**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers, in that: 1. The facility failed to provide preventive care, consistent with professional standards of practice, to Resident#1 who was at risk for pressure injury development. On 04/24/25, Resident #1's admission progress note revealed skin integrity concerns that included, Resident #1 had redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to the left big toe, redness to the groin area, and redness to the buttock and coccyx (tailbone) area. 2. The facility failed to consult the Wound Medical Doctor (WMD) or implement additional pressure relieving devices for Resident #1 to prevent skin breakdown of the heels or coccyx and buttocks on 04/25/25. 3. The facility failed to monitor early signs of a pressure injury (PI) to promote the prevention of pressure ulcer (PU) development to Resident #1's right heel, left heel, and sacrum. On 05/09/25, the RP discovered altered skin integrity on Resident #1's right heel, left heel, and sacrum. On 05/09/25, the WCN inspected Resident #1 based on the RP's concern(s). The WCN took pictures and documented that Resident #1 had a pressure injury to the right heel, a pressure injury to the left heel, and a Stage 3 pressure ulcer to the sacrum. 4. The facility failed to appropriately place pressure offloading wedges when staff repositioned Resident #1 to reduce pressure on bony prominences. An Immediate Jeopardy (IJ) was identified on 05/30/25. The IJ template was provided to the facility on [DATE] at 3:00 PM. While the IJ was removed on 05/31/25, the facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: A record review of Resident #1's admission MDS Assessment, dated 04/27/25, revealed a [AGE] year-old female who admitted on [DATE]. Resident #1 had Medically Complex Conditions that included active diagnoses of Diabetes Mellitus (DM) (a chronic condition that affects the way the body processes glucose [blood sugar]); Stroke; Aphasia (a disorder that impairs the expression and understanding of language, as well as reading and writing abilities); Hemiplegia (refers to complete paralysis) or Hemiparesis (characterized by weakness on one side of the body) of the right side; and Malnutrition. A BIMS score of 05 suggested Resident #1 had severe cognitive impairment. Resident #1 was dependent in self-care and mobility needs. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. The admission MDS reflected Resident #1 did not have current unhealed pressure ulcers/injuries at any stage and was at risk of developing pressure ulcers/injuries. Resident #1 was transferred to the hospital on [DATE] for a non-wound related issue at the RP's request. Record review of Resident #1's Discharge MDS assessment, dated 05/13/25, revealed Resident #1 had one or more unhealed pressure ulcers/injuries. The Discharge MDS assessment reflected one Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (a type of dead tissue that accumulates on the surface of a wound. It is typically soft, yellowish, or white) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) and four unstageable pressure injuries presenting as deep tissue injury (a unique form of a pressure injury that affects the underlying layers of skin, muscle, and other soft tissues) that were not present on admission. A record review of Resident #1's care plan report, initiated 04/25/25 reflected the following: [Resident #1] is incontinent. (Initiated: 04/25/25). Interventions included Brief Use: The resident uses disposable briefs. Change as needed.; Clean peri-area with each incontinence episode; Incontinent: Check every 2 - 3 and as needed for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.; Skin: Provide skin care with each incontinent episode. (Initiated: 04/25/25). Goal: [Resident #1] will have minimal complications related to incontinence episodes through the review date. (Target Date: 06/22/25). [Resident #1] is at risk for alteration in skin integrity. (Initiated: 04/25/25). Interventions (Initiated: 04/25/25) included Apply barrier cream per facility protocol to help protect skin from excess moisture; Change bedding/clothing if moist; Do not allow linens to be creased/folded under resident, keep bedding as smooth as possible; Encourage/assist with turning and repositioning ever 2-3 hours; Guest refuses offloading and turning/re-positioning at times. Provide re-education and re-approach when care is refused.; Monitor skin when providing care, notify nurse of any changes in skin appearance; Provide skin/wound treatments as ordered. Goal: [Resident #1] will remain free of new skin impairment through the review date. (Target Date: 06/22/25). [Resident #1] has actual impairment to skin integrity r/t Poor Nutrition. 5/28/25 - DTI - left great toe, left heel, right heel; Stage 3 right lateral foot. (Initiated: 05/09/25). Interventions (Initiated: 04/25/25) included Evaluate and treat per physician's orders; LALM (Low Air Loss Mattress) as ordered (Initiated: 05/12/25); Prevalon boots as ordered (Initiated: 05/12/25); and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observation by wound nurse or provider. Goal: [Resident #1] skin injury will be healed by review date -and- will have no complications r/t documented skin impairment through the review date. (Target Date: 06/22/25). A record review of Resident #1's Order Summary Report printed 05/19/25 reflected the following: Order date 04/24/25: Wound Consult as needed. Order date 04/25/25: Barrier Cream apply after Incontinent episodes every shift. Order date 04/27/25: Skin Checks Weekly every Day shift every Monday. Must open and document Skin Evaluation for each assessment (including no new areas found). Order date 05/08/25: Wound care to eval and treat coccyx area one time a day for wound care. [Discontinued 05/11/25] Order date 05/09/25: Monitor for LALM (Low Air Loss Mattress) every shift for wound healing. Order date 05/09/25: Monitor for Prevalon boots (for heel protection) every shift for wound healing. Order date 05/09/25: Cleanse right heel, pat dry, apply skin prep every Day shift for wound healing. Order date 05/09/25: Cleanse left great toe, pat dry, apply skin prep every Day shift for wound healing. Order date 05/09/25: Cleanse left heel every Day shift for wound healing. Order date 05/09/25: Cleanse right lateral foot every Day shift for wound healing. Order date 05/09/25: Cleanse sacrum, pat dry, apply collagen [did not indicate form or type of collagen] and Anasept (an antimicrobial skin and wound cleanser), cover with dry dressing every Day shift for wound healing. Order date 05/09/25: [Prescriber (Physician) Entered] Vascular consult. [Order status: Pending Confirmation] Record review of Resident #1's April 2025 MAR revealed a weekly skin check was completed on 04/28/25 and barrier cream was applied after incontinent episodes every shift as the order was written. Record review of Resident #1's May 2025 MAR revealed a weekly skin check was completed on 05/05/25 and barrier cream applied after incontinent episodes every shift were implemented as written. The orders to monitor for LALM and Prevalon boots every shift for wound healing was implemented 05/09/25 during the night shift and every shift thereafter as written. Record review of Resident #1's May 2025 TAR revealed orders to cleanse right heel, great toe, left heel and right lateral foot, pat dry, apply skin prep everyday shift for wound healing were implemented on 05/10/25 and performed daily as written. The order to cleanse sacrum, pat dry, apply collagen [did not indicate form or type of collagen] and Anasept, cover with dry dressing every day shift for wound healing was implemented 05/10/25 and performed daily as written. The WCN signed off on the order entered on 05/08/25 for Wound care to eval and treat coccyx area one time a day for wound care on 05/09/25. Record review of Resident #1's admission progress note, dated 04/24/25 at 8:59 PM, completed by RN A, revealed Resident #1 had skin integrity concerns that included, redness to bilateral heels, Eschar (a hardened, dry, black, or brown dead tissue that forms a scab-like covering over deep wounds) to left big toe, redness to groin area, and redness to buttock. RN A entered an order on 04/24/25 for a Wound Consult as needed. The Wound Care Nurse (WCN) completed a skin assessment on Resident #1 on 04/25/25. Record review of Resident #1's completed Weekly Skin Observations reflected: admission Skin Observation Date: Friday, 04/25/25. Completed by the WCN. Does the Resident have ANY Skin Issues Observed (including new and old)? No If No, Reason: No open wounds noted. Document and Describe ALL Skin Issues: Coccyx (tailbone) - Redness; Left toe(s) - Big toe has scab Other Observations: Skin clean dry and intact. The Wound Team was not notified and there were no intervention/treatment in place. admission Skin Observation Date: Monday, 04/28/25. Completed by LVN B. Does the Resident have ANY Skin Issues Observed (including new and old)? Yes MD notified: Yes Document and Describe ALL Skin Issues: Coccyx (tailbone) - Redness; Other Observations: No new skin issues noted at this time. The Wound Team was not notified. Intervention/treatment in place: Yes. Weekly Skin Observation Date: Monday, 05/05/25. Completed by the WCN. Does the Resident have ANY Skin Issues Observed (including new and old)? No If No, Reason: No open wounds noted. Document and Describe ALL Skin Issues: Right buttock - Redness; Left buttock - Redness; Other Observations: Skin clean dry and intact. The Wound Team was notified, and intervention/treatment was in place. Weekly Skin Observation Date: Monday, 05/12/25. Completed by LVN B. Does the Resident have ANY Skin Issues Observed (including new and old)? Yes MD notified: Yes Document and Describe ALL Skin Issues: Coccyx (tailbone) - Pressure Sore; Other (specify) - Eschar to multiple toes; Groin - Redness; Other (specify) - Redness/pressure sore to BIL heels (Boots applied); Other Observations: No new skin issues noted at this time. The Wound Team was not notified. Intervention/treatment in place: Yes. During an interview on 05/17/25 at 12:07 PM, LVN B said that she worked at the facility for 2 years. LVN B said that she was familiar with Resident #1. LVN B said that she completed the weekly skin assessments for Resident #1. LVN B said that she recalled Resident #1 had redness on her coccyx (tailbone) and CNAs applied barrier cream to the area to protect from breakdown. LVN B said that the CNAs should reposition, and offload pressure points every 2 hours. LVN B said that Resident #1 was at risk for skin breakdown because she had a poor nutritional intake, was incontinent, and made occasional slight changes in body position and was unable to make frequent changes independently. LVN B said the last skin assessment (05/12/25) she completed on Resident #1, the reddened area at the coccyx was open and the WCN documentation reflected a Stage 3 pressure ulcer. LVN B said that Resident #1 had dark discolorations at the heels, and she made sure that the Prevalon boots (heel protectors) were placed on Resident #1's feet before (LVN B) exited the room. LVN B said that all nursing staff was responsible for ensuring residents at risk for skin breakdown have appropriate interventions in place. LVN B said that the CNAs would use pillows to offload Resident #1's ankles before the Prevalon boots were ordered by the WCN. LVN B said that Resident #1 was turned and repositioned every two hours. LVN B said the purpose of turning and repositioning a resident every two hours was to prevent avoid skin breakdown. LVN B could not verbalize how she monitored if Resident #1 was repositioned, and offloading devices were properly placed. During an interview on 05/17/25 at 2:45 PM, Resident #1's RP stated that Resident #1 was admitted to the facility for nearly 3 weeks and was discharged to the hospital for a low blood pressure on 05/13/25. The RP said that he had electronic monitoring in Resident #1's room and was able to provide images of [Resident #1] slumped over to the right side in bed and the green (pressure offloading) wedges were not placed under Resident #1. The RP said that a (pressure offloading) wedge was at the foot of the bed and the other (pressure offloading) wedge was on a chair next to the bed. Record review of an undated and timed picture submitted by the RP, revealed Resident #1 asleep in bed. The head of bed was raised approximately 45 degrees. Resident #1 was in a semi-seated position with knees bent. Resident #1's upper body was leaned over to the right side. A green (pressure offloading) wedge was observed at the right-side foot of the bed. A corner of the (pressure offloading) wedge hung off the edge of the bed. At the left-side head of the bed, 2 green (pressure offloading) wedges were observed stacked on the chair resting on the left arm and the seat of the chair. During record review and an interview on 05/19/25 at 3:09 PM, the WCN said that she provided wound care, new resident skin assessments, measured and took pictures of wounds; performed weekly skin assessments on residents she followed for wound care and occasionally assisted nurses with weekly skin assessments if they became too busy. The WCN said that she took wound pictures every 7 days to monitor improvement and followed all altered skin integrity that included skin tears to pressure wounds. The WCN said that the nurses performed wound care in the WCN's absence and on the weekends. The WCN said that she conducted the admission skin assessment on Resident #1 and skin was intact. The WCN said that Resident #1 did not have redness to the right and left heels and although there was redness to the buttocks she was not concerned because the skin was intact. The WCN said that the facility policy and procedure for PU/PI prevention was to order a LALM for residents with actual skin breakdown, keep residents clean and dry if incontinent, turn and reposition every 2 hours to prevent skin breakdown if the resident could not reposition on their own. The WCN said that staff were aware of care plan interventions by reviewing the care plan. The WCN said that she did not participate in care plan develop or updates and did not monitor if care plan interventions were implemented for the management of skin. The WCN said the wound doctor was involved with intervention suggestions. The WCN said that she did not need to follow Resident #1 because she did not have any skin issues. The WCN said that the RP complained of bruises to Resident #1's right and left heels (on 05/09/25) and she told the RP that they were blood blisters. The WCN replied when asked if blood blisters were considered DTIs, she said no. The WCN went on to say that the RP was concerned about Resident #1's buttocks and the WCN said that she visualized the area and said that it looked like shearing from friction (a superficial injury that occurs when skin is dragged across a surface). The WCN stood up and demonstrated how a resident's brief could be placed incorrectly and rubbed against the skin when pulled across the bed. The WCN denied that was the situation with Resident #1 and said that she was just giving an example. The WCN said that she thought the shearing could have been caused by skin contact with the mechanical lift sling. The WCN said that she did not think that Resident #1's bottom would be bare on the mechanical lift sling and said that she was giving an example. The WCN said that she took pictures of the discovered areas and forwarded to the NP for guidance. The WCN said that the NP was unsure about Resident #1's altered skin issues. The WCN said that she documented the right and left heels as DTIs and the sacrum as a Stage 3 pressure ulcer. When the WCN was asked, what information was obtained to determine the altered skin integrity was a Stage 3, she said that she measured the wound and it looked like a Stage 3 (pressure ulcer). The investigator reviewed the picture of the sacrum with the WCN, asked about the measurements entered underneath the picture (6.00 cm length x 3.00 cm width x unknown depth), and if a depth of a wound was necessary to consider a pressure ulcer a Stage 3; the WCN said No, the depth was not needed to stage a wound. The WCN could not define in her own words the differences between Stage 1 & 2 (partial thickness), Stage 3 & 4 (full thickness), Unstageable/DTI, or eschar. The WCN said that she obtained orders from Resident #1's PCP and did not consult the Wound Medical Doctor (WMD). During an interview on 05/19/25 at 7:12 PM, CNA C stated she worked at the facility for 2 years. CNA C denied ever seeing the green (pressure offloading) wedges at the bottom of Resident #1's bed or on the chair beside the bed. CNA C said that the wedges must be placed underneath Resident #1 to prevent falls. CNA C said that the wedges were placed at the shoulders and at the hips. CNA C said that rounds were done every 2 hours and as needed. CNA C said if she observed the wedges placed incorrectly or not underneath the resident, she would immediately correct the issue. CNA C was unaware of the purpose for the wedges to help maintain a lateral side-lying position and to ensure proper offloading for pressure injury prevention. During record review and an interview on 05/19/25 at 7:53 PM, the CNO said that she expected nurses and the WCN to follow facility protocols for pressure ulcer prevention and skin management. The CNO said the green wedges were to be placed underneath Resident #1 to off-load pressure and prevent skin breakdown. The CNO said the green wedges were also used to support Resident #1 when sitting upright due to her stroke related left sided weakness. The CNO said, labeled Patient's Side, were not used properly in the pictures shown to her. The CNO stated if the green (pressure offloading) wedges were not placed properly underneath Resident #1, there was a risk of pressure ulcer development due to pressure on the skin for a long time. The CNO said that the LALM assisted with off-loading pressure to the resident to prevent wounds and avoid pre-existing wounds from worsening. The CNO said that the facility recently held a Skills Fair with nurses to ensure up-to-date knowledge and competency in skin management and wound care. The CNO said that Resident #1's wounds were unavoidable and that she started the documentation on 05/09/25 to reflect the factors that made the wounds unavoidable but did not complete the documentation. The CNO said that a resident should be assessed and evaluated at admission to determine if at risk for unavoidable PI/PU. The CNO said that Resident #1 was not assessed or evaluated during admission because the electronic health record, PCC, did not include that type of assessment at admission. The CNO said that the WMD did not need to be consulted for redness and could be treated by the WCN, but the WCN should have consulted the WMD on 05/09/25 when the altered skin integrity was discovered and if she had questions about wound staging. The investigator reviewed the picture of the sacrum with the CNO, and she said that the area to Resident #1's buttocks looked like a superficial skin injury and not a Stage 3. The CNO said that the measurements of a Stage 3 wound would include the length, width, and depth. The CNO said if there was not a measurable depth to a wound because the margins were even with the surrounding skin or was covered by slough or eschar, the wound would be considered unstageable and would require the WMD to be consulted. On 05/19/25, an outbound call to the NP was unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to the exit on 05/31/25. Record review of the facility's Skin Integrity Management policy, revised October 5, 2016, reflected: Reposition residents at risk for pressure sore or with pressure sores at least every two (2) hours, if unable to turn themselves. Use pillows or foam wedges to keep bony prominences from direct contact . The presence of a pressure reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two (2) hours in order to prevent pulmonary and renal complications as well as pressure sores . If eschar or necrotic tissue is present, debridement may be indicated. Physicians do surgical debridement only. The National Pressure Ulcer Advisory Panel ([NPUAP], 2016) revised the definition and stages of pressure injury. Review of the new definition of suspected DTI is: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description is also given: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. (Reference: Edsberg LE, Black JM, [NAME] M, [NAME] L, [NAME] L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016; 43(6):585-597. doi:10.1097/WON.0000000000000281 https://pmc.ncbi.nlm.nih.gov/articles/PMC5098472/) The Centers for Medicare & Medicaid Services ([CMS], 2024), defined pressure ulcer/injury characteristics as: - Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI. - Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. (Reference: Centers for Medicare & Medicaid [CMS], State Operations Manual, Appendix PP. (Rev. 225; Issued: 08-08-24). F686 Skin Integrity, p. 298. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf The NFA was notified of an Immediate Jeopardy (IJ) on 05/30/25 at 3:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 05/31/25 at 11:14 AM and included: [FACILITY NAME] is committed to ensuring the safety and well-being of all Residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes [FACILITY NAME]'s written credible allegation of compliance for the immediate jeopardy noted. Policy Statement It is the facility's policy to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers/injuries and do not develop pressure ulcers/injuries unless clinically unavoidable, and that residents with pressure ulcers/injuries receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing, in accordance with F686. Immediate Action for Affected Residents On 05/30/25: Resident #1 is currently hospitalized . Upon return to the facility, the resident will: o Receive a complete skin assessment by two licensed nurses o Have a new care plan developed addressing all areas of skin integrity o Be evaluated by the Wound Care Physician within 24 hours of readmission o Have pressure-relieving devices implemented including heel protectors and pressure-redistributing mattress o Receive repositioning every 2 hours and as needed Identifying Other Residents at Risk On 05/30/25: Conduct skin sweep of current residents completed by licensed nurses Review of current residents' medical records to identify those with diabetes, impaired mobility, or other risk factors for pressure injuries Creation of a facility-wide list of at-risk residents requiring enhanced monitoring Root Cause Analysis Root causes identified through staff interviews, record reviews, and process analysis on 05/30/25: Lack of communication between nursing staff and Wound Care Nurse Systemic Changes and Preventive Measures Effective 05/30/25: Revised skin assessment protocol requiring two-nurse verification of skin concerns on admission Residents with skin alterations will be reviewed during clinical stand-up meetings DON and or Designee will provide mandatory in-service education to all nursing staff until all nurses have been trained prior to next shift worked. o Pressure injury prevention and identification o Proper wound staging o Communication requirements o Documentation requirements o Reporting requirements DON and or Designee will provide mandatory in-service education to all Updated wound care policy requiring physician notification of identified skin concerns Implementation of wound care rounds weekly by WCN and or designee Monitoring and Evaluation Plan Beginning 05/30/25: Director of Nursing or designee will: o Audit 100% of new admissions for skin assessments daily for 2 weeks, then 50% weekly for 4 weeks o Review wound documentation daily for 2 weeks, then 3x/week for 4 weeks o Monitor physician notification compliance daily for 2 weeks o Observe random wound care rounds weekly for 8 weeks Quality Assurance Nurse And or Designee will: o Conduct random audits of 10 resident skin assessments weekly for 8 weeks o Review new pressure injuries for appropriate interventions and physician notification o Monitor staff compliance with new protocols weekly The Director of Nursing will report monitoring results to the QAPI committee weekly for 8 weeks, then monthly until sustained compliance is achieved for 3 consecutive months. The QAPI committee will adjust the plan as needed based on audit findings. On 05/31/25 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by the following: Interviews conducted with nursing staff scheduled on 05/31/25 between 11:30 AM - 3:00 PM, included PRN and new hire staff [RN F, LVN G, LVN B, and LVN D] indicated they participated in the mandatory in-service education about Pressure Injury Prevention and Identification, Proper Wound Staging, Communication Requirements, Documentation Requirements, and Reporting Requirements. The nurses summarized the topic of discussion included policy, procedure, and the facility/leadership expectations. Each nurse stated in their own words the procedures for resident skin management to prevent pressure injury/ulcer development rather avoidable or unavoidable (pressure injury development or failure to heal because of the resident's clinical condition regardless of the interventions provided to treat or prevent development). Nurses said that they would notify the WCN and/or ADONs and notify the physician immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee and the wound physician, if applicable, including what actions to take if unable to contact a physician. Observations on 05/31/25 of nurses [RN F, LVN G, LVN B, and LVN D] demonstrated in the chart how to locate observation documents, how to complete a weekly skin assessment, document skin observations in a daily skilled note, and how to enter an order for a wound consultation for the WCN to assess, evaluate, and treat. The WCN would consult the third-party WMD as needed. Observation on 05/31/25 of CNAs [CNA P and CNA E] performed pressure relief measures that included, resident positioning; support device placement to offload and prevent pressure to bony areas; and apply skin protectant to intact peri-wound skin during incontinent care. Interviews co[TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #1, #2, and #3) reviewed for pain management. 1. The facility failed to provide medication oxycodone Oral tablet 10 MG per doctor's order for Resident #1 on 6-5-2024 after Resident #1 complained of continued pain and requested medication. Resident #1 admitted to the facility on [DATE] at 3:30 PM and only received Acetaminophen Capsule 500 MG for pain at 11:55 PM. Resident #1 did not receive oxycodone oral tablet 10 MG until 6-6-2024 at 1:20 AM, at which time Resident #1's pain level was at an 8. 2. The facility failed to provide effective medication for Resident #2 who admitted to the facility on [DATE] and received Tramadol oral tablet 50 MG per order starting on 5-13-2024 at 8:56 PM and Oxycodone oral tablet 5 MG for pain on 6-14-2024 at 1:59 PM. Resident #2's pain levels remained high from 6-14-2024 through 6-27-2024 without physician notification or intervention. 3. The facility failed to provide effective pain medication for Resident #3, who admitted to the facility on [DATE]. Resident #3 received Oxycodone-Acetaminophen oral tablet 5-325 MG from 6-1-2024 through 6-17-2024 with pain levels ranging from 5-9 and received Acetaminophen-Codeine tablet 300-600 MG only one time a day as needed. Resident #3's pain levels stayed elevated from 6-1-2024 through 6-27-2024 without intervention or physician notification. An Immediate Jeopardy (IJ) situation was identified on 6-28-2024 at 12:52 PM. The IJ template was provided to the facility on 6-28-2024 at 12:52 PM. While the IJ was removed on 6-28-2024 at 3:53PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents on controlled pain medication at risk of not receiving appropriate pain management resulting in pain. Findings included: 1. Record review of Resident #1's face sheet dated 6-26-2024 revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included fracture of the right acetabulum, fracture of shaft of right ulna, pain due to internal orthopedic prosthetic devices, implants, and grafts, intracapsular fracture of right femur, and pelvic and perineal pain. Record review of Resident #1's MDS indicated a BIMS score of 15, revealing Resident #1 was cognitively intact. Resident #1's pain assessment interview indicated she was at a level 7. Record review of Resident #1's care plan dated 6-11-2024, indicated she was planned for pain indicating the facility should anticipate resident's need for pain relief and respond immediately to any complaint of pain, identify and record previous pain history, and management of that pain and impact on function, and identify previous response to analgesia including pain relief, side effects, and impact on function. Record review of Resident #1's orders revealed her pain medications ordered on the day of admission were: Oxycodone oral tablet 10 MG given by mouth every 6 hours as needed for pain. Record review of Resident #1's nursing notes dated 6-5-2024 at 11:00 PM, revealed Resident #1 was upset as she was in pain and not getting relief. Resident #1 stated she was informed that her pain medications would be available upon discharge from the hospital to the facility. Resident #1 spoke to her family indicating her desire to leave the facility due to lack of pain relief. On 6-7-2024 at 5:48 AM, Resident #1's nursing notes stated she was complaining of not getting effective pain medication. Record review of Resident #1's MAR dated 6-26-2024, indicated Resident #1 did not receive Oxycodone oral tablet until 6-6-2024 at 1:20AM. Resident #1 only received Acetaminophen 500 MG two tablets, on 6-5-2024 at 11:55 PM with a pain level of 8. The MAR further revealed pain levels of Resident #1 remained at levels 5-9 from 6-5-2024 through 6-24-2024. On 6-22-2024 and 6-23-2024 the record indicated Resident #1 received no pain medication. In an interview/observation on 6-26-2024 at 11:15 AM, Resident #1 stated she arrived at the facility on 6-5-2024 at 3:30 PM, was in pain, and did not get any pain medicine until around 11:30 PM. She stated it was a weaker medicine like Tylenol and she was still at a high pain level. Resident #1 stated she did not receive anything stronger until 6-6-2024 and was still at a high pain level. She stated her pain level was so bad that she sent a text message to the facility telling them she wanted to leave the facility as her pain level caused her to feel depressed. 2. Record review of Resident #2's face sheet dated 6-26-2024 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of right lower leg (tibia & fibula) with surgery, pain due to internal orthopedic prosthetic devices, implants, and grafts, low back pain, compression fracture of third lumbar vertebra, and osteoarthritis. Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating she was cognitively intact. In the pain assessment interview for Resident #2 revealed her pain rating at a level 8. Record review of Resident #2's care plan dated 6-3-2024, indicated she is planned for pain stating: o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. o Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. o Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Record review of Resident #2's MAR dated 6-27-2024 indicated she was ordered to receive Tramadol oral tablet 50 MG to be given by mouth every 4 hours for pain on 6-13-2024 and was ordered to receive Oxycodone oral tablet 5 MG to be given by mouth one every 6 hours as needed for pain. Resident #2's pain levels stayed elevated on 6-13-2024 to 6-27-2024 from level 5 to 10. In an observation and interview on 6-28-2024 at 2:20 PM, Resident #2 was observed grimacing in pain. Resident #2 stated she was in pain. Resident #2 said she has been at the facility since 06-13-2024. Resident #2 stated she was an LVN, had a motor vehicle collision, had a fracture in her back, had a broken tibia and fibula, and was in pain at a level 8. Resident #2 said she used her call light when she was in pain but by the time a nurse got to her, she would be at a level 10 for pain. Resident #2 stated many times when she had asked a nurse for pain medicine, she was told it wasn't time to get it or they gave her something weak like Tramadol which did not effectively stop the pain. Resident #2 stated the night nurse argued with her when she has told her that her pain level was too high. The night nurse started raising her voice toward her and it made her feel scared. Resident #2 stated another staff member, an LVN, told her not to use the call light too much because the facility was short staffed, and she must deal with other patients. When most nurses have come into her room, they do not ask her what her pain level was. She stated when she was at a level 10, it was too much. When she had not received adequate pain relief, she had thought she did not want to live, which caused her depression and panic attacks. Resident #2 stated she has not been able to speak to a doctor about getting better pain relief. Many times, when her pain level was high, no one responded to her call light, and this caused her to have to scream out for a staff member to come bring her pain medicine. 2. Record review of Resident #3's face sheet dated 6-27-2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dislocation of the left shoulder joint, pain due to internal orthopedic prosthetic devices, implants, and grafts, atherosclerotic heat disease, chest pain, precordial pain (chest pain that can feel like a burning, stabbing, or throbbing sensation, and can occur under or in the left breast), and acute cystitis (urinary tract infection causing inflammation of the bladder). Record review of Resident #3's MDS dated [DATE], disclosed a BIMS score of 15, indicating being cognitively intact. During her pain assessment interview Resident #3 revealed she was at a level 7. Record review of Resident #3's care plan dated 6-3-2024, indicated she has the potential for pain and instructing staff to: 1- Anticipate the resident's need for pain relief and respond immediately to any complaints of pain 2- Identify and record previous pain history and management of that pain and impact on function. 3- Identify previous response to analgesia including pain relief, side effects and impact on function. 4- Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Record review of Resident #3's orders revealed that her pain medications included: Acetaminophen-Codeine tablet 300-600 MG to be given every 12 hours as needed for pain ordered on 5-28-2024, Oxycodone-Acetaminophen tablet 5-325 MG given every 6 hours as needed for pain ordered on 5-27-2024, Ibuprofen tablet 600 MG tablet given every 8 hours for pain ordered on 5-30-2024, and Ibuprofen table 800 tables given for pain every 8 hours as needed ordered on 6-18-2024. Record review of Resident #3's MAR, for the month of June, dated 6-27-2024 revealed her pain levels ranged from 5-9 from 6-1-2024 through 6-27-2024. In an interview/observation on 6-28-2024 at 2:15 PM Resident #3 was observed lying in bed grimacing in pain. Resident #3 said she was in a lot of pain, had nerve damage, and could not use her left arm. She said the last few days her pain had been worse. Resident #3 said her pain level was at an 8 and it had been up to a 10. She stated she told the staff earlier in the day that her pain was at an 8 and it was still at an 8 after 2:00 PM. Resident #3 stated when her pain level was that high, she would not want to do any physical therapy or activities. When the facility changed pharmacies, it caused delays for her getting pain medication. Resident #3 stated over the last 4 or 5 days getting her pain medication had been a big problem and she had to contact the DON because a nurse would not contact the doctor to get effective pain medicine. In an interview on 6-28-2024 at 1:34 PM, RN A stated her process for pain management was when a resident expressed pain, she checked to see when the last time a resident had the pain medicine. If it was not time yet, she would let the resident know. If a resident still complained she would let the doctor know. RN A stated she thought a resident needs to be at a level 9-10 before she believed a pain medicine isn't effective. RN A stated she was a PRN nurse and was not so familiar with the residents at the facility. She stated when she gave a pain medicine, she would wait for 30 minutes to an hour to see if it was working. She said she would call the doctor's office and the office would get in contact with the doctor to let the doctor know the patient was still in pain after receiving medicine. In an interview with LVN A on 6-26-2024 at 4:00 PM she stated if a resident was at a pain level 3, but the resident says she was still in pain, then the pain medicine was considered not effective. Her process for pain management was to check the orders and assess the patient to see how bad the pain was. If the pain was high, she just followed the orders. LVN A stated the nurse covering the patient was responsible for monitoring the patient's pain levels. If a CNA saw that a patient was in pain, they should come and tell a nurse. The nurse, doctor or nurse practitioner work together to determine if a different pain medication would be more effective. After showing LVN A the MAR for Resident #1 for 6-6-2024 showing a pain level 8 from 1:20 AM through 7:39PM with her initials indicating she administered Oxycodone 10 MG at 7:40 AM without any reduction in the level of pain - she stated, I must have mis-charted the MAR. LVN A said she did not remember that day well, but Resident #1 was upset because her pain medicines were not at the facility and Resident #1 had a rough night. LVN A did not remember if a doctor was notified or not. LVN A stated when the pain levels are at the level the MAR was showing for Resident #1, (a constant 8) a doctor should be notified. She stated the risk to Resident #1 is her blood pressure could rise and other health problems could occur. In an interview with CNA A on 6-26-2024 at 4:25 PM, it was revealed she worked 12 hour shifts from 6AM-6PM. She stated her pain management protocol was if a patient was in pain, she asked the patient where the pain was and how bad does it hurt them. CNA A then would tell a nurse. The nurse knew what pain medication the patient could or could not have and gave the patient what they could have. CNA A stated the nurses were the ones in charge of monitoring a patient's pain levels. She stated a pain level higher than a 7 would indicate a patient might need a higher dose or different pain medicine to be effective. She stated an example would be if a patient received pain medicine at 7:00 AM and the patient was still in pain by 7:30 PM, the facility would need to try something different. CNA A stsated the risk to the patient not getting adequate pain relief could be an infection problem, cause high vital signs, put them in a bad mood, cause them to not eat food, and can cause them to become non-compliant with the facility. On 6-27-2024 at 10:15 AM an interview was conducted with LVN B revealed she had worked at the facility for 2 years as a PRN nurse. She stated her protocol for pain management was when a patient has asked for pain medicine and if it was time for them to have it, she would give the patient the pain medicine. If, however, it was not time for the patient to receive pain medicine, she would explain to the patient the last time they had the pain medicine and would tell them when they would be able to get some more. She stated the nurses monitor the patients for pain, then ask the patient what pain level they were experiencing and document the MAR. LVN B considered a pain level of 10 to prove that pain medicine is not working for a patient. She stated the nurse determined if a higher dose of medicine was needed or if another pain medication would be needed. If she determined a pain medicine was not effective, she would text the doctor or NP. After showing LVN B the MAR for Resident #1 indicating LVN B gave Oxycodone one tablet 10 MG each time and marked a pain level of 8 on 6-6-2024 at 1:20AM, a pain level of 8 on 6-6-2024 at 7:39 PM, on 6-14-2024 showing a pain level of 7 at 1:09 AM, and on 6-17-2024 showing a pain level of 9 at 9:10PM, LVN B stated she marked those levels of pain but Resident #1 never told her the medicine was not working. LVN B conveyed the reason Resident #1 stayed at such high pain levels was because she had hip surgery and a broken arm. She stated when someone was at high pain levels, as Resident #1, she just gave them the pain medicine ordered if the patient does not complain. LVN B said she was not sure what the risk would be for a patient to stay at high pain levels, but they could get high blood pressure or something else could be going on. Attempted to call LVN H on 6-27-2024 at 2:00 PM and left a voice message but never received a call back. Record review of Resident #1's MAR, LVN H gave Resident #1 Oxycodone one tablet 10 MG each time and marked a pain level in the MAR on 6-8-2024 of 7 at 5:23 AM and level 7 at 10:20 PM, on 6-10-2024 a pain level of 5 at 1:00 AM, and on 6-13-2024 a pain level of 6 at 9:10 PM. In an interview on 6-27-2024 at 2:55 PM, the ADON said the process to follow for pain management was as soon as a patient comes into the facility, they receive their discharge orders and what pharmacy the resident uses. Then that information goes to the doctor, and they forward that information to the pharmacy. The ADON stated the facility used a newer system, that had a pharmacy, that is closer than the one in San [NAME]. She stated they followed the orders and the time frames of the orders. The ADON stated she could order pain medicine stat, if needed but it cost the facility more money. The ADON said Resident #1 was admitted to the facility on [DATE] between 3:00 PM-4:00 PM, learned about the stat fee, and got Resident #1's pain medicine sooner. She said the floor nurses are responsible for monitoring residents for pain. The ADON stated whenever she has been in a resident's room, she always asked how their pain is. If the patient was non-verbal, she looked at their blood pressure and other signs to see if they are in pain. She said the patient lets the staff know if the pain medicine isn't working. If a patient was constantly at a level 8, she would consider the pain medicine to be effective. She told the patients if you are hurting so bad you can't stand it, let her know. At that point, she would call the doctor and he would either strengthen the dose or shorten the time frames between doses. The doctors determine if a patient needs a different pain medicine or a different dose. After showing the ADON Resident #1's MAR from 6-5-2024 through 6-24-2024, she stated Resident #1's pain levels are somewhat high and she would consider increasing Resident #1's dosage for pain. The ADON said pain is subjective as some people take pain better than others. When asked why the physician was not called during the high pain levels recorded in Resident #1's MAR, the ADON said the only thing she can think of is when the nurses went back into Resident #1's room, Resident #1 did not complain of pain. The nurses do not pull of the MAR history the see the pain levels for patients. The ADON said the nurses should pull up the MAR history for patients to see the patterns of pain to adequately assess them. She stated when the patterns of pain are like that of Resident #1, she would have called a doctor to let him know and maybe get a dosage change or a change in medicine to be more effective. The ADON said the risk to patients if their pain isn't effectively managed would be they would not sleep well, would not do therapy, would be restless, and irritable. In an interview on 6-27-2024 at 3:26 PM, the DON stated she had worked at the facility for 2 years. The DON said the process the facility follows for pain management was to follow the doctor orders. Most of the orders come from the hospital and the facility follows them. She said sometimes the pain medicine works and sometimes it doesn't. It is a hot topic and varies with individuals. If a pain medicine was not working, the facility would know it sooner than later. The doctors and PA come to the facility twice a week, the NP is at the facility on Mondays and Fridays, and the PA is at the facility several times a week. If a patients pain medicine is not being managed, the doctors will change it. It is a team effort if pain management isn't working to make adjustments as needed. The DON stated whoever has the care of the patient at the time (the charge nurse) is responsible for monitoring the pain levels of the patient. When asked what level of pain a patient had to reach for the facility to consider pain management not being effective, the DON said the facility doesn't judge pain by a number on the pain scale. Pain is an individual thing. It depends on whether one is dealing with chronic pain opposed to someone who had surgery. The DON said the patient determines if the patient needs a different pain medicine. The nurse on duty only has what is in front of them and isn't looking at the MAR history of the patient. The nursing staff doesn't have time to do a full MAR history review of the patient. When the DON was shown the MAR for Resident #1, #2, and #3, showing high pain levels from 6-1-2024 through 6-27-2024 said without knowing who the patients are, she wouldn't know why those levels were as high as they were. When asked was a doctor called for Resident #1, #2, or #3 during the MAR levels of pain from 6-1-2024 to 6-27-2024 ranging from level 4-10, she said no - but they have been called now. As of today, the facility is doing in-servicing on pain management and all nurses have signed a pain management course. The DON said she will inform the nursing staff of how to look for more signs of pain after a patient has had surgery, and then follow up with residents to see how effective the pain medicine was. The DON stated she believes the doctor was not called for pain management being ineffective for Resident #1, #2, and #3, from 6-1-2024 through 6-27-2024, when the MAR indicated pain levels ranging from level 5-10 because the nursing staff did not connect the dots to realize they should. After showing the MAR for Resident #1, #2, and #3 with the pain levels being mostly above a 5 all the way to a 10 from 6-1-2024 through 6-27-2024, the DON said the nursing staff should have asked the patients where the pain was at, when did the pain start, was the pain medicine working, and was this a new pain. She said there should have been a more in-depth assessment of Resident #1, Resident #2, and Resident #3. The DON said the risk to the patient having levels of pain such as Resident #1, #2, and #3, was more of a mental thing. It would depend on where the pain was an acute pain or a continuation of what has already been there. Record review of the facility's Pain Management Policy dated 10-2022 (revised 5-2023) states: Policy: It is the policy of this facility to respect and support the resident's right to optimal pain assessment and management .Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain .It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain During the initial nursing assessment, the resident will be screened for identification of pain o If the resident does not indicate present or chronic pain, this will be noted on the initial assessment form. o The resident will have routine reassessments performed per policy weekly. o admission assessment will include but is not limited to: ? History of pain and its treatment including non-pharmacological interventions ? History of addiction, past and/or ongoing and related treatment of OUD ? Characteristics of pain ? Impact of pain on quality of life ? Factors such as activities, care or treatment that precipitate or exacerbate pain as well as those that reduce or eliminate pain ? Additional symptoms associated with pain ? Physical and psychosocial issues ? Current medical conditions and medications including medication assisted treatment for OUD ? Resident's goals for pain management and resident's satisfaction with current level of pain control . Pain Recognition o Expressions of pain may be verbal or nonverbal and are subjective to the resident including but not limited to: ? Negative verbalizations and vocalizations (groaning, crying, whimpering, screaming) ? Facial expressions (grimacing, frowning, fright, clenching of jaw ? Changes in gait, skin color, vital signs, perspiration ? Behavior such as resisting care, distressed pacing, irritability, depressed mood or decreased participation in usual physical and/or social activities ? Loss of function or inability to perform ALDs ? Difficulty eating or loss of appetite ? Difficulty sleeping All other clinical department staff will also question the resident regarding pain during initial resident assessment activities and reassessment activities performed by the department's care provider If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers. Healthcare providers from any department, that have implemented a pain control mechanism, will reassess the resident timely to determine the amount of pain control or relief achieved. Pain control mechanisms may include, but are not limited to: o Medications administered for the control or relief of pain o Medications administered for the control or relief of anxiety o Repositioning of the resident o Ambulation of the resident o Heat or cool therapy o Mild resident exercise o Therapeutic massage, i.e., back rub, etc. o Bathing or whirlpool bath o Diversion techniques, i.e., television or video tape viewing, reading, etc. o Therapeutic communication o Spiritual counseling o Visitation from family/significant others. Management of the resident's pain is an interdisciplinary process and is to be included on the resident's interdisciplinary care plan o Inclusion of this component of the resident's care process will alert and educate all members of the healthcare team regarding the resident's pain experience o Pain management issues will be included in topics of discussion during interdisciplinary care planning conferences and discharge planning . An Immediate Jeopardy (IJ) was identified on 6-28-2024 at 12:52 PM. The Administrator and DON were notified. The IJ template was provided to the administrator via email on 6-28-2024 at 12:52 PM and a POR was requested. The following Plan of Removal was submitted by the facility and accepted on 6-28-2024 at 3:53 PM: F697 - Pain Management Immediate Interventions: 1. Notification made to [Physician Name] and [Physician Name], physicians and Medical Directors, of Immediate Jeopardy on 6-28-2024 at 1:12 PM. 2 . Emergent Meeting conducted with action plan developed. This occurred at 1:15 PM on 6-28-2024. Attendance included: [Administrator Name] - Administrator [DON Name] - Director of Nursing Action Plan: Daily Pain Assessment will be completed on patients 3. Direct Care Nursing Staff in-serviced on Pain Management, pain medication follow up on effectiveness after medication administration, physician notification if no improvement in pain level after medication administration on 6-28-2024 by [DON], DON, [ADON A] ADON, and [ADON B] ADON. - All PRN Pain Medications require a pre and post administration pain assessment number (or Wong-Baker Scale) - This must be documented - All guest who have received PRN pain medication must have a follow-up to determine level of pain relief achieved. - If there was a little to no improvement with the level of pain, a call must be make to the guest's physician for further intervention. - Please document this in clinical record - If a guest is asking for pain medication sooner than ordered, a call must be made to the physician for further intervention. - Please document this in clinical record. 4. Meeting with the following managers to review Immediate Jeopardy on 6-28-2024. We reviewed Pain Management, notifying physician when Pain Medications are not effective. The following managers attended: a. [Administrator Name], Administrator b. [DON Name], Director of Nursing c. [DOR], Director of Rehabilitation d. [ADON A] Assistant Director of Nursing e. [ADON B], Assistant Director of Nursing f. [Activities Director], Activities Director g. [Dietary Manager], Dietary Manager h. [SW] Social Services i. [LVN Name], MDS Nurse j. [LVN Name], MDS Nurse Training: 1. [DON] Director of Nursing, to be in-serviced by [Corporate Nurse] [NAME] President of Clinical Services. [NAME] will be in-serviced on Pain Management, Physician Notification, Monitoring Pain management, and reviewing Pain Assessments. 2. An immediate in-service was initiated on 6/27/24 and 6/28/24 By [DON], Director of Nursing, on Pain Management and physician notification. 3. Beginning 6/28/2024 and on-going: A posttest will be completed by direct care nursing staff to ensure competency on Pain Management. Staff must answer all questions correctly before returning to work. 4. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 5. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration ([DON], [ADON A], and [ADON B]) will interview random patients that receive pain medication to ensure effective pain management is in place. 2. [Administrator], Administrator, or appointed designee will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's decision. This will be on-going. [Facility Name] requests that the measures we have implemented be reviewed and that our allegation of removal of jeopardy be accepted as of 6/ 28/ 24. The facility was monitored for compliance with the POR on 6-28-2024 as follows: In an interview on 6-28-2024 at 3:28 PM, it was discovered that LVN C has worked at the facility for one year, was on vacation, returned today from vacation, and was not in-serviced on pain management yet. She said her procedure for pain management was to know when it is scheduled, give the medicine within a one-hour timeframe. If the medicine is PRN, she would only give it as the patient request it. She checks back 30 minutes to an hour to see if the pain level decreases. If the pain level was still above a level 6, she would call the doctor. LVN C stated the risk to a patient for having constant levels of pain above a 6 is the patient might not be able to do their therapy, it would a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents reviewed (Resident # 7's and Resident # 26) for abuse and neglect. The facility failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT, on 10/27/23, they observed Resident #26 with a heavily soiled ostomy bag that was leaking. An Immediate Jeopardy (IJ) was identified on 11/01/23. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and the severity level of actual harm. The resident had to receive sutures, was covered in feces, and suffered the emotional distress of not receiving help from the facility. Resident #7 suffered actual harm. because all staff had not been trained on Abuse and Neglect, call light responding, and documenting abuse on 11/02/23. These failures could affect other residents in need of assistance and mobility limitations placing them at risk for abuse, physical harm, serious injuries, serious harm, serious impairment, pain, mental anguish, and infections. Findings included: In a review of Resident #7's face sheet dated 10/31/23 revealed a [AGE] year-old female with an admission date of 10/27/23. Diagnoses included: enterocolitis(inflammation of digestive tract) due to Clostridium difficile (bacterial infection of the colon), primary admitting dx recurrent other specified diseases of gallbladder,(disease involving the gallbladder digestive), unspecified dementia, (decline in cognition) unspecified severity, with other behavioral disturbance, acute kidney failure personal (kidney's not functioning) history of other venous thrombosis and embolism (artery blockage/blood clotting). In a record review of Resident #7's 3-day MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment Resident #7's ADL function for transfer, repositioning, hygiene (bath/shower), toileting and dressing required extensive assistance from staff. Resident was coded as high risk for falls with an actual fall on 10/27/23. In a review of Resident #7's care plan dated 10/27/23 revealed the resident had an actual fall .self-attempt to transfer .Resident will resume usual activities without further incident through the review date. Staff will offer assistance to transfer and assist with toileting as needed .Nursing will Anticipate and meet resident needs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs prompt response to all requests for assistance .Monitor/document /report PRN for 72 hours to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleep. In a record review of Resident #7's MD orders revealed an order for fall mats, Bed rails; date 10/30/23 at 8:11 PM . Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM . Skin checks weekly 10/27/23; weekly weights, wound consult as needed, Acetaminophen Oral -pain assessment every shift, neuro monitoring for 72 hours, evaluation for OT, PT, and OT Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed. every shift. Level of Care: Skilled monitor laceration to right forehead every shift for signs and symptoms of infection .-Report to MD if any. every shift for Wound care Prescriber Written Active 10/29/2023 10/29/23 Monitor skin tear to right palm every shift .Leave Steris trips in place till falls off on its own . Re-enforce as needed. every shift for Wound care Prescriber Written Active 10/29/23 10/29/23. Tablet Mirtazapine Seizures dated 10/17/2023 stated that she had a seizure activity after she started this medication 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain. In a record review of Resident #7's admission assessment dated [DATE] read Initial admission base line assessment no communication barriers, full code, pain, elopement, functions and needs, were addressed. Resident was oriented to use of call light and bed rails. Depression was addressed. No cognitive impairment. Review information on past falls and attempt to determine cause of falls. Record root causes. Alter and/or remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. In a recorded review of #7's progress notes dated 10/27/23 at 9:59 PM LVN-F Received a call from a dispatcher from [company name] at 7:30 PM about a resident calling for another guest who was screaming. EMT (Emergency Medical Technician) showed up at the facility at 7:35 PM, said they got a call from another Resident (#26) that Resident #7 was screaming. EMT found Resident #7 on floor adjacent to the bed with loose stool all over floor. She took her brief off, had her left hand in it, her right palm had a laceration with deep tissue bruising observed, and above her right eye had a big gash/laceration. When asked what she was trying to do, she said she 'know I should have waited but I was trying to get up. 'Call placed to MD N to notify and DON (Director of Nursing), CNO while CNA (Certified Nursing Assistant) assisted one of the EMT in cleaning. MD N okayed that guest needed to be sent to hospital. FM was notified that guest was on her way back to the hospital. EMT left with guest at 8:00 PM. In an interview of Resident #7's progress note dated 10/27/23 at 9:47 PM by LVN F reflected, FM was notified that Resident #7 was on her way to the hospital .EMT left with guest at 8:00 PM. In a record review of Resident #7's progress notes by LVN F dated 10/30/23 at 8:11 PM read Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM. Record review of EMT report dated 10/27/23 at 7:19 Titled response # 2989218 . EMT arrived at 7:30 PM .complaint (Fall from bed) Duration of Complaint (3 hours) primary symptoms: (head injury and multiple injuries) [company name] responded to a priority 5 sick person call at a nursing and rehab facility, called in by another patient at the facility. The patient was a [AGE] year-old female with a chief complaint of multiple injuries following a fall from bed. On scene, the patient is found on the floor, alert and disoriented, not in any respiratory distress and has obvious signs of trauma to her head and lower extremities. The caller stated that the patient has been yelling for help for approximately 3 hours and no one has come to assist the patient. The nurse for the patient states the patient was just a screamer, when she checked on her 30 minutes ago, she was fine. Upon assessment, some of the blood was dry on her head, the patient has soiled herself, has a head laceration, lacerations to her knees, unknown LOC (Level of Care), and family states she was on a blood thinner but can't remember the name of it. The patient was lifted to the stretcher with a blanket, with no injuries or incidents. The crew secured the patient to the stretcher with safety belts and safety rails and loaded the stretcher into the ambulance. The crew applied dressings to the wounds and wrapped the wounds. The patient agrees to be transported to hospital for further treatment and evaluation. The patient denies any pain, just discomfort where the laceration was located. During transport to hospital, the crew continued to monitor vital signs and no new complaints developed. In a record review of Resident #7's EMT patient care timeline reflected Symptom onset: 10/27/23 at 7:12 PM Unit Notified by Dispatch 10/27/23 at 7:12:PM PSAP Call. Unit En route 10/27/23 at 7:19 PM Dispatch Notified 10/27/23 at 7:26 PM Initial responder on scene 10/27/23 at 7:26 PM Unit Arrived on Scene 10/27/23 at 7:43: PM Arrived at Patient Exam. 10/27/23 at 7:45 PM Bandage -Application of bandage. 10/27/23 at 7:53 PM Vitals and departed. 10/27/23 at 8:18 PM transporting to hospital. 10/27/23 at 8:32 PM arrived at destination. At destination, the crew unloaded the stretcher from the ambulance with no injuries or incidents. The crew delivered patient information, a verbal report and obtained a signature for patient care from the receiving ER nurse. The patient is moved from the stretcher to the hospital gurney via the drawsheet method with no injuries or incidents. An APS report is started and was forwarded to proper channels to investigate negligence on the facility. Report number: 7818 In a record review of Resident #7's progress note dated 10/28/23 at 6:27 AM by LVN F read FM brought Resident #7 back from the hospital at 5:48 PM . Vitals assessed, 97.7, 88, 18, 152/61, 95% on RA. Forehead has 10 sutures, right palm is steri-stripped. Multiple bruises to BLE, skin tears to both knees. Dried skin tear to right anterior shin. Guest assisted to bed with Ax1. Informed MD N guest is back. No new orders at this time. Paperwork from the hospital placed in medical records basket. Report given to oncoming nurse. Follow up fall assessments conducted on resident. In a record review of Resident #7s progress note dated 10/28/23 11:52 PM by LVN F Resident continues fall follow up and neuro checks monitoring. No new c/o pain or discomfort voiced at this time. Vitals stable and documented. resident was found attempting to get out of bed again this evening, was easily re-directed, bed lowered to floor and floor mats in place on either side of the bed. Continues vancomycin as well for c-diff, afebrile. Continues to have loose stools. In a record review of Resident #7's MD notes dated 10/28/23 reflected she was admitted due to generalized weakness secondary to C-Diff (infection 10/21/23), Colitis (inflammatory bowel disease), cataracts (decreased vision from cloudiness of the eye), HLD Hyperlipidemia (high cholesterol), chronic pain, right knee, depression (mood feeling down), anemia (blood disorder due to transition of oxygen in blood), vitamin D deficiency ( inadequate nutrition value from sun), falls, dementia (cognitive decline w/o Behavior Disturbances, Congestive Heart Failure (heart disease and function), anorexia (thin in appearance lacking nutrients), Deep Vein Thrombosis (blood clotting), GERD (difficulty with digestion flow), frequent UTI (infection of urinary tract), HOH . Guest is AOX1-2, Guest can make needs known and engage in discussions related to her care. Upon admission, guest scored a 14/15 BIMS. Moderate to severe levels of confusion noted despite high BIMS score, guest was so confused that SW contacted FM to complete social services assessments. PHQ 9 Depression assessment) conducted, score is a 10, mild/moderate symptoms of depression noted. Discussed advanced directives, and Resident #7 desires to be a DNR status at this time. Resident #7's goal is to return home upon completion of skilled stay. Discussed general facility expectations with guest [family member], discharge planning, and SW role in care. Discussed home health services upon discharge. SW discussed general length of stay being 2-3 weeks, with the focus of IDT authorizing stays a week at a time. Current plan of care remains, SS to follow up as needed. Care plan meeting scheduled; guest notified of meeting scheduled. In an observation and interview with Resident #7 on 10/31/23 at 10:15 AM revealed the resident lying in bed on her back with visible injuries to her head above right eye, bandage on right hand, and both knees. Resident 7 stated that she fell on the floor injuring her head, hand, and knees. She was yelling for help over 45 minutes, and no one responded. She said EMT entered her room and assessed and assisted resident, then transported her to the hospital. She received sutures on her head. Resident #26 In a record review of Resident #26's face sheet dated 10/31/23 revealed he was a [AGE] year-old male admitted on [DATE] with current diagnoses: significant for end-stage renal disease on hemodialysis, benign essential hypertension (high blood pressure), chronic hepatitis-C (liver infection), and adenocarcinoma (cancerous tumor on the colon.) In a record review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. Resident had an ADL deficit and required extensive assistance with dressing, transferring and toileting. In a record review of Resident #26's Care plan dated 10/18/23 reflected Resident #26 had ADL self-care performance deficits and limitations in physical mobility. The resident/guest will improve self-care and mobility function by the next review date. Toileting Hygiene: Substantial/maximal assistance -Shower/bathe self: Substantial/maximal assistance lower and upper body dressing: Substantial/maximal assistance Substantial/maximal assistance -Personal Hygiene: substantial/maximal assistance Date Initiated: 10/18/2023 -Roll left and right: Resident has an ostomy r/t adenocarcinoma of colon. Date Initiated: 10/18/23 Resident will have no complications with ostomy through the review date. Monitor for changes in consistency, odor, and/or color of stool and notify physician as needed. Nursing Monitor stoma color for any changes and notify doctor if necessary. Nursing Provide ostomy care per protocol. Nursing evaluation admission [DATE]. In a record review of Resident #26's MD progress note by SW dated 10/25/23 11:54 AM Social Service Note Weekly Interdisciplinary Team meeting held today. IDT members present for this meeting: CNO, Social Worker, Director of Rehab, BOM, LNFA, and MD N. Admitting dx: Cervical spine fracture, DM2, ESRD, Hepatitis C, HTN, stroke. PT: for transfers and bed mobility. OT: for transfers and bed mobility. In a record review of Resident #26's Discharge summary dated [DATE] at 2:49 PM Resident discharged to another facility. Report called to facility. Resident signed discharge paperwork. Advised guest that he will be transported to new facility right after dialysis. Resident verbalized understanding with no further questions or concerns. Copy of discharge papers given to guest. In an interview with Resident #26 on 10/31/23 at 10:30 AM revealed on the day of 10/27/2 3he was changing his ileostomy bag because the nursing staff don't answer the call light or make rounds and he does not want doo (bowel) on him. He stated that the bag constantly leaks, so he requested extra ileostomy bags to change it himself. He said he put the soiled bag inside the urinal on his bed side table and waited for a nurse or aide to come and discard. He said the nurse gave him the extra bag and he did not know her name. Resident #26 said on 10/27/23 he heard a Resident #7 yelling for help for over 3 hours. After a while he called 911 to ask for help because the crying did not stop. He spoke with EMT but did not know the Resident's room number. He guided them to his hall where they found Resident #7 on the floor. He said the EMT also came to his room to assess. He said the CNA and Nursing had not checked on the residents for over 3 hours. In an interview with EMT on 10/31/23 1:09 PM revealed on 10/27/23 another resident contacted 911 after hearing Resident #7 yelling for help. She stated that dispatch contacted the facility, and no one answered. EMT entered the building searching for the resident. EMT arrived at the nursing station at the top of the hall and observed LVN F sitting at the desk ignoring Resident's yell for help. EMT said she could hear a resident yelling for help. EMT asked LVN F do you hear the resident yelling? LVN F stated that they had another resident with behaviors of yelling. EMT said LVN F was ignoring the resident. EMT proceeded down the hall toward Resident #7's room following the yell for help. While simultaneously reporting to LVN F that a 911 call was received from a resident at the facility, reporting a resident had been lying on the floor yelling for help for hours. EMT entered Resident #7's room and found her on the floor with dried and fresh blood observed on the resident's forehead above the left eye, skin tear right palm, and both knees. Resident's brief was heavily soiled with feces. Resident #7 told EMT that she was sitting on the end of her bed and nose-dived on the floor. EMT then checked on Resident #26 on 10/27/23 after examining and assessing Resident #7 (EMT did not provide a time) and observed him with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. In a telephone interview with LVN F on 10/31/23 at 2:12 PM, she stated when she arrived for work on 10/27/23 at 6:00 PM, she proceeded to prepare passport mediation for her unit a (device used to release resident medications by shift), due to LVN C completing final documentation for the end of shift report. LVN F stated LVN C told her that the Resident #7 was newly admitted and was on isolation. LVN F and LVN C, then completed shift reports. LVN F stated that neither nurse completed rounds to assess baseline conditions, which was the nursing protocol. LVN F said she did not hear any yelling out; however, she referenced knowledge of some residents displaying behaviors of yelling for help frequently. She did not respond to the resident's call for help, because she was reviewing shift medication for Resident administration. LVN F said she does not know why Resident # 14 yells out for help during shift. She said it was her responsibility to assist with call lights and follow up on residents calling out for safety to assist for current need. LVN F reported she did not know that Resident #7 fell, until she received a call from the [company name] dispatcher reporting the incident, resident location, and whereabouts, as a neighboring Resident called 911 for help saying a female resident was yelling for help for hours. LVN F stated shortly after the call, the EMT arrived with the same information, and they went together to Resident #7's room and found her on the floor. LVN F stated the EMT arrived after 7:00 PM and the resident was found on the floor, and soiled herself, and was trying to get up and slid from the floor to the bed She said the floor in Resident # 7 was room was soiled with feces (bowel). Resident reported to LVN F that she slid off the bed from a sitting position to the floor. LVN F observed injuries to her right palm with deep tissue pooling, both knees, and bleeding from a laceration to her forehead above her right eye. LVN F said she notified the MD of the fall and injuries. MD approved order for transfer to ER for treatment. EMT transported resident to hospital. The FM returned resident 10/28/23 at approximately 5:48 AM to the facility MD orders. In a telephone interview on 10/31/23 at 4:36 PM, LVN C stated she arrived at 6:00 PM. LVN C said she and LVN F did not conduct rounds due to end of shift report completion from two admissions. She said once she completed the new admissions assessments and documentation, notified LVN F that all reports were completed, and she left. She said the last time she observed Resident #7 was at 5:45 PM after setting up isolation precaution supplies outside the door, due to an infection to C-Diff. Upon exiting Resident #7's room, she placed call light near to reach. In an interview on 10/31/23 at 4:43 PM with CNA T revealed she was the assigned CNA for Resident #7 on 10/27/23 from 6:00 PM to 6:00 AM. She stated that she arrived at 6:15 PM and conducted rounds with CNA K. She was not aware that Resident #7 had a history and risk of falls, as she was a new admission and proceeded with answering call lights after report and rounds with CNA K. CNA T said she should be checking on Residents every 2 hours and as needed to prevent extensive exposure to the resident's skin that could result in skin damage. CNA T stated she did not hear yelling coming from Resident #7's room, but other residents were calling out and she responded and provided care. The expectation for aides upon arrival to shift, were to conduct rounds together while giving reports, then respond to call lights. She said a negative outcome from not answering call lights could lead to injuries. She said not cleaning resident's bag and discarding properly could result in infection. LVN T stated that call light responses depend on CNA's availability at the time, as she may be providing care to another resident. She said when hearing yelling, she responds as soon as she can. She said on 10/27/23, she had not checked on Resident #7 prior to EMT arriving. In an interview with the DON on 11/01/23 at 4:40 PM, she said she had not reported Resident #7's fall, injuries, and EMT, and ER visit from 10/27/23 to HHS, due to LVN F failing to report all of the details to the fall. LVN F did not report that she was not responding to Resident #7s yell for help, failure to conduct resident rounds, and condition resident was found in by EMT. The DON said LVN F did report that another Resident called 911 after hearing Resident #7 yell for help. The DON said she was not told that the Resident # 7 was lying on the floor yelling for over an hour for help until the EMT arrived and found the resident. She expected all staff to respond immediately to calls lights, resident yelling out to provide assessments, interventions, and care. The DON said that she and ADON's were responsible for overseeing LVN 's patient care as well as monitoring job task and needs for help. She reported that LVN C and LVN F should have conducted rounds at the top of the shift. The phone should have been answered, and more information should have been provided about the incident and it would have been investigated. In an interview on 11/01/23 at 4:45 PM, the Administrator stated she was notified that Resident #7 fell and EMT were present on 10/27/23 after the EMT left aby the DON. There was no additional information about staff not responding to the Resident yelling out for help, and EMT arriving seeking resident location as the nurse were not answering the phone. She stated it was her expectation for staff to answer when they hear yelling, call lights, and provide care immediately to the residents to prevent further injuries, and harm from occurring. The Administrator said that all staff were aware that she was the abuse coordinator. She expects the DON and ADON to monitor the clinical task and care of residents by monitoring and auditing, addressing concerns in IDT meeting to implement interventions. She said that residents should not be yelling for help and not getting immediate care. She said that additional task will be implemented to assure Resident safety and timely response from staff to meet medical needs and prevent accidents and injuries. In an interview with CNA J on 11/02/23 at 11:01 AM revealed she did not hear yelling from any resident's or calling out for help while working on 10/27/23. CNA J said the protocol for assisting residents with call lights and yelling out included an immediate response to assure the resident's safety, try to comfort and calm the resident. She said LVN C was observed counting medication with LVN F when she left at on 10/27/23 at 6:20 PM. She last saw Resident #7 upon her arrival at 4:45 PM. Record review of the facility's CNA and LVN assignments for 10/27/23, reflected CNA K relieved CNA T. LVN F relieved LVN C. Shifts were scheduled 6A to 6P. In a record review of the facility's in-service dated 11/01/23 revealed on abuse, neglect, call light response priority, and resident's yelling .find the source of the yelling, reporting abuse and neglect resident behaviors and implementing interventions .A resident lying on the floor and not responding is considered abuse. In an interview on 11/02/23 at 10:10 AM, Resident #7's family member, he reported that he followed the hospital transport of Resident #7 to facility for admission on [DATE] and the nursing staff educated and orientation him and Resident #7. Resident #7 understood call light usage for safety and waiting for assistance to prevent injuries. The FM said he was notified by LVN F of the fall and hospital location for Resident #7. On 10/27/23 around 8:00 PM. Resident #7 told FM that she should have asked for help, and she was sitting at the end of her bed and fell on the floor. Resident #7 told him that she tried to get up on her own, however, she was not successful. Resident #7 said when she could not get up, she yelled for help, as the call light was not nearby. The FM said the resident sustained injuries to the head requiring sutures and injuries to hand and knees. The FM said he transported the resident back to facility. In an interview with CNA K on 11/02/23 at 11:12 AM revealed she was working on 10/27/23, the date Resident #7 was admitted at 4:20 PM. She assisted Resident #7 by transferring her to bed, assessed her and orienting her on call light and asking for help. CNA K said the resident was not confused and she understood the call light process. She said at approximately 5:45 PM, Resident #7 used the call light for incontinent care. She responded immediately and provided care prior to shift ending at 6:00 AM. She said the resident was on isolation for C-Diff and called via call light frequently (Q 10 minutes) for care, due to the loose stool. She said CNA S and CNA T arrived at approximately 6:15 PM. They completed rounds and reports, then she left. CNA K said she did not hear any resident's yelling when she was leaving her shift. Staff were expected to respond regardless of the resident behaviors. She stated that call lights should be responded to immediately and the failure to respond could lead to a resident getting hurt. In a record review of the facility policy titled Abuse Neglect and Exploitation dated April 2023. reflected in part the following: Policy: It is the policy of this facility that each resident will be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff members, volunteers, contractors, residents and family members and visitors and other applicable individuals in techniques to protect all parties. In a record review of facility policy titled To provide guidance on use of call light for residents dated 04/2023 reflected in part the following: 1 The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care. 5. Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. This was determined to be an Immediate Jeopardy on 11/01/23 at 3:00 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the Immediate Jeopardy Template on 11/01/23 at 5:34 PM. The following Plan of Removal submitted by the facility was accepted on 11/02/23 at 11:50 AM: F 600 Allegation of Credible Compliance Immediate Interventions: 1. Notification made MD N and MD B, physicians, and Medical Directors, of Immediate Jeopardy on 11/01/2023 at 4:15 PM. 2. Emergent Meeting conducted with action plan developed. This occurred at 4:30 pm on 11/01/2023. Attendance included the following: Administrator DON 3. Direct Care Nursing Staff in-serviced on neglect, expectations in responding timely to calls for assistance. 11/01/2023 by DON and ADON 4. 11/01/2023 and 11/02/2023: Nursing staff educated on timely response to answering the phone. Education provided by DON. And LVN, ADON. 5. Nurse involved in incident with pt #7 has been suspended pending further facility investigation. This Nurse will be referred to the State Board of Nursing. This nurse will not return to work at [facility name]. 6. Further education to direct care staff to respond immediately to calls for help to prevent significant injuries, prolonged care, assessments, and treatment. Education provided by ADM, DON, ADON-A on 10/31/23 and 11/1/2023. 7. if EMT notifies facility of a resident call for help, an immediate staff response is required to ensure resident safety. Meeting with the following managers to review Immediate Jeopardy on 11/1/2023: a. Administrator b. Director of Nursing c. Director of Rehabilitation d. Assistant Director of Nursing e. Activities Director f. Dietary Manager g. Social Services h. Social Services i. MDS Nurse Training: 1. An immediate in-service was initiated on 10/31/23 and 11/01/2023, by the Director of Nursing, on Neglect and responding to calls for assistance. 2. 11/01/2023 and on-going: A post-test will be completed by direct care staff to ensure competency on Neglect education. Staff must answer all questions correctly before returning to work. 3. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 4. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration (ADM, DON, and ADON) will review 24-hour report for any change in condition to ensure timely follow up and intervention occurs. The Care plan and the Nurse Aide Kardex will be updated at that time to reflect the intervention. 2 Administrator, or appointed designee, will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's (IDT) decision. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, dated 10/31/23, 11/01/23, and 11/02/23, reflected curriculum covered the facility's policy on abuse and neglect, fall response, answering calls, interventions and reporting abuse and behaviors of resident's that yell out or have behaviors. Additional training was conducted online with post testing about Abuse and neglect. Record review of in-service dated 10/31/23 conducted by DON and ADON B reflected Monitoring call lights, assure they are operational .Provide appropriate care/intervention to address behavior issues, and doc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect establish policies and procedures to investigate any such allegations for 2 (Resident 7 and Resident #26) of 5 residents reviewed for abuse and neglect in that: The facility failed to implement their abuse and neglect policy because Resident #7 and #26 were not free from abuse/neglect and failed to: 1. Respond and assist Resident #7 after a fall and constantly yelling out for help. on 10/27/23. The resident was found by EMT, lying in feces and with partially dried blood to laceration on her head requiring 10 sutures. LVN F ignored the pleas for help according to the EMT. Resident #26 had to call 911 and guided the EMTs to Resident #7's room. 2. (Non IJ in IJ) Provide Resident #26 ostomy care during shift on 10/31/23 leaving the bag soiled that was connected due to him emptying independently. According to the EMT Resident #26 on 10/27/23 observed Resident #26 with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. An Immediate Jeopardy (IJ) was identified on 11/01/23. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and the severity level of actual harm. The resident had to receive sutures, was covered in feces, and suffered the emotional distress of not receiving help from the facility. Resident #7 suffered actual harm. because all staff had not been trained on Abuse and Neglect, call light responding, and documenting abuse on 11/02/23. Findings included: In a record review of the facility policy titled Abuse Neglect and Exploitation dated April 2023. reflected in part the following: Policy: It is the policy of this facility that each resident will be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff members, volunteers, contractors, residents and family members and visitors and other applicable individuals in techniques to protect all parties. In a review of Resident #7's face sheet dated 10/31/23 revealed a [AGE] year-old female with an admission date of 10/27/23. Diagnoses included: enterocolitis(inflammation of digestive tract) due to Clostridium difficile (bacterial infection of the colon), , primary admitting dx recurrent other specified diseases of gallbladder,(disease involving the gallbladder digestive), unspecified dementia, (decline in cognition) unspecified severity, with other behavioral disturbance, acute kidney failure personal (kidney's not functioning) history of other venous thrombosis and embolism (artery blockage/blood clotting). In a record review of Resident #7's 3-day MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment Resident #7's ADL function for transfer, repositioning, hygiene (bath/shower), toileting and dressing required extensive assistance from staff. Resident was coded as high risk for falls with an actual fall on 10/27/23. In a review of Resident #7's care plan dated 10/27/23 revealed the resident had an actual fall .self-attempt to transfer .Resident will resume usual activities without further incident through the review date. Staff will offer assistance to transfer and assist with toileting as needed .Nursing will Anticipate and meet resident needs. Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed .The resident needs prompt response to all requests for assistance .Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleep. In a record review of Resident #7's MD orders revealed an order for fall mats, Bed rails; date 10/30/23 at 8:11 PM . Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM . Skin checks weekly 10/27/23; weekly weights, wound consult as needed, Acetaminophen Oral -pain assessment every shift, neuro monitoring for 72 hours, evaluation for OT, PT, and OT Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed. every shift. Level of Care: Skilled monitor laceration to right forehead every shift for signs and symptoms of infection .-Report to MD if any. every shift for Wound care Prescriber Written Active 10/29/2023 10/29/23 Monitor skin tear to right palm every shift .Leave Steris trips in place till falls off on its own . Re-enforce as needed. every shift for Wound care Prescriber Written Active 10/29/23 10/29/23. Tablet Mirtazapine Seizures dated 10/17/2023 stated that she had a seizure activity after she started this medication 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain. In a record review of Resident #7's admission assessment dated [DATE] read Initial admission base line assessment no communication barriers, full code, pain, elopement, functions and needs, were addressed. Resident was oriented to use of call light and bed rails. Depression was addressed. No cognitive impairment. Review information on past falls and attempt to determine cause of falls. Record root causes. Alter and/or remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. In a recorded review of #7's progress notes dated 10/27/23 at 9:59 PM LVN-F Received a call from a dispatcher from [company name] at 7:30 PM about a resident calling for another guest who was screaming. EMT (Emergency Medical Technician) showed up at the facility at 7:35 PM, said they got a call from another Resident (#26) that Resident #7 was screaming. EMT found Resident #7 on floor adjacent to the bed with loose stool all over floor. She took her brief off, had her left hand in it, her right palm had a laceration with deep tissue bruising observed, and above her right eye had a big gash/laceration. When asked what she was trying to do, she said she 'know I should have waited but I was trying to get up. 'Call placed to MD N to notify and DON (Director of Nursing), CNO while CNA (Certified Nursing Assistant) assisted one of the EMT in cleaning. MD N okayed that guest needed to be sent to hospital. FM was notified that guest was on her way back to the hospital. EMT left with guest at 8:00 PM. In an interview of Resident #7's progress note dated 10/27/23 at 9:47 PM by LVN F reflected, FM was notified that Resident #7 was on her way to the hospital .EMT left with guest at 8:00 PM. In a record review of Resident #7's progress notes by LVN F dated 10/30/23 at 8:11 PM read Grab bars to assist guest to reposition self in bed upward/downward or turning side-to-side. Also assist guest with safety exiting or entering bed . resident educated by Post Fall dated 10/27/23 at 10:19 PM. Record review of EMT report dated 10/27/23 at 7:19 Titled response # 2989218 . EMT arrived at 7:30 PM .complaint (Fall from bed) Duration of Complaint (3 hours) primary symptoms: (head injury and multiple injuries) [company name] responded to a priority 5 sick person call at a nursing and rehab facility, called in by another patient at the facility. The patient was a [AGE] year-old female with a chief complaint of multiple injuries following a fall from bed. On scene, the patient is found on the floor, alert and disoriented, not in any respiratory distress and has obvious signs of trauma to her head and lower extremities. The caller stated that the patient has been yelling for help for approximately 3 hours and no one has come to assist the patient. The nurse for the patient states the patient was just a screamer, when she checked on her 30 minutes ago, she was fine. Upon assessment, some of the blood was dry on her head, the patient has soiled herself, has a head laceration, lacerations to her knees, unknown LOC (Level of Care), and family states she was on a blood thinner but can't remember the name of it. The patient was lifted to the stretcher with a blanket, with no injuries or incidents. The crew secured the patient to the stretcher with safety belts and safety rails and loaded the stretcher into the ambulance. The crew applied dressings to the wounds and wrapped the wounds. The patient agrees to be transported to hospital for further treatment and evaluation. The patient denies any pain, just discomfort where the laceration was located. During transport to hospital, the crew continued to monitor vital signs and no new complaints developed. In a record review of Resident #7's EMT patient care timeline reflected Symptom onset: 10/27/23 at 7:12 PM Unit Notified by Dispatch 10/27/23 at 7:12:PM PSAP Call. Unit En route 10/27/23 at 7:19 PM Dispatch Notified 10/27/23 at 7:26 PM Initial responder on scene 10/27/23 at 7:26 PM Unit Arrived on Scene 10/27/23 at 7:43: PM Arrived at Patient Exam. 10/27/23 at 7:45 PM Bandage -Application of bandage. 10/27/23 at 7:53 PM Vitals and departed. 10/27/23 at 8:18 PM transporting to hospital. 10/27/23 at 8:32 PM arrived at destination. At destination, the crew unloaded the stretcher from the ambulance with no injuries or incidents. The crew delivered patient information, a verbal report and obtained a signature for patient care from the receiving ER nurse. The patient is moved from the stretcher to the hospital gurney via the drawsheet method with no injuries or incidents. An APS report is started and was forwarded to proper channels to investigate negligence on the facility. Report number: 7818 In a record review of Resident #7's progress note dated 10/28/23 at 6:27 AM by LVN F read FM brought Resident #7 back from the hospital at 5:48 PM . Vitals assessed, 97.7, 88, 18, 152/61, 95% on RA. Forehead has 10 sutures, right palm is steri-stripped. Multiple bruises to BLE, skin tears to both knees. Dried skin tear to right anterior shin. Guest assisted to bed with Ax1. Informed MD N guest is back. No new orders at this time. Paperwork from the hospital placed in medical records basket. Report given to oncoming nurse. Follow up fall assessments conducted on resident. In a record review of Resident #7's progress note dated 10/28/23 11:52 PM by LVN F Resident continues fall follow up and neuro checks monitoring. No new c/o pain or discomfort voiced at this time. Vitals stable and documented. resident was found attempting to get out of bed again this evening, was easily re-directed, bed lowered to floor and floor mats in place on either side of the bed. Continues vancomycin as well for c-diff, afebrile. Continues to have loose stools. In a record review of Resident #7's MD notes dated 10/28/23 reflected she was admitted due to generalized weakness secondary to C-Diff (infection 10/21/23), Colitis (inflammatory bowel disease), cataracts (decreased vision from cloudiness of the eye), HLD Hyperlipidemia (high cholesterol), chronic pain, right knee, depression (mood feeling down), anemia (blood disorder due to transition of oxygen in blood), vitamin D deficiency ( inadequate nutrition value from sun), falls, dementia (cognitive decline w/o Behavior Disturbances, Congestive Heart Failure (heart disease and function), anorexia (thin in appearance lacking nutrients), Deep Vein Thrombosis (blood clotting), GERD (difficulty with digestion flow), frequent UTI (infection of urinary tract), HOH . Guest is AOX1-2, Guest can make needs known and engage in discussions related to her care. Upon admission, guest scored a 14/15 BIMS. Moderate to severe levels of confusion noted despite high BIMS score, guest was so confused that SW contacted FM to complete social services assessments. PHQ 9 Depression assessment) conducted, score is a 10, mild/moderate symptoms of depression noted. Discussed advanced directives, and Resident #7 desires to be a DNR status at this time. Resident #7's goal is to return home upon completion of skilled stay. Discussed general facility expectations with guest [family member], discharge planning, and SW role in care. Discussed home health services upon discharge. SW discussed general length of stay being 2-3 weeks, with the focus of IDT authorizing stays a week at a time. Current plan of care remains, SS to follow up as needed. Care plan meeting scheduled; guest notified of meeting scheduled. In an observation and interview with Resident #7 on 10/31/23 at 10:15 AM revealed the resident lying in bed on her back with visible injuries to her head above right eye, bandage on right hand, and both knees. Resident 7 stated that she fell on the floor injuring her head, hand, and knees. She was yelling for help over 45 minutes, and no one responded. She said EMT entered her room and assessed and assisted resident, then transported her to the hospital. She received sutures on her head. Resident #26 In a record review of Resident #26's face sheet dated 10/31/23 revealed he was a [AGE] year-old male admitted on [DATE] with current diagnoses: significant for end-stage renal disease on hemodialysis, benign essential hypertension (high blood pressure), chronic hepatitis-C (liver infection), and adenocarcinoma (cancerous tumor on the colon.) In a record review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating he was cognitively intact. Resident had an ADL deficit and required extensive assistance with dressing, transferring and toileting. In a record review of Resident #26's Care plan dated 10/18/23 reflected Resident #26 had ADL self-care performance deficits and limitations in physical mobility. The resident/guest will improve self-care and mobility function by the next review date. Toileting Hygiene: Substantial/maximal assistance -Shower/bathe self: Substantial/maximal assistance lower and upper body dressing: Substantial/maximal assistance Substantial/maximal assistance -Personal Hygiene: substantial/maximal assistance Date Initiated: 10/18/2023 -Roll left and right: Resident has an ostomy r/t adenocarcinoma of colon. Date Initiated: 10/18/23 Resident will have no complications with ostomy through the review date. Monitor for changes in consistency, odor, and/or color of stool and notify physician as needed. Nursing Monitor stoma color for any changes and notify doctor if necessary. Nursing Provide ostomy care per protocol. Nursing evaluation admission [DATE]. In a record review of Resident #26's MD progress note by SW dated 10/25/23 11:54 AM Social Service Note Weekly Interdisciplinary Team meeting held today. IDT members present for this meeting: CNO, Social Worker, Director of Rehab, BOM, LNFA, and MD N. Admitting dx: Cervical spine fracture, DM2, ESRD, Hepatitis C, HTN, stroke. PT: for transfers and bed mobility. OT: for transfers and bed mobility. In a record review of Resident #26's Discharge summary dated [DATE] at 2:49 PM Resident discharged to another facility. Report called to facility. Resident signed discharge paperwork. Advised guest that he will be transported to new facility right after dialysis. Resident verbalized understanding with no further questions or concerns. Copy of discharge papers given to guest. In an interview with Resident #26 on 10/31/23 at 10:30 AM revealed on the day of 10/27/2 3 he was changing his ileostomy bag because the nursing staff don't answer the call light or make rounds and he does not want doo (bowel) on him. He stated that the bag constantly leaks, so he requested extra ileostomy bags to change it himself. He said he put the soiled bag inside the urinal on his bed side table and waited for a nurse or aide to come and discard. He said the nurse gave him the extra bag and he did not know her name. Resident #26 said on 10/27/23 he heard a Resident #7 yelling for help for over 3 hours. After a while he called 911 to ask for help because the crying did not stop. He spoke with EMT but did not know the Resident's room number. He guided them to his hall where they found Resident #7 on the floor. He said the EMT also came to his room to assess. He said the CNA and Nursing had not checked on the residents for over 3 hours. In an interview with EMT on 10/31/23 1:09 PM revealed on 10/27/23 another resident contacted 911 after hearing Resident #7 yelling for help. She stated that dispatch contacted the facility, and no one answered. EMT entered the building searching for the resident. EMT arrived at the nursing station at the top of the hall and observed LVN F sitting at the desk ignoring Resident's yell for help. EMT said she could hear a resident yelling for help. EMT asked LVN F do you hear the resident yelling? LVN F stated that they had another resident with behaviors of yelling. EMT said LVN F was ignoring the resident. EMT proceeded down the hall toward Resident #7's room following the yell for help. While simultaneously reporting to LVN F that a 911 call was received from a resident at the facility, reporting a resident had been lying on the floor yelling for help for hours. EMT entered Resident #7's room and found her on the floor with dried and fresh blood observed on the resident's forehead above the left eye, skin tear right palm, and both knees. Resident's brief was heavily soiled with feces. Resident #7 told EMT that she was sitting on the end of her bed and nose-dived on the floor. EMT then checked on Resident #26 on 10/27/23 after examining and assessing Resident #7 (EMT did not provide a time) and observed him with a heavily soiled ostomy bag that was leaking. EMT stated that both residents had been neglected and nursing failed to meet their needs and respond calls for help. In a telephone interview with LVN F on 10/31/23 at 2:12 PM, she stated when she arrived for work on 10/27/23 at 6:00 PM, she proceeded to prepare passport mediation for her unit a (device used to release resident medications by shift), due to LVN C completing final documentation for the end of shift report. LVN F stated LVN C told her that the Resident #7 was newly admitted and was on isolation. LVN F and LVN C, then completed shift reports. LVN F stated that neither nurse completed rounds to assess baseline conditions, which was the nursing protocol. LVN F said she did not hear any yelling out; however, she referenced knowledge of some residents displaying behaviors of yelling for help frequently. She did not respond to the resident's call for help, because she was reviewing shift medication for Resident administration. LVN F said she does not know why Resident # 14 yells out for help during shift. She said it was her responsibility to assist with call lights and follow up on residents calling out for safety to assist for current need. LVN F reported she did not know that Resident #7 fell, until she received a call from the [company name] dispatcher reporting the incident, resident location, and whereabouts, as a neighboring Resident called 911 for help saying a female resident was yelling for help for hours. LVN F stated shortly after the call, the EMT arrived with the same information, and they went together to Resident #7's room and found her on the floor. LVN F stated the EMT arrived after 7:00 PM and the resident was found on the floor, and soiled herself, and was trying to get up and slid from the floor to the bed She said the floor in Resident # 7 was room was soiled with feces (bowel). Resident reported to LVN F that she slid off the bed from a sitting position to the floor. LVN F observed injuries to her right palm with deep tissue pooling, both knees, and bleeding from a laceration to her forehead above her right eye. LVN F said she notified the MD of the fall and injuries. MD approved order for transfer to ER for treatment. EMT transported resident to hospital. The FM returned resident 10/28/23 at approximately 5:48 AM to the facility MD orders. In a telephone interview on 10/31/23 at 4:36 PM, LVN C stated she arrived at 6:00 PM. LVN C said she and LVN F did not conduct rounds due to end of shift report completion from two admissions. She said once she completed the new admissions assessments and documentation, notified LVN F that all reports were completed, and she left. She said the last time she observed Resident #7 was at 5:45 PM after setting up isolation precaution supplies outside the door, due to an infection to C-Diff. Upon exiting Resident #7's room, she placed call light near to reach. In an interview on 10/31/23 at 4:43 PM with CNA T revealed she was the assigned CNA for Resident #7 on 10/27/23 from 6:00 PM to 6:00 AM. She stated that she arrived at 6:15 PM and conducted rounds with CNA K. She was not aware that Resident #7 had a history and risk of falls, as she was a new admission and proceeded with answering call lights after report and rounds with CNA K. CNA T said she should be checking on Residents every 2 hours and as needed to prevent extensive exposure to the resident's skin that could result in skin damage. CNA T stated she did not hear yelling coming from Resident #7's room, but other residents were calling out and she responded and provided care. The expectation for aides upon arrival to shift, were to conduct rounds together while giving reports, then respond to call lights. She said a negative outcome from not answering call lights could lead to injuries. She said not cleaning resident's bag and discarding properly could result in infection. LVN T stated that call light responses depend on CNA's availability at the time, as she may be providing care to another resident. She said when hearing yelling, she responds as soon as she can. She said on 10/27/23, she had not checked on Resident #7 prior to EMT arriving. In an interview with the DON on 11/01/23 at 4:40 PM, she said she had not reported Resident #7's fall, injuries, and EMT, and ER visit from 10/27/23 to HHS, due to LVN F failing to report all of the details to the fall. LVN F did not report that she was not responding to Resident #7's yell for help, failure to conduct resident rounds, and condition resident was found in by EMT. The DON said LVN F did report that another Resident called 911 after hearing Resident #7 yell for help. The DON said she was not told that the Resident # 7 was lying on the floor yelling for over an hour for help until the EMT arrived and found the resident. She expected all staff to respond immediately to calls lights, resident yelling out to provide assessments, interventions, and care. The DON said that she and ADON's were responsible for overseeing LVN 's patient care as well as monitoring job task and needs for help. She reported that LVN C and LVN F should have conducted rounds at the top of the shift. The phone should have been answered, and more information should have been provided about the incident and it would have been investigated. In an interview on 11/01/23 at 4:45 PM, the Administrator stated she was notified that Resident #7 fell and EMT were present on 10/27/23 after the EMT left aby the DON. There was no additional information about staff not responding to the Resident yelling out for help, and EMT arriving seeking resident location as the nurse were not answering the phone. She stated it was her expectation for staff to answer when they hear yelling, call lights, and provide care immediately to the residents to prevent further injuries, and harm from occurring. The Administrator said that all staff were aware that she was the abuse coordinator. She expects the DON and ADON to monitor the clinical task and care of residents by monitoring and auditing, addressing concerns in IDT meeting to implement interventions. She said that residents should not be yelling for help and not getting immediate care. She said that additional task will be implemented to assure Resident safety and timely response from staff to meet medical needs and prevent accidents and injuries. In an interview with CNA J on 11/02/23 at 11:01 AM revealed she did not hear yelling from any resident's or calling out for help while working on 10/27/23. CNA J said the protocol for assisting residents with call lights and yelling out included an immediate response to assure the resident's safety, try to comfort and calm the resident. She said LVN C was observed counting medication with LVN F when she left at on 10/27/23 at 6:20 PM. She last saw Resident #7 upon her arrival at 4:45 PM. Record review of the facility's CNA and LVN assignments for 10/27/23, reflected CNA K relieved CNA T. LVN F relieved LVN C. Shifts were scheduled 6 AM to 6 PM. In a record review of the facility's in-service dated 11/01/23 revealed on abuse, neglect, call light response priority, and resident's yelling .find the source of the yelling, reporting abuse and neglect resident behaviors and implementing interventions .A resident lying on the floor and not responding is considered abuse. In an interview on 11/02/23 at 10:10 AM, Resident #7's family member, he reported that he followed the hospital transport of Resident #7 to facility for admission on [DATE] and the nursing staff educated and orientation him and Resident #7. Resident #7 understood call light usage for safety and waiting for assistance to prevent injuries. The FM said he was notified by LVN F of the fall and hospital location for Resident #7. On 10/27/23 around 8:00 PM. Resident #7 told FM that she should have asked for help, and she was sitting at the end of her bed and fell on the floor. Resident #7 told him that she tried to get up on her own, however, she was not successful. Resident #7 said when she could not get up, she yelled for help, as the call light was not nearby. The FM said the resident sustained injuries to the head requiring sutures and injuries to hand and knees. The FM said he transported the resident back to facility. In an interview with CNA K on 11/02/23 at 11:12 AM revealed she was working on 10/27/23, the date Resident #7 was admitted at 4:20 PM. She assisted Resident #7 by transferring her to bed, assessed her and orienting her on call light and asking for help. CNA K said the resident was not confused and she understood the call light process. She said at approximately 5:45 PM, Resident #7 used the call light for incontinent care. She responded immediately and provided care prior to shift ending at 6:00 AM. She said the resident was on isolation for C-Diff and called via call light frequently (Q 10 minutes) for care, due to the loose stool. She said CNA S and CNA T arrived at approximately 6:15 PM. They completed rounds and reports, then she left. CNA K said she did not hear any resident's yelling when she was leaving her shift. Staff were expected to respond regardless of the resident behaviors. She stated that call lights should be responded to immediately and the failure to respond could lead to a resident getting hurt. In a record review of facility policy titled To provide guidance on use of call light for residents dated 04/2023 reflected in part the following: 1 The call light system is provided as a tool for residents to communicate with staff. 2. Residents will be evaluated for ability to use call light on admission, quarterly and annually. 3. If residents are determined to be physically unable to use call lights, alternative call buttons (touch, whistle, etc.) will be provided. 4. If residents are determined to be cognitively unable to use call lights, residents will be monitored for needs by staff members during rounds and while delivering care. 5. Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. This was determined to be an Immediate Jeopardy on 11/01/23 at 3:00 PM. The Administrator and the DON were notified. The Administrator and the DON were provided with the Immediate Jeopardy Template on 11/01/23 at 5:34 PM. The following Plan of Removal submitted by the facility was accepted on 11/02/23 at 11:50 AM: F 600 Allegation of Credible Compliance Immediate Interventions: 1. Notification made MD N and MD B, physicians, and Medical Directors, of Immediate Jeopardy on 11/01/2023 at 4:15 PM. 2. Emergent Meeting conducted with action plan developed. This occurred at 4:30 pm on 11/01/2023. Attendance included the following: Administrator DON 3. Direct Care Nursing Staff in-serviced on neglect, expectations in responding timely to calls for assistance. 11/01/2023 by DON and ADON 4. 11/01/2023 and 11/02/2023: Nursing staff educated on timely response to answering the phone. Education provided by DON. And LVN, ADON. 5. Nurse involved in incident with pt #7 has been suspended pending further facility investigation. This Nurse will be referred to the Texas Board of Nursing. This nurse will not return to work at [facility name]. 6. Further education to direct care staff to respond immediately to calls for help to prevent significant injuries, prolonged care, assessments, and treatment. Education provided by ADM, DON, ADON-A on 10/31/23 and 11/1/2023. 7. if EMT notifies facility of a resident call for help, an immediate staff response is required to ensure resident safety. Meeting with the following managers to review Immediate Jeopardy on 11/1/2023: a. Administrator b. Director of Nursing c. Director of Rehabilitation d. Assistant Director of Nursing e. Activities Director f. Dietary Manager g. Social Services h. Social Services i. MDS Nurse Training: 1. An immediate in-service was initiated on 10/31/23 and 11/01/2023, by the Director of Nursing, on Neglect and responding to calls for assistance. 2. 11/01/2023 and on-going: A post-test will be completed by direct care staff to ensure competency on Neglect education. Staff must answer all questions correctly before returning to work. 3. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 4. A payroll report listing current employees will be used to track in-service completion. Monitoring: 1. Nursing Administration (ADM, DON, and ADON) will review 24-hour report for any change in condition to ensure timely follow up and intervention occurs. The Care plan and the Nurse Aide Kardex will be updated at that time to reflect the intervention. 2 Administrator, or appointed designee, will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's (IDT) decision. Monitoring of the POR included the following: Record review of in-service titled Abuse and Neglect, dated 10/31/23, 11/01/23, and 11/02/23, reflected curriculum covered the facility's policy on abuse and neglect, fall response, answering calls, interventions and reporting abuse and behaviors of resident's that yell out or have behaviors. Additional training was conducted online with post testing about Abuse and neglect. Record review of in-service dated 10/[TRUNCATED]