and called EMS at 10:30 PM. Review of LVN C's statement, undated, reflected on 09/05/24, Resident #1's family was in the room at 10:00 p.m. Resident #1 had an ice pack on her left knee. Resident #1 was not complaining of pain at the time, and the left knee was swollen and warm to touch. The staff member gave Tylenol and muscle rub at that time. Resident #1's family member stated, something is wrong, and she needs and orthopedic Dr. LVN C and the 2-10 PM nurse called the NP and the NP ordered to send Resident #1 to the ER for x-rays. Review of Resident #1's pain assessment, dated 09/04/24, reflected Resident #1 had pain in left knee on 09/04/24. The cause of the pain was Resident #1's left leg was caught on the floor. Resident #1 received a scheduled Norco 5/325 MG that was administered as needed. Review of Resident #1's progress notes reflected the following: -LVN A documented as a late entry on 09/09/24 at 11:45 a.m. for 09/05/24 at 7:30 a.m., Addendum: Notified NP about her [Resident #1's] knee pain at 0730 am. She said if there is no swelling to monitor for any changes. Started the 72 hour follow up. -LVN B documented as a late entry on 09/06/24 at 3:49 p.m. for 09/05/24 at 4:00 p.m., Resident requesting to go to bed as she is sitting in wheelchair in common area. Aide pushed her into the shower room and nurse transferred to shower chair with no pain indicated. She was showered and nurse transferred back to wheelchair with no pain indicated. Nurse transferred resident to bed from wheelchair with no pain indicated with left leg elevated. Spent 30 mins time in room getting all the items situated for resident. She also wanted her movie put on, set up laptop with movie for resident. She is able to communicate pain verbally and via body language and she did not indicate any pain at this time when being placed back to bed. Noticed the left knee was swollen more than the right and hot/warm to touch. At 10pm, [Resident #1's family] translated from resident 'something is wrong and needs to see orthopedic doctor.' At this point we called NP and got verbal order to send her to ED for Xray. -LVN B documented on 09/05/24 at 10:21 p.m., Tylenol and muscle rub on left knee with an ice pack for pain. Knee is swollen and hot to touch. -LVN C documented on 09/05/24 at 10:37 p.m., Left knee swollen and warm to touch. Called NP. Send to ER for x-ray. If nothing is new to knee call for additional pain meds. Family, DON notified. 911 called. Review of Resident #1's 72-hour follow-up, dated 09/05/24, reflected on 09/05/24 LVN A noted during the 6-2 PM shift that Resident #1 had pain to her left knee area. LVN B noted during the 2-10 PM shift that Resident #1's knee was swollen and warm to touch and an ice pack was provided. LVN C noted during the 10-6 AM shift that Resident #1's knee was swollen and warm to touch and Resident #1 was sent to the ER for an x-ray. Review of Resident #1's orders, as of 09/30/24, reflected staff were given a general order on 09/05/24 to send Resident #1 to the ED per NP on-call. Review of Resident #1's hospitalist history and physical, dated 09/06/24, reflected she was sent to the hospital on [DATE] for a chief complaint of knee pain. Left knee x-ray results reflected Resident #1's bones were osteopenic (having reduced bone density) and she had a new acute fracture of the mid patella with approximately 10 mm distraction between major fracture fragments and adjacent soft tissue swelling. Review of Resident #1's operative report, dated 09/06/24, reflected her pre- and post- operative diagnosis was left patella displaced transverse fracture. Resident #1 received surgery on her left patella fracture on 09/09/24. During an interview on 09/30/24 at 10:18 a.m., the ADM stated Resident #1 started swelling in her left knee on 09/05/24. During an observation and interview on 09/30/24 at 12:26 p.m., Resident #1 was lying in her bed with family at bedside. Resident #1 had a black brace on her left leg. Resident #1 stated she told the nurses whenever she was experiencing pain in her left knee on 09/05/24. Resident #1 stated on 09/05/24, she told her family that she felt something was wrong inside her left knee. Resident #1 did not indicate whether she observed swelling in her left knee. Resident #1 stated she went and got surgery at the hospital for her left knee. Resident #1's family stated they observed Resident #1's knee was swollen the night Resident #1 was sent to the hospital. During an interview on 09/30/24 at 1:58 p.m., LVN A stated Resident #1 went to the hospital because she complained of pain to her left knee. LVN A stated she did not observe any swelling to Resident #1's knee on 09/05/24. LVN A stated she did not know why the other nurse (LVN B) reported Resident #1 had swelling to her left knee because she did not see swelling to Resident #1's left knee during her shift, which was before LVN B's shift. LVN A stated she put a progress note later that she observed Resident #1 in the morning (09/05/24 at 7:30 a.m.) and Resident #1 complained of pain to her left knee. LVN A stated she notified the NP about Resident #1's knee pain and was instructed to notify her if there were any changes in Resident #1's knee condition . During an interview on 09/30/24 at 2:11 p.m., LVN B stated on 09/05/24 she observed Resident #1 holding and rubbing her left knee. LVN B stated she believed Resident #1 was holding and rubbing her left knee because Resident #1 was not often up in her wheelchair. LVN B stated she did not notify the NP about observing Resident #1's left knee was swollen more than the right and that it was hot/warm to touch because Resident #1's left knee was always bigger than the other knee. It was Resident #1's surgery leg, there was no swelling any more than normal. LVN B stated the LVN A (day nurse) told her that she notified the NP earlier on 09/05/24 (7:30 a.m.) and the NP told LVN A to let her (NP) know if there were any changes in Resident #1's left knee condition. LVN B stated on 09/05/24 at 10:00 p.m., Resident #1's family translated to her that Resident #1 said something was wrong inside her left leg, and she then notified the NP and got a verbal order to send Resident #1 out to the hospital for an x-ray . During an interview on 09/30/24 at 2:39 p.m., the NP stated Resident #1 complained of pain to her left knee in the morning on 09/05/24 (NP did not indicate what time in the morning Resident #1 complained of pain). She stated staff told her about the pain Resident #1 experienced on 09/05/24 around 1:00 p.m. or 2:00 p.m. and that there was no swelling or redness to her left knee. The NP stated she told staff to monitor and notify her of any changes or swelling to Resident #1's left knee. The NP stated staff did not notify her that Resident #1's left knee was swollen more than the right and hot/warm to touch and would have wanted to be notified of those changes. The NP stated later on in the evening (09/05/24 around 10:00 p.m.), her NP on-call was notified of the pain Resident #1 experienced. The NP stated her NP on-call ordered staff to send Resident #1 to the ER for an x-ray evaluation because the staff told the NP on-call that Resident #1 started to have swelling in her left knee. The NP stated if there was swelling earlier on 09/05/24 in Resident #1's left knee, she should have been notified by staff earlier . During an interview on 09/30/24 at 5:17 p.m., the DON stated LVN A notified the NP about Resident #1 experiencing pain in the left knee earlier in the day on 09/05/24. The NP instructed LVN A and staff to monitor Resident #1's left knee and notify the NP if there were any changes to Resident #1's left knee condition. The DON stated if there was a change in condition and the change in condition was not reported to the NP, then a resident's health and safety could be at risk. The DON stated she was not notified about staff noting that Resident #1's left knee was swollen more than the right and hot/warm to touch earlier in the day on 09/05/24 . The DON stated she expected staff to notify the NP/Physician of any changes in condition. Review of the facility's admission and discharge report, from 09/01/24 through 09/30/24, reflected Resident #1 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the facility's in-services reflected staff were educated on change in condition on 09/21/24 by RN D, which covered nurses assessing and documenting/reporting change in condition or level of consciousness. Staff were also in-serviced on assessing, treating, and documenting pain and follow-ups and incident reporting on 09/06/24 . Review of the facility's change in a resident's condition or status policy and procedure, revised May 2017, reflected the following: Policy Statement: 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 (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for change in condition. LVN A did not ensure Resident #1, who had a history of a left hip fracture, had a footrest on her wheelchair before transferring her, resulting in a fractured left patella (kneecap). The noncompliance was identified as PNC IJ. The IJ began on 09/04/24 and ended on 09/21/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of not receiving adequate assistance devices, accidents during transfers, harm, sustaining injuries, and hospitalization. Findings included: Review of Resident #1's face sheet, dated 09/30/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 had diagnoses including displaced transverse fracture (the pieces of an individual's bone moved so much that a gap formed around the fracture when the individual's bone broke) of the left patella with routine healing, unspecified pain, multiple fractures of the ribs on the left side with routine healing, unspecified fracture of the shaft (the main part of a cylindrical body) of the left femur (thigh bone) with routine healing, and an encounter for other orthopedic aftercare. Review of Resident #1's comprehensive MDS assessment, dated 07/25/24, reflected there was no BIMS score documented. Resident #1 also required partial/moderate assistance with most ADLs except transfers, in which she was dependent on staff assistance. Review of Resident #1's BIMS assessment, dated 09/02/24, reflected a 5 BIMS score, which indicated she had severe cognitive impairment. Resident #1 had a fall prior to admission and no falls since admission. Review of Resident #1's care plan, revised on 09/09/24, reflected staff noted Resident #1 had a left patella fracture without surgical intervention and had the potential for pain and limited joint movement complications. The staff were required to apply non weight bearing to her left leg, the immobilizer was not to be removed, transfer her with a sheet using more than four staff members, anticipate her needs, notify the MD with changes, follow-up with x-rays as ordered with results sent to the MD, implement fall risk precautions, maintain extremity alignment as directed, assess for complications, pain, limited range of motion, signs and symptoms of infection, abdominal bruising or numbness, post-op instruction as directed, arrange follow-up appointments as indicated, range of motion/activity as ordered, monitor tolerance/pain control, vitals assessment as directed, pain assessment ongoing, weekly skin assessment and as needed during care, wound care/treatments as directed, and monitor effectiveness. Review of Resident #1's orders, dated 09/30/24, reflected staff were given a general order on 09/05/24 to send Resident #1 to the ED per the NP on-call. Review of Resident #1's progress notes reflected the following: -LVN A documented on 09/04/24 1:34 p.m., Max assist x2 with transfer. Non-weight bearing on left leg. While pushing Resident #1 to the van for appointment, she yelled. Noted Resident #1 dragged her left leg to the floor. Assessed, no swelling or redness noted. Provided footrest. Administered Norco 5/325 mg as needed. After appointment, assessed again, no swelling, no redness. Notified physical therapy. Family aware. -LVN A documented as a late entry on 09/09/24 at 11:45 a.m. for 09/05/24 at 7:30 a.m., Addendum: Notified NP about her [Resident #1's] knee pain at 0730 am. She said if there is no swelling to monitor for any changes. Started the 72 hour follow up. -LVN B documented as a late entry on 09/06/24 at 3:49 p.m. for 09/05/24 at 4:00 p.m., Resident requesting to go to bed as she is sitting in wheelchair in common area. Aide pushed her into the shower room and nurse transferred to shower chair with no pain indicated. She was showered and nurse transferred back to wheelchair with no pain indicated. Nurse transferred resident to bed from wheelchair with no pain indicated with left leg elevated. Spent 30 mins time in room getting all the items situated for resident. She also wanted her movie put on, set up laptop with movie for resident. She is able to communicate pain verbally and via body language and she did not indicate any pain at this time when being placed back to bed. Noticed the left knee was swollen more than the right and hot/warm to touch. At 10pm, [Resident #1's family] translated from resident 'something is wrong and needs to see orthopedic doctor.' At this point we called NP and got verbal order to send her to ED for Xray. -LVN B documented on 09/05/24 at 10:21 p.m., Tylenol and muscle rub on left knee with an ice pack for pain. Knee is swollen and hot to touch. -LVN C documented on 09/05/24 at 10:37 p.m., Left knee swollen and warm to touch. Called NP. Send to ER for x-ray. If nothing is new to knee call for additional pain meds. Family, DON notified. 911 called. Review of LVN A's statement, dated 09/06/24, reflected while she was pushing Resident #1 through the lobby on 09/04/24, at about 7:30 a.m. to the van for an appointment, Resident #1 called out and she stopped. LVN A stated Resident #1's knee was slightly bent and got caught on the floor. LVN A stated she assessed Resident #1 and did not note any swelling or redness. LVN A stated Resident #1 received a narcotic pain medication before the incident. LVN A stated she provided the footrest and Resident #1 left for an appointment. LVN A stated Resident #1 returned from her appointment, complained of pain to the knee area, she administered Norco 5/325 MG, and noted no swelling or redness. LVN A stated Resident #1's family was aware of the incident, and she notified the physical therapy department to offer any changes to Resident #1's treatment. LVN A stated the physical therapy department assessed Resident #1, noted there was no swelling and suggested to apply ice. LVN A stated on 09/05/24, she received a report that Resident #1 complained of pain, she reached out to the NP, and the NP requested an x-ray of Resident #1's knee. Review of the van driver's statement, undated, reflected a nurse was wheeling Resident #1 out in the lobby and the blanket that was on Resident #1's lap got caught up in the wheels of Resident #1's wheelchair. Resident #1 started yelling. The van driver stated the nurse was checking Resident #1 and asking Resident #1 if she was okay. The van driver continued to state the nurse asked Resident #1 if she was in pain and offered pain medication. The van driver stated the nurse left, went to the back somewhere, and returned with pain medication. The van driver stated he thought there was a footrest on Resident #1's wheelchair. The van driver stated Resident #1 kept telling her family that she fell, but that did not happen. The van driver stated that the nurse did not appear to be in a hurry or rush. Review of LVN B's statement, undated, reflected on 09/05/24, revealed she was giving a shift change report to the 10-6 AM nurse, went to Resident #1's room to say goodnight, and a family member told her that Resident #1 was saying something was wrong with her leg on the inside and she needed to see an orthopedic doctor. Resident #1 had no complaint of pain, but she had an ice pack on her left knee that she gave to Resident #1. LVN B called the NP and explained the situation and the NP told her to send Resident #1 to the ED for an x-ray. LVN B notified Resident #1's family and called EMS at 10:30 PM. Review of LVN C's statement, undated, reflected on 09/05/24, Resident #1's family was in the room at 10:00 p.m. Resident #1 had an ice pack on her left knee. Resident #1 was not complaining of pain at the time, the left knee was swollen and warm to touch, the staff member gave Tylenol and muscle rub at that time. Resident #1's family member stated, something is wrong, and she needs and orthopedic Dr. LVN C and the 2-10 PM nurse called the NP and the NP ordered to send Resident #1 to the ER for x-rays. Review of Resident #1's pain assessment, dated 09/04/24, reflected Resident #1 had pain in left knee on 09/04/24. The cause of the pain was Resident #1's left leg was caught on the floor. Resident #1 received a scheduled Norco 5/325 MG that was administered as needed. Review of Resident #1's 72-hour follow-up, dated 09/05/24, reflected on 09/05/24 LVN A noted during the 6-2 PM shift that Resident #1 had pain to her left knee area. LVN A stated she witnessed left leg incident that was not a fall. LVN B noted during the 2-10 PM shift that Resident #1's knee was swollen and warm to touch and an ice pack was provided. LVN B stated Resident #1 had left leg pain. LVN C noted during the 10-6 AM shift that Resident #1's knee was swollen and warm to touch and Resident #1 was sent to the ER for an x-ray. LVN C stated Resident #1 had left leg/knee pain. LVN A documented on 09/04/24 at 7:30 a.m. that while pushing Resident #1 in her wheelchair, Resident #1 yelled. LVN A stated she assessed Resident #1 and Resident #1's left leg got caught on the floor. LVN A stated there was no swelling to Resident #1's knee or surgery area and no redness noted. LVN A stated Resident #1 complained of pain and received Norco 5/325 MG routine pain medication. LVN A stated after Resident #1 returned from her appointment, Resident #1 complained of pain and she administered Norco 5/325 MG as needed, assessed Resident #1 again, noted no swelling or redness, family was aware, incident happened on 09/04/24, and NP was notified and told LVN A that if no swelling to monitor for any changes. Review of Resident #1's hospitalist history and physical, dated 09/06/24, reflected she was sent to the hospital on [DATE] for a chief complaint of knee pain. Left knee x-ray results reflected Resident #1's bones were osteopenic (having reduced bone density) and she had a new acute fracture of the mid patella with approximately 10 mm distraction between major fracture fragments and adjacent soft tissue swelling. Review of Resident #1's hospital progress notes, dated 09/06/24, reflected Resident #1 was admitted on [DATE] for a chief complaint of knee pain. The history and physical section reflected, Apparently had a twisting of knee a couple of days ago when transferring to wheelchair for gastrointestinal appointment. She had knee pain and swelling since then. EMS was called. Knee x-ray showed patella fracture with displacement on the left side. Ortho consulted. Plan is for surgery 9/9 afternoon. Review of Resident #1's operative report, dated 09/06/24, reflected her pre- and post- operative diagnosis was left patella displaced transverse fracture. Resident #1 received surgery on her left patella fracture on 09/09/24. During an interview on 09/30/24 at 10:18 a.m., the ADM stated she still did not know how Resident #1 sustained a fracture. The ADM stated Resident #1 had no falls at the facility. The ADM stated Resident #1 had one incident in which her dress got caught in her wheelchair and LVN A helped pull out her dress. The ADM explained that Resident #1 started swelling in her left knee a few days after that incident. The ADM stated Resident #1 had been doing fine and receiving pain management and treatment anytime she experienced pain . During an interview on 09/30/24 at 11:07 a.m., the ADM stated LVN A was suspended and still suspended at the time of the interview because the facility was waiting for the SSA to investigate Resident #1's incident. During an interview on 09/30/24 at 11:28 a.m., LVN A stated on 09/04/24, she moved Resident #1 out from where Resident #1 was sitting to take Resident #1 to the van. LVN A explained that as she and Resident #1 got to the lobby, Resident #1 yelled out and she stopped the wheelchair. LVN A stated Resident #1 pointed at her dress, she observed Resident #1's long dress was caught in the wheelchair wheel. LVN A stated Resident #1's leg was not really down on the floor. LVN A stated she noticed Resident #1's leg was slightly bent, but there was not any kind of serious falling and Resident #1 did not fall. LVN A stated Resident #1 showed her that her leg was out. LVN A stated at the time of the incident on 09/04/24, Resident #1 did not have footrest attached to her wheelchair. LVN A stated Resident #1 probably was supposed to have a footrest attached to her wheelchair for safety reasons. LVN A stated she did not attach Resident #1's footrest to her wheelchair because she oversighted (overlooked) and did not realize Resident #1 did not have a footrest attached to her wheelchair. LVN A stated staff were supposed to attach residents' footrest to their wheelchairs before pushing a resident in the wheelchair. LVN A stated she left, came back, attached the footrest to Resident #1's wheelchair, and placed Resident #1's leg on the footrest after the incident happened. LVN A stated Resident #1's feet were not on the footrests when she pushed Resident #1 to the lobby before the incident happened. LVN A stated Resident #1's legs were picked up (raised up) when she pushed Resident #1 in her wheelchair. LVN A explained staff usually made sure there was footrest on residents' wheelchairs. LVN A stated staff were required to place residents' feet on the footrest in their wheelchair at times, especially for residents who cognitively do not know how to move their legs. LVN A stated Resident #1 knew how to move her legs. LVN A stated when moving a resident in a wheelchair, staff must ensure resident safety. LVN A stated all nursing staff were responsible for ensuring residents' footrests were attached to their wheelchairs. LVN A stated residents' health and safety could be at risk if their footrest was not attached to their wheelchair because residents could fall out of the wheelchair during a transfer. During an interview on 09/30/24 at 11:54 a.m., the ADM stated she was unsure if staff were in-serviced on proper wheelchair transportation. During an interview on 09/30/24 at 12:07 p.m., CNA E stated she worked during the 6:00 AM through 2:00 PM shift. CNA E stated she was trained on wheelchair transportation. CNA E stated if a resident had issues with their feet or had a footrest, then the resident would have a footrest. CNA E stated CNAs attached footrests to residents' wheelchairs and had nurses monitor to ensure footrests were attached to residents' wheelchairs before transporting residents. CNA E stated residents health or safety could be at risk if a resident did not have a footrest attached to their wheelchair. CNA E stated she worked with Resident #1 and was unsure if Resident #1 required a footrest attached to her wheelchair. CNA E stated she was in-serviced last month on wheelchair transport by the ADON, who taught her how to securely lock the wheelchair in place, how to adjust footrests, and always ensure Resident #1's footrest was attached to her wheelchair when being transported. During an interview on 09/30/24 at 12:18 p.m., CNA F stated she worked during the 6:00 AM through 10:00 PM shift. CNA F stated she was trained on wheelchair transportation. CNA F stated if a resident was unable to lift their legs, then the resident required a footrest attached to their wheelchair. CNA F stated CNAs ensured residents footrests were attached to their wheelchairs after placing residents in their wheelchairs. CNA F stated residents health or safety could be at risk if no footrests were attached to their wheelchairs because residents' feet could get caught if they cannot lift their legs. CNA F stated she worked with Resident #1 and was unsure if Resident #1 required a footrest attached to her wheelchair because Resident #1 never got up when she worked with her. CNA F stated she was in-serviced on wheelchair transport on Monday or Tuesday of last week (09/23/24 or 09/24/24) by the DON. CNA F stated the in-service discussed how to lock residents' wheelchairs before transferring residents in wheelchairs and making sure footrests were attached if residents required footrests. During an observation and interview on 09/30/24 at 12:26 p.m., Resident #1 had two wheelchairs with footrests sitting on the wheelchair seat. Resident #1 was lying in bed and had a knee sleeve on her left leg. Resident #1 also had family in her room at the time of the observation. Resident #1 stated LVN A was transporting her to the van, her foot got caught, and she fell forward. Resident #1 stated she did not have a backrest and footrest attached to her wheelchair the day the incident happened (09/04/24). Resident #1 stated LVN A went back into her room and grabbed her footrest after the incident happened. Resident #1 stated she started feeling pain one or two days after the incident. Resident #1 stated she told the nurses whenever she was experiencing pain in her left knee. Resident #1 stated the following day of the incident (09/05/24), she told her family that she felt something was wrong inside her left knee. Resident #1 did not indicate if she observed swelling in her left knee. Resident #1 stated she went and got surgery at the hospital for her left knee. She stated the staff have been attaching her footrest to her wheelchair whenever they transported her, the staff have been checking on her, the staff have been managing and treating her pain, and she felt safe. Resident #1's family stated they observed Resident #1's knee was swollen the night she was sent to the hospital (09/05/24). During an observation and interview on 09/30/24 at 12:47 p.m., Resident #2 was sitting in his wheelchair. Resident #2's feet were resting on a footrest attached to his wheelchair. Resident #2 stated staff always made sure a footrest was attached to his wheelchair, staff checked on him, treated and managed his pain, and he had no concerns and issues. During an interview on 09/30/24 at 12:51 p.m., LVN G stated she worked during the 6:00 AM through 2:00 PM shift. LVN G stated she was trained and in-serviced on wheelchair transportation last week by the DON and the ADON. LVN G stated she was taught how to put the residents' footrests on their wheelchairs to ensure residents were steady and how to transfer residents according to their diagnoses. LVN G explained that before transporting residents, she ensured their footrests were attached to their wheelchairs. LVN G stated residents could be at risk of getting their legs hurt if footrests were not attached to their wheelchairs because residents' legs could get caught by the wheelchair. LVN G stated CNAs and nurses ensured the residents' footrests were attached to their wheelchairs. LVN G stated residents' health or safety could also be at risk if footrests were not attached to their wheelchairs because their legs could get caught and that could cause an injury and fall. LVN G stated Resident #1 should have been required to have a footrest attached to her wheelchair. LVN G stated Resident #1 did not have a footrest attached to her wheelchair at all times because she did not always want the footrest on. An attempt to interview the van driver was made on 09/30/24 at 1:56 p.m. A voicemail and call back number was left. The van driver did not return the call prior to exit. During an interview on 09/30/24 at 2:39 p.m., the NP stated she was notified on 09/04/24 of Resident #1's incident, but she could not recall the details of the incident at the time of the interview . During an interview on 09/30/24 at 5:17 p.m., the DON stated residents self-propelled themselves in their wheelchairs when they were transporting inside the facility. The DON stated outside the facility, she expected residents' footrests to be present for residents who were unable to self-propel themselves in their wheelchairs. The DON stated she determined residents required footrests by if residents could self-propel in the facility or not. The DON stated newly hired staff completed competencies on ambulating residents in wheelchairs before they began to work with residents. The DON stated she did not know if the facility had a policy on ambulating residents. The DON stated ambulating residents was more of an education topic than an actual policy. The DON stated residents' health and safety could be at risk if they were ambulated without wheelchair footrests by the nurse or a staff member because residents' feet can drop to the ground. The DON stated Resident #1 did not require a footrest in the facility, but she required a footrest when going out of the facility. The DON stated she was notified during the 24-hour report clinical meeting by LVN A of Resident #1's incident. The DON stated the ADON asked for the incident report, which LVN A documented per instruction from the ADON. The DON stated LVN A did not explain why she did not attach a footrest to Resident #1's wheelchair when transporting Resident #1. During an interview on 09/30/24 at 5:48 p.m., the ADM stated she was unsure if the facility had a policy that specifically outlined how to ambulate a resident who was wheelchair dependent. During an interview on 09/30/24 at 6:19 p.m., the DON stated the facility did not have a policy that specifically outlined how staff were to ambulate residents who were wheelchair dependent. The DON stated ambulating resident's protocols were reviewed under the new employee training orientation, which was completed before staff started working with residents. Review of the facility's provider investigation report reflected Resident #1's incident occurred at an unknown date, time, and location. The incident was reported to SSA on 09/06/24 at 2:00 p.m. There were no witnesses and alleged perpetrators. Resident #1 sustained a new acute fracture of the mid patella. LVN B assessed Resident #1 on 09/05/24 at 10:50 p.m. and indicated that Resident #1's family reported to her that Resident #1 said there was something wrong inside her left knee. LVN B noted the left knee was swollen and warm to touch during Resident #1's head-to-toe assessment, provided Resident #1 with pain medication and applied ice to the affected area. Provider response reflected, Once notified by the hospital of the fracture, an internal investigation began. Upon receipt and review of hospital records, it was discovered there were family statements charted by hospital staff that suggested an injury may have been sustained in our facility during transport to gastroenterology appointment on 09/04/24. Based on statements from the family and events reported by staff, it was decidedly prudent for the safely of our residences, to suspend the LVN A on 09/06/24 until it was determined this was not abuse or neglect. When it was substantiated, this did not demonstrate abuse nor neglect the LVN A was reinstated on 09/07/24. The investigation summary reflected, On 9/6/2024, the facility received a call from the hospital and reported that Resident #1 had been diagnosed with a fracture of the left patella with displacement. Resident #1 was admitted to the facility on [DATE] for skilled therapy and medical management. Resident #1 had a history of osteoporosis. Prior to admission to the facility, Resident #1 sustained a fall in July 2024 with left distal peri prosthetic femur fracture requiring open reduction and internal fixation left knee trauma requiring arthroscopic surgery, fractures of the sixth and seventh ribs, followed by a complicated postop course. She is a poor historian with diagnosis of age-related cognitive decline with a BIMS of 5. Investigation revealed hospital records from 09/16/24 stated she had twisted the knee a day or 2 ago when transferring to wheelchair and hit on edge of wheelchair. Employee statements did not support any evidence of that occurrence. LVN charge nurse reports on 09/04/24 while transporting the resident from nurse's station to lobby, in a wheelchair, her left leg slipped to the floor bending her knee slightly. LVN Immediately assessed the knee, and no swelling or redness was noted. Resident #1 did complain of pain but had been given her three times a day scheduled dose of Norco 5/325mg prior to the incident. Resident #1 was being treated for post-surgical pain. Upon return from her appointment, LVN charge nurse reassessed the left knee and no swelling or redness was noted. Resident #1 complained of pain and LVN charge nurse administered as needed Norco 5/325mg at 10:10 a.m. NP was notified, and order was given to monitor for redness and swelling. No redness or swelling was noted in the nurse's notes from 09/04/24 to the evening of 09/05/24. Late evening 09/05/24, Resident #1 presented with left knee redness and swelling. LVN charge nurse called the NP and received an order to transport to the hospital for evaluation and treatment. Per our Investigations, van driver reports on 09/04/24, LVN charge nurse was transporting resident through the lobby to the transport van and saw the resident's long dress get caught in the wheel pulling the leg to the floor. Van driver reports the LVN charge nurse stopped the chair immediately and provided care to Resident #1. Van driver reports the nurse did not appear to be hurried or in a rush. Resident #1's family reports on 09/06/24, Resident #1 reported to her she was put in wheelchair and rushed causing her leg to catch under the wheelchair and falling forward. However, Resident #1 is a poor historian and was unable to reveal details. GI medical assistant with MD stated on 09/19/24, Resident #1 attended an appointment on 09/04/24. The medical assistant stated Resident #1 did not complain of pain unrelated to GI origin during the appointment. Investigative summary reflected, On 9/6/2024, the facility was informed Resident #1 had been diagnosed with a fracture to the left patella with displacement. The investigative process could not definitively identify the cause of the injury therefore we are unable to confirm a specific incident to be solely responsible for the fractured patella. The belief remains the Resident #1 pathological process of osteoporosis increased her risk for serious injury lo the left knee and the injury was not found to be due to abuse or neglect. Provider action taken post-investigation reflected LVN A was suspended, but it was lifted after investigation findings were inconclusive. In-services were also conducted on abuse and neglect, treatment of pain, and ambulating the wheelchair dependent. Review of the facility's incident/accident tracking log for September2024 reflected on 09/04/24 during the day shift, Resident #1 sustained an injury during handling and sustained a patella fracture by an unknown cause in which she was treated in the hospital, the incident was investigated and reported, and staff were trained. Review of the facility's accident/incident report, dated 09/05/24, reflected while pushing Resident #1 through the lobby to an appointment, Resident #1's foot got caught on the carpet. Resident #1 complained of pain, was assessed, and had no redness or swelling noted. The footrest was attached to the wheelchair. The incident happened on 09/04/24 at 7:30 a.m. in the resident's room, the unwitnessed fall occurred while Resident #1 was in her chair, Resident #1 slipped/tripped, had discolored skin, was alert, had no apparent injury, and a minimal bruise on left leg. There were no medication and mental status changes in the last seven days. Resident #1 received a scheduled pain medication Norco 5/325 MG prior to the incident. Resident #1's footrest was provided on the wheelchair. Physical Therapy was notified and suggested applying ice. Review of the facility's admission and discharge report, from 09/01/24 through 09/30/24, reflected Resident #1 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the facility's in-services reflected staff were educated on abuse and neglect on 09/06/24 by the ADON. Staff were also educated on treatment of pain, ambulation, and abuse and neglect on 09/06/24 by the ADON. The staff were taught that when a resident complains of pain, the nurse must go and assess the resident for pain and administer pain medications as appropriate, the nurse must document administering the medication, outcome and effectiveness of the medication, documentation was paramount, nurses should be notified immediately when a resident complains of pain. Staff were also taught that while ambulating the wheelchair dependent resident to be aware of leg placement of the resident, ensure residents' legs were properly aligned, footrests were to be applied correctly and on the correct wheelchair, ensure their legs and feet were properly aligned, footrests were required every time a staff member assisted the resident with ambulation, only qualified staff may ambulate, self-propelled residents were not required to have footrests unless they were propelled by staff. and at that time footrests would be applied. Staff were also taught to ambulate a resident at a slow steady pace, be mindful of their feet at all times, only one resident was to be ambulated at a time, Trains were never acceptable for the ambulation of residents, all outside appointments required footrests, prepare residents for appointments the day prior and ensure the location of footrests, all incidents were not always falls, and to use the list on the incident report to determine incidents. Staff were educated on fall management clinical protocol on 09/21/24 by RN D, which taught them about all the steps in responding to a fall, assessing, and documenting, and reporting change in condition or level of consciousness. Staff were also educated on abuse prevention falls on 09/21/24 by RN D, which taught them about fall risk residents and fall interventions to implement. Staff were also taught and reviewed on abuse prevention on 09/21/24 by RN D. Review of the facility's change in a resident's condition or status policy and procedure, revised May 2017, reflected the following: Policy Statement: 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 (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): b. discovery of injuries of an unknown source; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Review of the facility's assistive devices and equipment policy and procedure, revised January 2020, reflected, Policy Statement: Our facility maintains and supervises the use of assistive devices and equipment for residents. Policy Interpretation and Implementation: 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are not limited to): c. Mobility devices (wheelchairs, walkers, and canes). 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 4. Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accid[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain, in that: The facility failed to provide effective pain management for Resident #1 while on hospice services and comfort measures in place. He was found by his Hospice Nurse on 12/24/23 writhing in pain, thrashing, grimacing, and mouthing help me. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/24 at 5:01 PM. While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia, prostate cancer, and COPD. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS was not performed. Section J (Health Conditions) reflected he had received PRN pain medications within the last five days. Review of Resident #1's quarterly care plan, revised 12/21/23, reflected he was on hospice services with an intervention of assessing and monitoring his status and to notify MD, hospice, RP of change in condition or ineffective pain medication. Review of Resident #1's progress notes in his EMR, dated 12/21/23 at 1:53 PM and documented by RN C, reflected the following: .Family (of Resident #1) decided to refer to (hospice agency), and keep [Resident #1] comfortable, NP aware of decision. Review of Resident #1's Hospice Nursing Initial Comprehensive admission Assessment, dated 12/21/23 at 5:00 PM and completed by HN D, reflected the following: What is most important to the [Resident #1] today? Family requests comfort . [Resident #1] appears pre-active and is using morphing PRN for pain and shortness of breath. He is also using a nebulizer. Staff nursing administer medications, and nebulizers. [Resident #1] is [AGE] year-old male veteran with a primary hospice diagnosis of prostate cancer with mets (metastasize) to pelvis and lymph nodes. [Resident #1] was diagnosed in 2016 s/p orchiectomy (a surgery to remove one or both testicles) and then did not follow up . was getting treatment for prostate cancer until late 11/2023 . Today [Resident #1] was diagnosed with hypernatremia (electrolyte problem characterized by increased sodium concentration in the blood), increased BUN and Creatinine and aspiration pneumonia via x-ray. He was on IV fluids and IM Rocephin and will stay on Rocephin till 12/27/23. Family wants to give him a chance have antibiotics help him and IVF but knows this likely will not work. . Pain: pain left hip managed with new pain regimen of morphine 5 mg po every 1-hour PRN Review of Resident #1's progress notes in his EMR, dated 12/22/23 at 11:58 AM and documented by the ADON, reflected the following: Palliative care form signed. Review of Resident #1's physician order, dated 12/21/23, reflected the following: Morphine concentrate - schedule II solution; 100 mg/5 mL (20 mg/ML); Amount to administer: 0.25ML; oral - every hour PRN for pain and dyspnea (shortness of breath) Review of Resident #1's TAR, December of 2023, reflected he was administered morphine by LVN B on 12/22/23 at 2:30 AM, on 12/23/23 at 7:24 AM for pain and agitation. It was documented as being effective (unknown time). He was also administered morphine on 12/23/23 after it was administered by the Hospice Nurse at 4:00 PM and 8:00 PM; on 12/24/23 at 12:00 AM, 4:00 AM, 8:00 AM, and 12:00 PM. Review of Resident #1's Hospice Visit Clinical Note, dated 12/23/23 at 10:22 AM and documented by HN E, reflected the following: [Resident #1] lying in his bed on his back upon RN arrival. [Resident #1] writhing in pain with mouth gaping open and gasping for breath. RN immediately spoke to his nurse [LVN B] who stated he did not receive any morphine overnight and she has given him 0.25 mils a few hours ago. RN called (hospice doctor) immediately and received an order to give one ML morphine Q 15 minutes as needed times three doses to get pain under control. This RN was nurse to administer morphine, [FM A] and [FM F]/MPA were at the beside and continued to stay they only want [Resident #1] to be comfortable. It did require three doses of morphine to get [Resident #1] comfortable as he continued to be in severe pain and shortness of breath until third dose took effect. [Resident #1] continually pulling off nasal cannula from oxygen with his current pain and agitation. For this reason, oxygen level was in the mid 80s when RN able to obtain via pulse oximeter when [Resident #1] finally calm and comfortable. Several medication orders were changed by (hospice doctor) and written to the facility. This includes scheduled morphine and lorazepam every four hours with continued availability of PRN. Morphine every hour for breakthrough pain. (Hospice doctor) sent changes to (pharmacy) as well per their request. RN counted number of medications with RN on staff and assured that [Resident #1] gas enough quantity of both morphine and lorazepam. [Resident #1] has had no intake of food or water in past 24 hours and is currently only oral care at this time. RN worked with staff CNA to get [Resident #1] into a comfortable position. [Resident #1] was resting calmly upon closure of RN visit. RN reminded staff to call hospice company at any time with any change in condition or for any needs, questions, or concerns. [FM A] and [FM F] to come back later to visit and grateful for hospice assistance. [Resident #1] is actively dying and expected to pass within the next 24 to 48 hours. Review of Resident #1's progress notes in his EMR, dated 12/23/23 at 1:15 PM and documented by LVN B, reflected the following: (Late Entry) Restless and agitated. Opens mouth but makes no verbal noise. Hospice nurse present and administered 3 does of 0.5ml Morphine 15 minutes apart per Hospice physician orders. New order for Ativan every 4 hours. Continues to remove oxygen. Morphine effective. Resting in bed in fetal position. During a telephone interview on 01/24/24 at 12:33 PM, HN D stated she admitted Resident #1 for hospice services on 12/21/23. She stated on that day he was not in any obvious pain but ensured facility staff knew he had an order for Morphine PRN for pain, shortness of breath, or agitation. She stated the family was adamant that they wanted palliative/comfort care only for Resident #1. She stated when HN E made her routine visit on 12/23/23 she found Resident #1 in extreme pain and distress. She stated she would have expected facility staff to contact them immediately if they were unable to control his pain. During a telephone interview on 01/24/24 at 12:47 PM, Resident #1's NP stated she last saw him on 12/22/23 and at that time, he appeared comfortable. She stated since Resident #1's order for Morphine was such a low dose and it had a short half-life., She stated she would expect nurses to assess the resident at least every hour after administering to assess the effectiveness. During a telephone interview on 01/24/24 at 12:58 PM, FM A and FM F stated when they walked into Resident #1's room on 12/23/23 around 10:30 AM, HN E was already there. FM A stated he was writhing in agony, thrashing in his bed, and pointing to his back. FM F stated HN E looked completely disheveled with the state Resident #1 was in. FM F stated HN E turned to them and said, He is mouthing 'help me, help me, help me'! FM F stated HN E stated, Honestly, I am not supposed to say this, but this is not okay. FM F stated LVN B walked in to the room and was surprised to see the condition Resident #1 was in and stated, Oh my God, I do not know how this happened and continued to apologize profusely. FM A and FM F continuously repeated how heart-breaking it was to walk in on their loved one in so much distress and pain. They both stated they repeatedly told the facility they wanted comfort measures only and felt like they neglected Resident #1. FM F stated after HN E administered three doses of morphine, Resident #1 finally looked peaceful and comfortable. FM A stated without the hospice agency, they did not know if Resident #1 would have passed away without pain or his dignity. FM A stated they just wanted to ensure this does not happen to anyone else's loved one. During a telephone interview on 01/24/24 at 2:27 PM, HN E stated Resident #1 had an order for morphine every hour or as needed for shortness of breath or pain since 12/21/23. She stated she was not contacted by the facility on 12/23/23 but was making a routine visit. She stated when she walked into Resident #1's room he was absolutely not comfortable as he was showing a lot of symptoms of pain such as thrashing his arms, mouth agape, and was extremely anxious. She stated even lightly touching him made him more agitated. She stated although it was hard to discern, but it did look like he was mouthing help me. She stated she asked LVN B when she last saw Resident #1 and she told her she administered morphine a few hours ago. She stated it appeared LVN B seemed to think his current condition at that time was normal. She stated she was extremely surprised because normally when a resident on hospice resided at a facility with nurses on staff, they typically do not see that type of situation because nurses are trained and licensed to know what to look for when it comes to pain and agitation. She stated she would expect for a resident who was on hospice services and receiving morphine to be assessed at least every hour if not more frequently. She reiterated she was very shocked at the state he was in and was glad she arrived when she did. During an interview on 01/24/24 at 2:44 PM, the ADON stated she saw Resident #1 on 12/21/23 and 12/22/23 and he seemed comfortable. She stated she was not in the building on 12/23/23 and had not heard of anything unusual happening. She stated it depended on resident's condition as to how often a resident should be assessed after being administered pain medication. She stated LVN B had administered Resident #1 morphine a few hours before HN E arrived and a change in condition could have happened five minutes before she arrived. She stated it could happen quickly especially with Resident #1 continuously taking his oxygen off. She stated LVN B marked the morphine as being effective. She stated there was no actual pain assessments in their electronic charting system for the nurses to complete. During a telephone interview on 01/24/24 at 4:17 PM, LVN B stated she started her shift on 12/23/23 at 6:00 AM. She stated she checked on Resident #1 sometime between 6:30-7:00 AM. She stated at that time he was restless, looked like he was in pain, grimacing, moving around a lot, and did not want to keep his oxygen on. She stated she administered morphine at 7:24 AM. She stated she went back assess to see if the morphine had been effective sometime that morning. She stated, nothing seemed to help and did not believe the morphine was helping. She was asked why she marked the morphine as being effective and she stated that must have been a time where he had quieted down. She stated she thought she had contacted hospice. She stated once HN E arrived, she (HN E) administered three doses of morphine every 15 minutes and that settled Resident #1 and he seemed calm and relaxed. She stated HN E then ordered scheduled morphine to be administered every four hours and PRN. She stated she was grateful for HN E as the morphine she administered really seemed to help Resident #1 a lot. Review of the facility's Pain Assessment and Management Policy, revised March of 2020, reflected the following: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after pain onset and reassessed as indicated until relief is obtained. Documentation 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of intervention for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of the facility's Hospice Program Policy, revised July of 2018, reflected the following: 10. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. d. Communicating with the hospice provider (and documenting such communication) to ensure the needs of the resident are addressed and met 24 hours per day. The ADM and ADON were notified on 01/24/24 at 5:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/25/24 at 12:35 PM: On 1/24/2024 an abbreviated survey was initiated at (facility). On 01/24/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constituteds an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 was supposed to be on comfort care measures and was found to be in an uncomfortable amount of pain after not being administered pain medication. The facility needs to take immediate action to ensure residents are receiving proper treatment to alleviate pain. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on ensuring resident pain control needs are met per current policy by facility staff. Initiated 1/24/2024. Completed 1/24/2024 Regional Nurse Consultant re-educated Interim Director of Nursing and Assistant Director of Nursing on ensuring resident pain control needs are met per current policy by facility. Initiated 1/24/2024. Completed 1/24/2024 Evaluation of all current residents for pain performed by DON/ADON and/or designee with orders verified and any changes required noted and enacted immediately upon finding of IJ allegation. Initiated 1/24/2024. Completed 1/24/2024 DON/designee completed audit of all resident charts for current pain documentation to be performed every shift and as needed according to individualized needs with routine pain assessments added to four consolidated orders found lacking routine pain assessment. There were no relevant findings of unaddressed pain found upon resident assessments and interviews as noted below. Initiated 1/24/2024. Completed 1/25/2024 Re-education of all licensed staff members occurred per DON/ADON and designees in areas of pain control, medication, pain scales, documentation, and communication to adjunct personnel such as hospice and monitoring noting concern, if any, following verbal understanding and post test noted by licensed staff. Initiated 1/24/2024 Completed 1/25/2024 All residents currently receiving pain control or possible pain indications immediately checked by ADON, unit managers, and a designated licensed nursing team member for appropriate interventions if any noted with no relevant findings of unaddressed pain found from resident assessment/interviews. Initiated 1/24/2024 Completed 1/24/2024 Interventions and Monitoring Plan to Ensure Compliance Quickly: The facility will follow current policy and procedure for compliance and maintenance of pain control with understanding of pain control management and communication by nursing staff to be obtained on hire by DON/ADON and/or appointed designee for all full time and PRN staff and at least annually with re-education to be performed by DON/ADON and/or appointed designee as noted per skills checklist. The facility does not employ the use of temporary or agency staff. Initiated: 1/24/2024 Completion: 1/25/2024 Audit of all existing and newly hired nursing staff to be performed weekly by DON and/or designee, to ensure completion of pain management understanding with emphasis on special circumstances, such as palliative care, to be ongoing following completion date per systems put in place. Initiated: 1/24/2023 Completion: 1/25/2024 and ongoing. Any nursing staff identified through ongoing education as noted above that require acute training on pain management will have education performed prior to presenting on shift until such time as knowledge and competencies in pain control and management are adequate. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee. For any nursing staff receiving re-education or training on pain control, including medication use, pain scales, documentation, communication, and management not found to be proficient through ongoing nursing proficiency checks following immediate education, on hire, annually, and as needed will receive one on one education with testing performed until such time as knowledge is of sound basis. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain competency check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This will be ongoing following the completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for competencies to include Administrator for continuum of care to be documented through signed attendance sheet in ongoing morning stand up. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Audit sheets to ensure nursing staff competency in pain management, documentation, medication, assessment, and communication to be reviewed by DON/ADON for completion by random chart audits and resident assessment at least weekly with indication of last performed check off to be ongoing to ensure addition of any new or returning staff. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All new admission or readmission orders to be checked within 24 hours for implementation of pain assessments as ordered and pain scales available for immediate use with discrepancies or omissions to be immediately resolved to ensure adequate pain management. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing The policy and procedure for maintenance and control of resident pain to be reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with current policy remaining in place. Any changes to policies that may be required to be implemented will have education provided by DON/ADON and/or appointed designee to affected staff members, including newly hired, full-time and PRN staff upon implementation. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All licensed staff not on duty during pain management and control education, as well as all newly hired staff in the future, which will be ongoing, will be checked as noted above prior to returning to the floor for their next scheduled shift. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Independent education to be performed in conjunction with facility DON and Regional Nurse Consultant, by hospice company educator designated by facility for all licensed nursing staff as adjunct to facility education on 1/25/24 and every week until all licensed staff has received external pain control and management education by outside, independent source. Any further education to be assessed and implemented from independent education findings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Pain control to include monitoring, medication, communication, and assessment will be reviewed by the QAPI committee to meet 1/25/24 and then q3months with changes to the plan to be made as needed with need for ongoing continuation of competency related to pain control as related to this IJ to be determined by findings during QAPI meetings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/24/2024 Completed: 1/24/2024 The Surveyor monitored the POR on 01/25/24 as followed: During an interview on 01/25/24 at 12:43 PM, the ADON stated all staff were in-serviced on all of the topics listed in the POR before the start of their shift. She stated she in-serviced staff the evening prior at 10:00 PM before their 10:00 PM - 6:00 AM shift. She stated a pain assessment was conducted on all residents in the facility with no concerns. During interviews conducted on 01/25/24 between 1:18 PM and 2:27 PM, two RNs, two LVNs, and two CNAs all stated they had been in-serviced prior to working their shift. They were able to describe signs and symptoms of pain such as moaning, yelling, facial grimacing, agitation, and restlessness. The CNAs stated if a resident voiced pain or if they noted any residents showing any signs and symptoms of pain, they would notify their nurse immediately. The nurses stated they needed to document all signs and symptoms of pain, ensure they re-assessed a resident after administering pain medication within 30 minutes to an hour, and completing a pain assessment. The nurses stated if the pain medication did not appear to be effective, they were to document it, and contact the hospice nurse or resident's NP immediately. During observations and interviews on 01/25/24 between 1:28 PM and 1:56 PM, three communicative residents stated they were not in pain and their pain was always addressed when they notified a staff member. Two residents who were sleeping in their rooms were observed and they were showing no signs or symptoms of pain. Observation on 01/25/24 at 2:05 PM revealed nurses, medication aides, and CNAs in the dining room being in-serviced by a hospice agency on signs and symptoms of pain and the importance of addressing and assessing pain. Review of all residents' pain assessments (utilized PAINAD for nonverbal residents), dated 01/24/24, reflected no pain concerns. Review of an in-serviced entitled Reporting Pain Symptoms, dated 01/24/24 and 01/25/25 and conducted by the ADM and the ADON, reflected all nursing staff from all shifts were reeducated on the following: Any staff that notes signs and possible pain or a resident tells staff they are in pain should report this to their charge nurse. The Charge nurse must assess for pain, treat pain, and record effectiveness. Communication is the key to proper care of our residents. Signs and symptoms of pain include: moaning, grimacing, restlessness, voiced pain, and change in behavior. Review of an in-serviced entitled PRN Pain Medication, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected nurses for all shifts were reeducated on PRN pain medication and monitoring for effectiveness. Review of an in-serviced entitled Pain Assessments, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected all nurses from all shifts were reeducated on the following: Pain assessments must be done at least every shift, and if change in condition causing increased pain. Notify NP/MD/hospice if pain management is not appropriate or not alleviating pain. Document in progress notes details - who notified, what response was given, any new orders, notification of RP and doctor. Review of the facility's Pain Assessment Post Test, dated 01/24/24 and 01/25/25, reflected all staff completed the test with the following questions: 1. Pain Assessments should be completed at least every shift for acute pain or significant changes in levels of chronic pain. (True/False) 2. If upon completion of pain assessment, it is determined that intervention is required, you may: 3. What are signs a resident can display of discomfort or pain? 4. What do you do if the pain medication is not effective? 5. If a hospice resident is experiencing a change in their pain intensity, the licensed nurse should notify the hospice agency immediately. (True/False) 6. What should be included in your progress note documentation regarding the pain event? While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.