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

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

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

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

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

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

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

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