**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident coffee was served at a safe temperature. This failure resulted in R57 receiving second degree burns to her right arm. The facility also failed to ensure fall preventative measures were in place for a resident. This applies to 2 of 6 residents (R57 & R28) reviewed for safety and supervision in the sample of 34. The findings include: 1. The Nurse's Notes for R57 showed, 1/6/25 at 12:19 AM - This writer was called to resident's room by CNA (Certified Nursing Assistant). Resident had spilled coffee on right arm. Right arm noted to have 2 reddened area with shiny skin, no blisters noted. Right forearm open area 3 cm (centimeters) x 2 cm, right elbow 5 cm x 8 cm. Cool water applied to right arm. DON (Director of Nursing) and supervisor made aware. Spoke with .physician assistant. New orders given and endorsed. Tylenol given for pain. Dressing applied per order/change daily. 1/6/25 at 12:23 AM - Dressing clean, dry, and intact. New order per (V9 Nurse Practitioner/NP). Apply bacitracin to right arm burns, apply petroleum gauze, cover with rolled gauze, and change daily. Monitor for signs/symptoms of infection. Wound care consult. The Provider Progress Note dated 1/5/25 (should have been dated 1/6/25) for R57 showed, patient seen and examined in her room today at the request of nursing. Patient has a burn on her right forearm, second degree. No signs/symptoms of infection. The Initial Wound Evaluation & Management Summary dated 1/8/25 for R57 showed, Patient presents with wounds on her right forearm, right elbow. At the request of the referring provider .a thorough wound care assessment and evaluation was performed today. Focused wound exam (site 1) burn of right elbow; etiology - burn; further etiology detail - hot liquid. Wound size (L x W x D) 7.0 x 6.5 x 0.1 cm. Moderate serous exudate; 100% granulation tissue. Additional wound detail: burn at right elbow and forearm from patient spilling coffee on herself while in bed. Dressing treatment plan: silver sulfadiazine - apply once daily for 30 days. Abdominal pad - apply once daily for 30 days; gauze roll 3.4 apply once daily for thirty days. Focused wound exam (site 2) burn of right forearm; etiology - burn; further etiology detail - hot liquid. Wound size (L x W x D) 2.6 x 3.6 x 0.1 cm. Moderate serous exudate; 5% slough; and 95% granulation tissue. Dressing treatment plan: silver sulfadiazine - apply once daily for 30 days. Abdominal pad - apply once daily for 30 days; gauze roll 3.4 apply once daily for thirty days. On 2/19/25 at 12:17 PM, the floor where R57 resides had an automatic coffee machine dispenser in the dining room on the counter accessible to anyone. On 2/19/25 at 12:19 PM, V5 (Dietary Director) filled a cup with coffee from the automatic coffee dispenser machine on the floor where R57 resides dining room. The temperature of the coffee was tested by V5 at the request of the surveyor. The temperature of the coffee from the machine was 187.2 degrees Fahrenheit. V5 stated the coffee machines were installed a couple of months ago. V5 stated he doesn't check the temperature of the coffee from the machine on a regular basis. V5 stated the company that services the machine will check the temperature when they come in for a service call and he was unsure of the last time the company was in to provide service. V5 stated the normal temperature that coffee is served is at 180 degrees. V5 stated all coffee comes from the machine and is not made in the kitchen. V5 stated he was told about the incident where someone had burned themselves from the coffee. V5 stated he didn't know who it was that burned themselves. V5 stated he was not part of the correction process for that. V5 stated nursing was a part of the correction process and the dietary department did not do anything for correction. The last Field Service Update for the coffee machines was dated 7/24/24 and showed it was for the main kitchen machine and the water temperature for that machine was 180 degrees Fahrenheit. On 2/19/25 at 12:25 PM, V8 (Licensed Practical Nurse/LPN) stated R57 had a burn to her right elbow from coffee. V8 stated R57 asked for coffee and spilled the coffee in bed. V8 stated R57 doesn't have sensation to her right arm and keeps her right arm immobile. V8 stated R57 received a second degree burn from the spilled coffee. On 2/19/25 at 12:55 PM, V3 (Director of Nursing/DON) stated she received call from nurse and was told R57 was in her room, had finished dinner, and wanted coffee. The CNA went and got more coffee and added the coffee to R57's cup. R57 ended up spilling the coffee on herself. R57 had second degree burns from the coffee that were treated right away. V3 stated she had dietary check the temperature of the coffee and it was within normal range. V2 stated she did not know what the temperature of the coffee should be. V2 stated the dietary manager would have been notified by the dietary department. On 2/20/25 at 11:21 AM, V9 (Nurse Practitioner/NP) stated the facility called telehealth the evening that it happened and got a treatment order. V9 stated she saw R57 the following day. R57 had a second degree burn to her arm. V9 stated she ordered Silvadene. The family refused that treatment and wanted bacitracin because they had a doctor friend that told them that is what they use for burns. V9 state she was not sure if R57 needed assistance with meals; however, R57 had been declining. V9 stated she believed R57 needed assistance. V9 stated this could have been prevented from happening by checking the temperature of the coffee and making sure it is not too hot. The Care Plan dated 6/28/24 - Present for R57 showed, R57 is at risk for impaired skin integrity. Offer staff assistance with hot beverages. Encourage use of clothing protector to protect skin for accidental spills. Encourage resident to sit up right at a table while drinking hot liquids. Serve hot liquids in a cup with a lid. The Face Sheet dated 2/19/25 for R57 showed diagnoses including Alzheimer's disease, depression, osteoporosis, hypertension, atherosclerotic heart disease, spinal stenosis, gastro-esophageal reflux disease, anxiety disorder, edema, osteoarthritis, abnormal posture, and muscle weakness. The MDS (Minimum Data Set) dated 12/20/24 for R57 showed severe cognitive impairment; dependent for eating; substantial/maximal assistance needed for toileting hygiene, bathing, upper body dressing, and personal hygiene. The facility's Safety of hot Liquids policy (October 2014) showed, Appropriate precautions will be implemented to maximize choice beverages while minimizing the potential for injury. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in care plan. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include a. maintaining hot liquids serving temperature of not more than 180 degrees Fahrenheit: e. staff supervision or assistance with hot beverages. 2. R28's face sheet printed on 2/20/25 showed diagnoses including but not limited to heart failure, chronic obstructive pulmonary disease, chronic kidney disease, anxiety, and dementia. R28's facility assessment dated [DATE] showed severe cognitive impairment. R28's fall risk assessment dated [DATE] showed a high risk of falls. The same assessment showed a history of falls in the last three months, weakness with gait and transfers, and forgets her limitations. R28's care plan showed a focus area related to the high risk for falls. Interventions included staff to place floor mats beside the bed and bed in lowest position when she is in it. On 2/18/25 at 12:27 PM, R28 was lying in bed with her eyes closed. R28's bed was low to the ground but there were no fall mats next to the bed. On 2/19/25 at 9:31 AM, R28 was in bed and was yelling out for help. R28 did not have any fall mats next to the bed. The mats were folded up and leaning against the wall at the foot of the bed. V7 and V10 (RN-Registered Nurses) responded to R28 and entered the room. V7 stated R28 has fallen out of bed in the past. About one month ago, she rolled out and hit her eye on the side rail. V7 was asked if the bed was in the lowest position and stated no. V7 lowered the bed further to the ground. At 9:54 AM, R28 was yelling out for help again and outwardly agitated. The fall mats were still not next to the bed and remained folded up against the wall. On 2/19/25 at 9:45 AM, V10 (RN) stated R28 has fallen out of bed several times in the past. She can get herself to the side of the bed and rolls herself out. She ends up on the floor. That is why the fall mats are important. V10 said R28 gets agitated and excited, like she is right now. She is highly confused and frequently ends up on the floor. On 2/19/25 at 12:06 PM, R28 was in bed and V11 (Certified Nursing Assistant) was in the room. The bed was not in the low position and the fall matts were folded up against the wall by the window. V11 stated she needs the mats next to her bed anytime she is in it. She falls out of bed a lot and they keep her from getting hurt. On 2/20/25 at 11:07 AM, V3 (Director of Nurses) stated R28 has had several falls out of bed related to her behaviors. She is confused, gets agitated, and rolls herself out of bed. She will try to get up by herself frequently. The low bed and fall mats need to be in place at all times. They both help minimize any potential for injury. She absolutely needs the interventions in place. The facility's Falls and Fall Risk Managing policy revision dated 3/2018 states: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident (R1) was assessed in a timely manner after being lowered to the ground during a mechanical lift transfer on 7/26/24 at 5:30 AM which resulted in a left hip fracture. The facility failed to notify the physician in a timely manner and provide ongoing nursing assessments from the time of the incident on 7/26/24 at 5:30 AM through 8/1/24 when R1 was transported to the emergency department for evaluation and treatment of a left hip fracture. These failures resulted in R1 not receiving required medical evaluations and treatment after being lowered to the ground when she was falling from a mechanical lift on 7/26/24. This applies to one of three residents (R1) reviewed for injury in the sample of three. The findings include: The facility face sheet for R1 shows diagnoses to include fibromyalgia, Atrial Fibrillation, congestive heart failure and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required maximum staff assistance with bed mobility and transfers. The final report dated 7/31/24 for a bruise of unknown origin shows upon further investigation it was discovered that the resident was being transferred by a sit to stand lift for a shower. During the transfer, R1 became agitated and began to come out of the sit to stand sling. The report shows this staff lowered the resident to the floor. The sling caused pressure to the left shoulder which developed into a bruise. An additional follow-up, post 5-day summary dated 8/2/24 shows R1 was noted with bruising to her left lower extremity and had an increase in pain. An x-ray revealed a fracture to the left distal femur. The undated facility final conclusion for bruise and fracture of unknown origin, upon completion of investigation shows it is believed that the left femur fracture is related to the reported incident of resident being lowered to the ground by staff on 7/26/24. On 8/7/24 at 3:00 PM, V5 (Certified Nursing Assistant/CNA) said he was the CNA caring for R1 on Friday 7/26/24. V5 said he was to give R1 a shower that morning. V5 said the shower began around 5:30 AM. After the shower was completed and he was preparing to transfer R1, she became agitated and resistive to having the lift sling placed under her arms. V5 said he proceeded with the transfer anyway and as the transfer was happening, she began to slide out of the lift sling. V5 said her legs were standing on the base of the lift and she never fell to the floor. V5 said he was alone during the transfer and knows he was to have assistance with the transfer. V5 said he did not report the incident to the nurse because R1 did not get hurt and he didn't feel he had to. V5 said R1 was lowered to the ground and a sling for the mechanical lift was placed under R1 as she lay on the floor, and she was lifted up off the floor into her wheelchair. On 8/7/24 at 6:39 PM, V6 (CNA) said on the morning of 7/26/24, at around 5:30 AM, she heard yelling from the shower room and noticed the door was ajar. V6 said when R1 gets a shower, she does yell out loudly. V6 said she wanted to close the door to avoid disrupting the other residents in the unit. V6 said she peeked in the room and saw R1 hanging from the sit to stand lift sling with her arms raised high and her legs dangling near the ground. V6 said R1 was not bearing any weight on her legs at the time. V6 said V5 (CNA) was just standing there looking at R1 with a shocked look on his face. V6 said V5 was not doing anything to help R1. V6 said she immediately went into the room, told V5 to grab R1 from behind and support her weight and V6 lowered the lift arm and detached the arm sling from R1 and V5 lowered R1 to the ground. V6 said V5 did not have the leg band secured around R1's legs. V6 said she went and got the mechanical lift and together her and V5 rolled R1 onto a sling and lifted her off the floor and into her wheelchair. V6 said she knew the incident should have been reported to the nurse and she assumed V5 would do that. On 8/8/24 at 9:45 AM, V3 (Director of Nursing) said a bruise of unknown origin was reported to her on 7/27/24 to R1's left shoulder. V3 said an investigation was started and it was discovered R1 was lowered to the ground on 7/26/24 in the shower room. V3 said bruising and resident complaints of pain were to her left shoulder only, until on 8/1/24 when bruising and limited range of motion was observed for R1. An x-ray revealed a fracture to R1's left femur. V3 said R1 was not complaining of any pain to her leg in the week between the incident and when the fracture was identified. V3 said she expects staff to have two CNA's present for all transfers involving a mechanical lift. V3 said this is for the safety of the resident. One staff to run the lift and another staff to guide and protect the resident. V3 said the staff should have gotten the nurse before moving the resident so an assessment could have been completed to check for injuries. On 8/8/24 at 2:13 PM, V10 (Advanced Practice Nurse) said when R1 was lowered to the ground on 7/26/24, it should have been reported to the nurse right away so an assessment for injuries could have been performed. V10 said she expects the staff to perform an assessment to check for any acute injuries and the resident should be closely monitored for at least 24 hours after an incident. On 8/8/24 at 5:27 PM, V13 (Orthopedic Surgeon) said R1 had very poor bone quality so being lowered to the ground during a transfer could have led to this type of fracture. V13 said R1 had a bad injury, and she should have been sent out to the emergency department after the incident for x-rays and treatment. The x-ray report dated 8/2/24 (seven days after the incident of being lowered to the ground) shows R1 had a fracture of the distal shaft (lower) of the left femur (thigh bone) with some overriding of the fracture fragments. The nursing progress note dated 8/1/24 at 12:55 AM, shows R1 was experiencing restricted range of motion to her lower extremities. R1 would scream in pain when leg was moved, substantial swelling to the entire leg and R1 not able to tolerate leg extension, flexion, or elevation. On the same day at 7:46 AM, it was documented in R1's records that R1 now had discoloration on the back of her leg and back of the knee. The hospital emergency department report dated 8/2/24 shows R1 had a fall reportedly one week ago and the details of the fall were unknown. R1's left leg was swollen with tenderness and bruising noted to the back of the leg and painful range of motion. The x-ray of the left leg showed a closed fracture of the distal end of the left femur. The hospital progress note dated 8/2/24 completed by the Orthopedic surgeon showed the left lower is shortened and R1 grimaces when the leg was palpated. The facility falls clinical protocol assessment and recognition revised March 2018 shows the nurse shall assess and document/report the following: vital signs, recent injury, observe for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, precipitating factors, details on how the fall occurred .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to safely transfer a resident using a mechanical lift. This failure resulted on R1 sustaining a femur fracture requiring surgery. This applies to one of three residents reviewed for safety in the sample of three. The findings include: The facility face sheet for R1 shows diagnoses to include fibromyalgia, Atrial Fibrillation, congestive heart failure and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required maximum staff assistance with bed mobility and transfers. The final report dated 7/31/24 for a bruise of unknown origin shows upon further investigation it was discovered that the resident was being transferred by a sit to stand lift for a shower. During the transfer, R1 became agitated and began to come out of the sit to stand sling. The report shows this staff lowered the resident to the floor. The sling caused pressure to the left shoulder which developed into a bruise. An additional follow-up, post 5-day summary dated 8/2/24 shows R1 was noted with bruising to her left lower extremity and had an increase in pain. An x-ray revealed a fracture to the left distal femur. On 8/7/24 at 12:55 PM, V1 (Administrator) said for the resident's safety during a mechanical lift transfer, there must be two staff present. On 8/7/24 at 3:00 PM, V5 (Certified Nursing Assistant/CNA) said he was the CNA caring for R1 on Friday 7/26/24. V5 said he was to give R1 a shower that morning. V5 said the shower began around 5:30 AM. After the shower was completed and he was preparing to transfer R1, she became agitated and resistive to having the lift sling placed under her arms. V5 said he proceeded with the transfer anyway and as the transfer was happening, she began to slide out of the lift sling. V5 said her legs were standing on the base of the lift and she never fell to the floor. V5 said he was alone during the transfer and knows he was to have assistance with the transfer. On 8/7/24 at 6:39 PM, V6 (CNA) said on the morning of 7/26/24, at around 5:30 AM, she heard yelling from the shower room and noticed the door was ajar. V6 said when R1 gets a shower, she does yell out loudly. V6 said she wanted to close the door to avoid disrupting the other residents in the unit. V6 said she peeked in the room and saw R1 hanging from the sit to stand lift sling with her arms raised high and her legs dangling near the ground. V6 said R1 was not bearing any weight on her legs at the time. V6 said V5 (CNA) was just standing there looking at R1 with a shocked look on his face. V6 said V5 was not doing anything to help R1. V6 said she immediately went into the room, told V5 to grab R1 from behind and support her weight and V6 lowered the lift arm and detached the arm sling from R1 and V5 lowered R1 to the ground. V6 said V5 did not have the leg band secured around R1's legs. V6 said she went and got the mechanical lift and together her and V5 rolled R1 onto a sling and lifted her off the floor and into her wheelchair. On 8/8/24 at 9:45 AM, V3 (Director of Nursing) said a bruise of unknown origin was reported to her on 7/27/24 to R1's left shoulder. V3 said an investigation was started and it was discovered R1 was lowered to the ground on 7/26/24 in the shower room. V3 said bruising and resident complaints of pain were to her left shoulder only, until on 8/1/24 when bruising and limited range of motion was observed for R1. An x-ray revealed a fracture to R1's left femur. V3 said R1 was not complaining of any pain to her leg in the week between the incident and when the fracture was identified. V3 said she expects staff to have two CNAs present for all transfers involving a mechanical lift. V3 said this is for the safety of the resident. One staff to run the lift and another staff to guide and protect the resident. On 8/8/24 at 5:27 PM, V13 (Orthopedic Surgeon) said R1 had very poor bone quality so being lowered to the ground during a transfer could have led to this type of fracture. The x-ray report dated 8/2/24 shows R1 had a fracture of the distal shaft (lower) of the left femur (thigh bone) with some overriding of the fracture fragments. The nursing progress note dated 8/1/24 at 12:55 AM, shows R1 was experiencing restricted range of motion to her lower extremities. R1 would scream in pain when leg was moved, substantial swelling to the entire leg and R1 not able to tolerate leg extension, flexion, or elevation. On the same day at 7:46 AM, it was documented in R1's records that R1 now had discoloration on the back of her leg and back of the knee. The undated facility final conclusion for bruise and fracture of unknown origin, upon completion of investigation shows it is believed that the left femur fracture is related to the reported incident of resident being lowered to the ground by staff on 7/26/24. The facility policy with a revision date of March 2024 for lifting machine, using a mechanical lift shows at least two nursing assistants or nurse are needed to safely move a resident with a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to supervise a cognitively impaired resident (R1) while being toileted which resulted in R1 falling off the toilet and requiring emergent transport to a local hospital where she was admitted with diagnosis of a basal ganglia hemorrhage (brain bleed) and a frontal scalp hematoma. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1's admission nursing note dated 4/26/24 showed R1 was admitted to the facility with a diagnosis of CVA (cerebrovascular accident/stroke) which resulted in weakness to R1's right arm and right leg. R1 was nonverbal due to her stroke. The note showed, Per POA (power of attorney), patient is a fall risk and will attempt to get out of bed. R1's nursing note dated 4/27/24 showed facility staff found R1 attempting to get out of bed without assistance. R1's care plan dated 4/26/24 showed R1 was at risk for falls due to her impaired cognition, poor safety awareness, overall weakness, and need for assistance with activities of daily living (ADLs). R1's resident assessment dated [DATE] showed R1 was dependent on staff for toileting and transfers. R1's nursing noted dated 5/7/24 showed R1 sustained a fall off the toilet after two staff members (V9 Certified Nursing Assistant/CNA and V12 Licensed Practical Nurse/LPN) left her unsupervised in the bathroom. R1 was found on the floor by staff, lying on her right side, with swelling and bruising noted to the right side of R1's forehead. R1 was emergently transported to a local hospital via ambulance. The note showed, Patient was admitted for intracranial bleeding. R1's hospital neurology progress note dated 5/9/24 showed R1 presented to the ER (emergency room) on 5/8/24 after multiple falls. She sustained head contusion. CT head (computed tomography scan) showed hemorrhage in the left BG (basal ganglia) region . On 5/13/24 at 10:36 AM, V12 (LPN) stated she and V9 (CNA) placed R1 on the toilet on 5/7/24. V12 stated, I told (V9) to go get the shower chair. It was (R1's) shower day. I would stay with (R1) in the bathroom. I heard someone yelling in the hallway outside of (R1's) room. I ran out of (R1's) room to see what was going on. Just as I turned around to go back to (R1), I heard a thud. I found (R1) lying on her right side, on the floor next to the toilet. She was awake but had a large bump on her forehead . I shouldn't have left her alone. On 5/13/24 at 11:04 AM, V9 (CNA) stated, I had taken care of (R1) before. She was a fall risk. She isn't someone that can be left alone on the toilet. I didn't see her fall (on 5/7/24). I had left to go get the shower chair. V12 (LPN) was going to stay with (R1) while she was on the toilet. I came back to her room to find her on the floor with (V12) next to her. On 5/13/24 at 9:45 AM, V2 (Director of Nursing) stated due to R1 being at a high risk for falls, staff should not have left her on the toilet unsupervised on 5/7/24. On 5/13/24 at 11:00 AM, V11 (R1's Physician) stated, (R1) was here for more rehab. She had a history of a CVA with deficits to one side of her body. When I saw her, she was pretty weak all over. She couldn't walk. She was nonverbal but would occasionally shake her head yes or no when asked questions. It was hard to tell how cognitively intact she really was. No, she was not someone who should be left alone on the toilet. The facility's Safety and Supervision of Residents policy dated July 2017 showed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the resident's assessed needs and identified hazards in the environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer a resident's post-surgical pain medication as ordered for 1 of 7 residents (R326) reviewed for pain management in the sample of 18. This failure resulted in R326 experiencing severe pain overnight (approximately 7-10 hours) on 3/8/24-3/9/24. The findings include: R326's Face Sheet shows R326 has admitting diagnoses including fusion of spine in the lumbar region, encounter for surgical aftercare following surgery on the nervous system, presence of other vascular implants and grafts, spondylolisthesis in the lumbar region, spinal stenosis in the lumbosacral region, and low back pain. R326's hospital discharge paperwork dated 3/8/24 shows that R326 had an order for Oxycodone (narcotic analgesic) 5 mg every 4 hours for pain management. R326 last received 10 milligrams (mg) of Oxycodone at 5:15 PM on 3/8/24, before being discharged from the hospital. R326's Face sheet shows that R326 was admitted to the facility at 7:10 PM on 3/8/24. On 3/12/24 at 9:29 AM, R326 said she admitted to the facility on [DATE] following lower back surgery and that she was here to receive therapy and pain management. Overnight from 3/8/24 to 3/9/24, R326 said there was a mix up with her pain medication and she was in severe pain, stating pain was a 9 out of 10 and she did not receive pain medication to relieve the pain. R326 said she was only offered acetaminophen (Mild analgesic). On 3/13/24 at 11:17 AM, V17 (Registered Nurse/RN) said that she was the one who took report from the hospital regarding R326. V17 said that R326 was admitting following a L3 and L4 spinal nerve laminectomy and that she had a paper script sent with her for Oxycodone 5mg one tablet by mouth every four hours as needed for pain. V17 said she completed her shift around midnight on 3/8/24 and R326 had not requested pain medication during V17's shift. R326's Nurse's Note dated 3/9/24 at 9:54 AM, written by V18 (RN) states, . Slept on and off, c/o (complains of) severe back pain. PRN (as needed) Tylenol (acetaminophen) administered . Encouraged to reposition, refusing due to pain. Oxycodone not yet available from pharmacy overnight. On 3/13/24 at 11:26 AM, V18 was attempted to be contacted by phone and was unable to be reached. R326's Medication Administration Report for March 2024 shows that R326 did not receive Oxycodone 5 mg until 3/9/24 at 7:40 AM. (approximately 14 hours after the last documented dose from the hospital). This form also documents R326's pain as Bracing. On 3/13/24 at 12:00 PM, V19 (Licensed Practical Nurse/LPN) said that if the facility has not received the prescription and the time frame to receive the next dose has passed, the nurse on duty would call the pharmacy and go through the protocols to access and retrieve the medication from the locked medication dispenser in the nurse's station. V19 said if the pain level is a 9 out of 10, providing PRN acetaminophen is not going to be very effective. On 3/13/24 at 11:35 AM, V5 (LPN) stated a resident's pain is subjective to the resident. When a resident has pain, it needs to be addressed as soon as possible. On 3/13/24 at 9:31 AM, V16 (RN) said that the locked medication dispenser is there for when residents require PRN pain medications or antibiotics, and the facility has not yet received them from the pharmacy. V16 said to retrieve medications from the locked medication dispenser, the nurse on duty has to call the pharmacy, provide the paper script sent from the hospital, and they will receive a one-time code to access the medication to provide to the resident. V16 said that the facility had the paper script from the hospital and the nurse on duty would have been able to remove the medication from the locked medication dispenser on 3/8/24 or 3/9/24, when the medication was needed. Facility Active Inventory form (locked medication dispenser) shows Oxycodone HCL 5 mg tablet is available in the locked medication box in the nurse's station on the 3rd floor. On 3/13/24 at 1:12 PM, V20 (Nurse Practitioner) said that the facility had the medication available in the locked medication box. V20 would have expected the nurse on duty to retrieve the medication from the locked medication box to give to R326. The facility Pain Assessment and Management policy dated 10/22 states, . 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals . Monitoring and Modifying Approaches . 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.