**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely assist in arranging emergency dental services for a resident with an abscessed tooth resulting in a delay of dental services for the abscessed tooth which was painful and infected 1 of 1 Resident reviewed for Dental (Resident 2). Findings include: The clinical record for Resident 2 was reviewed on 8/16/23 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia and dysphagia (difficulty swallowing). She was admitted from an acute care hospital to the facility on 7/7/23. Resident 2 resided in the facilities attached memory care assisted living prior to her hospitalization. A nursing progress note, dated 7/9/23 at 6:17 p.m., indicated a family member informed staff member that Resident 2 was to have oral surgery prior to her hospitalization. Resident 2 had multiple teeth which needed extracted. A follow up appointment needed to be scheduled as soon as possible. An assessment of Resident 2 revealed pain to mouth and throat and a large, abscess-like area along the gum line on the bottom left side of her mouth. A physician's progress note, dated 7/10/23 at 11:29 a.m., indicated Resident 2 had a possible dental abscess. Her right jaw showed as to be painful and mildly swollen. Augmentin (antibiotic) was started and an order for urgent outpatient dental appointment was written. A physician's order, dated 7/10/23, read as written URGENT: DENTIST TO EVAL AND TREAT FOR POTENTIAL ABSCESS. The order was discontinued on 7/14/23. There was no documentation in the clinical record that a dental appointment had been scheduled or that the Resident 2's POA (Power of Attorney) had been contacted about dental services. A physician's order, dated 7/10/23, read amoxicillin-pot[sic] clavulanate [Augmentin] tablet; 875-125 mg[milligram]; 1 tablet; oral DX [sic] periapical [dental] abscess without sinus] Twice a Day . The order was discontinued on 7/17/23. An admission MDS (Minimum Data Set) Assessment, completed 7/13/23, indicated Resident 2 was severely cognitively impaired, needed extensive assistance of 2 staff members to transfer, and had no dental concerns present. A physician's order, dated 7/14/23, read as written SCHEDULE A DENTIST TO EVAL[SIC] AND TREAT FOR POTENTIAL ABCESS. Special Instructions: may d/c[sic] order when completed . The order was discontinued on 7/18/23. A social services note, dated 7/15/23 at 1:44 p.m., indicated that a Resident 1st meeting was held and that hospice services were discussed. The POA (Power of Attorney) wanted to continue therapy for a few more weeks and see progress before making a decision about hospice. Plan of care is in place with no changes made. The meeting notes did not indicate that Resident 2's tooth pain was addressed during the meeting. A nursing progress note, dated 7/18/23 at 1:07 p.m., read writer notified family in regards of setting up dental appt[sic] family made aware will schedule appt [sic] will continue to monitor. A nurse practitioner progress note, dated 7/18/23 at 1:20 p.m., indicated Resident 2 was being seen to evaluate condition after antibiotic therapy. No record of dental appointment. Resident 2 was an unreliable historian. When she was asked, she denied jaw pain. A nursing progress note, dated 7/24/23 at 1:46 a.m., indicated that Resident 2's appetite and oral intake remained poor. Resident 2 periodically complained of mouth and tooth pain. Resident 2's family stated that she is to be seen by the facility dentist in preparation for a potential tooth extraction. Resident 2 is unable to use a straw for liquids due to cognition deficit and potential tooth pain. A physician's progress noted, written by NP (Nurse Practitioner) 30 on 7/24/23 at 12:26 p.m., indicated that Resident 2 was being seen as a follow up to the acute log report of mouth pain. There was still no word on outpatient dental appointment. A second round of Augmentin was started. A care plan, initiated 7/25/23, indicated Resident 2 had the potential for mouth pain related to abscess and tooth decay per daughter's report. The goal was for her not to exhibit mouth pain or infection. The interventions, initiated 7/25/23, included but were not limited to, encourage fluids, offer and provide mouth care as needed, administer medications as ordered, and dental evaluation and interventions as needed. A physician's order, dated 7/25/23, indicated she was to receive tramadol (pain medication) 25 mg twice daily for pain and every 4 hours as needed for pain. A nursing progress note, written by the DON (Director of Nursing) on 7/25/23 at 12:35 p.m., indicated the Nurse Practitioner was aware of mouth and tooth pain with a new order for tramadol (pain medication) 25 mg twice daily. and every 4 hours as needed for pain. The family member was at the facility for a meeting and was aware of the new order. A physician's progress note, written by NP 30 on 7/25/23 at 1:37 p.m., indicated Resident 2 was on the acute log again due to mouth pain. Augmentin restarted yesterday. Resident 2 was on the list to be seen by in-house dentist. The Dental Provider Note, dated 7/25/23, indicated Resident 2 had a limited exam for pain on the left upper side. X-rays were taken to confirm. The recommendation is extraction of this tooth. The dental provider could try to extract in house, if approved by the resident representative, the tooth could be extracted in the facility. The dental provider also sent a referral for her to be sent out for extraction, so that Resident 2 would be covered for either scenario. A physician's progress note, written by NP 30 on 7/31/23 at 10:53 a.m., indicated Resident 2 was being seen as a follow up for the end of antibiotic therapy. The staff reports that resident is on the list to be seen by the in-house dentist this week. We will continue to monitor closely. The July MAR (Medication Administration Record) indicated that the Augmentin, ordered on 7/10/23, had been administered as ordered, with the exception of refused evening dose on 7/10/23. The July 2023 MAR did not contain documentation that Augmentin, ordered on 7/24/23, was given at all. A social services progress note, dated 8/1/23 at 9:03 a.m., indicated that had Resident 2 had expressed mouth pain. Antibiotics had been started by the physician to help eliminate any signs or symptoms of infection and to reduce pain. The POA (Power of Attorney) was offered an opportunity for resident to be sent out to dental services within the community for a prompt resolution. The POA expressed that due to Resident 2's physical and mental decline, an in-house dentist was preferred. The dental group provided an emergency visit on 7/25/23. Consents for in house services were signed and sent back to the dental group on 7/28/23. Awaiting confirmation of upcoming appointment. A nursing progress note, dated 8/4/23 at 5:06 p.m., indicated Resident 2 now on routine pain medication as she is unable to express discomfort. She has flaccid facial expressions with no indicator of pain. A Physicians order, dated 8/4/23, indicated Resident 2 was to receive tramadol 25 mg at 8 a.m., 12 p.m., 4 p.m., and 8 p.m. for pain and may receive tramadol 25 mg as needed twice daily for pain. A nursing progress note, dated 8/5/23 at 9:14 p.m., indicated Resident 2 had very poor oral intake during the shift. A Family Member at bedside earlier in the shift had expressed concerns regarding teeth extractions. A social services progress note dated 8/7/23 at 12:04 p.m. read Writer contacted in house dental group, regarding emergency scheduling of extractions for resident. Upon last contact made, appointment would be scheduled, and writer was to be made aware of date/[sic] time. As of today, writer had received no updated information. Upon contact with clinical support manager, next available appointment is 8/22/23. Writer requested that clinical support manager supervisor make contact in efforts to find opportunities of an earlier visit date as resident is exhibiting pain and discomfort related to tooth. Writer currently awaiting return call/[sic] email from supervisor related to scheduling. POA [sic] made aware. Pain medications have been reviewed and ATB [sic] treatment ordered and in place to provide resident with comport and relief. A physician's order, dated 8/7/23, indicates Resident 2 was to receive amoxicillin- pot clavulanate (Augmentin) 875-125 mg tablet twice daily for pain. A physician's progress note, written by NP 30 on 8/15/23 at 12:37 p.m., indicated that on 8/7/23, Resident 2 continued to complain of mouth pain. Has been decreasing oral intake due to pain. The social worker to get dentist here as soon as possible. Will restart Augmentin while awaiting dental intervention. On 8/15/23, complaints of pain today. Will begin oral saline rinse in the morning, after food intake, and at bedtime. She is on the list to be seen by in-house dentist. On 8/17/23 at 1:30 p.m., Resident 2 was observed sitting in the common area with a staff member. Her teeth were noted to be dark brown in color. During an interview on 8/18/23 at 12:30 p.m., FM (Family Member) 31 indicated that Resident 2's dental issues had been going on for a long time. Resident 2 had complained that her teeth were bothering her and she was scheduled to have some teeth extracted prior to leaving the Assisted Living part of the facility but had been hospitalized prior to having it done. When she was admitted to the facility on [DATE] she was complaining of tooth pain. FM 31 was not offered the option of having Resident 2 see an inside dentist when she was admitted to the facility on [DATE] and had not declined in house services for dental care upon admission. FM 31 was unable to transfer Resident 2 to a dental chair and was not sure how she would get Resident 2 to the oral surgeon because it took two people to transfer her. FM 31 did not know what else to do about getting a dental appointment. FM 31 had made the facility aware of the need for a dental visit on several occasions and had received no direction, which was frustrating. The facility started her on an antibiotic and Tylenol and the pain got better. On around 7/22/23 Resident 2 started to say that her teeth hurt again. The antibiotic course was over. During a meeting on 7/25/23, FM 31 had told SSD that Resident 2's teeth were hurting again, and the DON came into the meeting to discuss pain medication options. The facility ordered some pain medication for her to help with the tooth pain. The facility offered an inside dentist to see Resident 2 and she was seen on 7/25/23. FM 31 had given verbal permission to the dental provider for them to provide treatment in house, over the phone on 7/27/23 and had signed a consent for dental treatment on 7/28/23. During an interview on 8/18/23 at 1:50 p.m., the SSD indicated that in house dental services are normally offered upon admission and at the Resident First meeting. The consent would be signed and faxed to the provider. On 8/18/23 at 3:40 p.m. NP 30 and NP Compliance Officer 33 were interviewed. NP 30 indicated she had written the 7/10/23 order for Resident 2 to be seen by the dentist. She had written another order on 7/14/23 for Resident 2 to have a dental consult because she had not heard any updates from the facility on if the appointment was scheduled and NP 30 had been aware the family had wanted in house dental services. NP 30 had intended for Resident 2 to receive a second round of Augmentin on 7/24/23 to treat her oral abscess and for a possible urinary tract infection. She was unaware it had not been given. NP Compliance Officer 33 indicated that the 7/24/23 Augmentin order had been written in Resident 2's Assist Living chart in error. During an interview on 8/21/23 at 1:25 p.m., Pharmacist 20 indicated that the 7/24/23 order for Augmentin had been filled. There had been 14 tablets of Augmentin delivered to the 200 hall of the facility on 7/24/23. Seven of the Augmentin tablets had been returned to the pharmacy. Resident 2 had resided on the 200-hall portion of the facilities Assisted Living, which was connected to the health center unit Resident 2 was admitted to on 7/7/23. Resident 2's tooth was extracted at the facility on 8/22/23. During an interview on 8/24/23 at 1:13 p.m., Dental Provider Scheduler 38 indicated that the first time the facility contacted the in-house dental provider to arrange a dental exam was 7/21/23. The Dental Provider had a Dentist in the facility on 7/21/23, but the triage form had been received by the dental provider after the dentist had already left the facility. If the facility had reached out sooner, Resident 2 could have been seen for her initial triage appointment on 7/21/23, and a treatment plan could have been started. Resident 2 was seen by a Dentist for a triage appointment on 7/25/23 and a treatment plan was set up at that time. When a tooth is abcessed it is normally very uncomfortable for the patient due to the pain and pressure from the infection. During an interview on 8/18/23 at 2:06 p.m., the Executive Director indicated the facility did not have a specific dental policy, the facility followed the regulation. 3.1-24(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record for Resident L was reviewed on 3/9/22 at 11:30 a.m. The Resident's diagnosis included, but were not limited to, anemia and chronic kidney disease. A care plan, initiated on 6/6/21, indicated she was at risk for skin breakdown related to decreased mobility, history of falls, history of incontinence, anemia, and diabetes. The goal was for her skin to remain intact. A Quarterly MDS (Minimum Data Set) Assessment, completed 12/20/21, indicated she was cognitively intact. A physician's order, dated 3/7/22, indicated to cleanse skin tear with normal saline and pat dry. A dry dressing was to be applied to the skin tear and changed daily and as needed for soiling or dislodgement. On 3/9/22 at 11:38 a.m., she was observed in her room sitting in a wheelchair. She had a skin tear on her left arm which had steri strips applied to it. There was no dressing over the skin tear. During an interview on 3/9/22 at 11:39 a.m., Resident L indicated the skin tear had happened a couple of days ago and they put a bandage over it sometimes. On 3/14/22 at 10:15 a.m., she was observed in her room sitting in her chair. The skin tear on her left arm was visible. There was no dressing over the skin tear. During an interview on 3/14/22 at 10:30 a.m., LPN (Licensed Practical Nurse) 6 indicated she needed to put a new dressing on her skin tear. It frequently did not have a dressing on it in the morning. She did the dressing each day. On 3/14/22 at 2:17 p.m., the Nurse Manager provided the Dressing Changes Procedure, revised 5/11/16, which read . To ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize/ control contamination .11. Follow doctors[sic] recommendations for treatments . Based on observation, interview and record review the facility failed to timely address a resident's change of condition which resulted in a delay in treatment to the resident's fractured left hand and failed to timely apply dressings, as ordered by the physician, for 1 of 1 resident reviewed for skin conditions and to administer a resident's medication, as ordered, and collaborate with hospice regarding an ordered medication and Broda chair for 1 of 1 resident reviewed for hospice and 1 of 2 residents reviewed for hospitalization. (Resident L, O, W) Findings include: 1. The clinical record for Resident O was reviewed on 3/9/22 at 12:00 p.m. The diagnoses for Resident O included, but were not limited to, fracture of the lower end of left radius and wrist, Alzheimer's disease, and dementia with behavioral disturbances. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident O was cognitively impaired. She was extensive assistance with 1 staff person for bed mobility, transfer and dressing. A care plan dated 12/27/20 indicated .Resident is at risk for falling r/t [related to]: decreased mobility, need for assistance with toileting, transfers, bed mobility, Alzheimer's disease, dementia, HTN [hypertension]. Goal .Resident will remain free of falls with major injury .Interventions: .provide non-skid footwear . An interview was conducted with Resident O's Representative on 3/9/22 at 12:40 p.m. He indicated the resident had fallen out of bed and had broken something in her wrist. An observation was made of Resident O on 3/10/22 at 9:32 a.m. Resident was observed sitting in her wheelchair with a brace on her left arm. A nursing progress note written by License Practical Nurse (LPN) 10 dated 1/29/22, indicated Writer notified by the CRCA [Certified Resident Care Assistant] 12 that resident [O] was on the floor. Writer entered [Resident O's room number] and noted resident lying on L [left] side of the floor next to bed, (+) [had] ROM [range of motion] x [times] 4 extremities, no in/outward or length difference of BLE [bilateral lower extremities], no visual injuries, up with assist x 2 [staff members]. Resident A&O [alert and oriented] x 1, unable to tell what happened. Resident was laying in bed before incident. Writer notified MD [medical doctor] and [family], will cont. [continue] to monitor. A fall event dated 1/29/22 at 3:30 p.m., indicated Resident O had an unwitnessed fall in her room. She was observed and assessed by LPN 10 at that time. The resident was observed not wearing appropriate footwear, she had range of motion to all extremities and was not in any pain. It indicated physician and family notified. A bruise event written by LPN 10 dated 1/29/22 at 6:39 p.m., indicated Resident O's left hand and distal forearm was blue in color and her hand had swelling. The resident was experiencing pain at level of 3 using the following pain scale: 0-no pain, 1-mild pain, 2, 3, 4-moderate pain distressing/miserable, 5, 6, 7-severe pain-horrible/intense, 8, 9, 10-Excruciating pain - worst possible -interferes with ability to carry on with daily routines, socialization or sleep. The event indicated a progress note dated 1/29/22 at 6:45 p.m., after putting resident to bed the CRCA [12] noted L hand and distal forearm was bruise (blue) and nursing swollen. Writer noted bruises and applied ice, bruising from previous fall today-resident rolling out of low bed, will cont. to monitor . The physician and family was notified. A physician order dated 1/30/22 at 6:00 a.m., indicated Resident O was to have an x-ray of her left wrist. A nursing progress note written by LPN 11 dated 1/30/22 indicated Resident L hand and distal forearm bruising, swelling, and severe pain indicated by Nursing extreme guarding of area; assessment revealed need for x-ray ordered by NP [Nurse Practitioner] on call. X-ray completed this day at 11am (sic) that confirmed an acute fracture of the distal radius of left extremity. Nurse notified on-call NP of findings and new orders given to send resident to ER [emergency room] for further evaluation and treatment. Resident [family] notified. Resident being transported to [name of hospital] via ambulance. A lab report dated 1/30/22 indicated an acute fracture to Resident O's left wrist was reported to the facility at 12:30 p.m. The Hospital Records was provided by the Nurse Manager on 3/10/22 at 3:14 p.m. It indicated Resident O was brought in to the emergency room and seen on 1/30/22 at 4:30 p.m.Chief complaint: Patient presents with arm injury. left arm fracture from fall out of bed yesterday evening .X-ray today showed radial fx [fracture]. Splinted by medics . An interview was conducted with Nurse Practitioner 22 on 3/11/22 at 9:24 a.m. He indicated Resident O's fall occurred over a weekend. The staff can either write in a medical provider book if a fall occurs with no injury, and it would be reviewed the following business day. If a fall occurred with injury the staff would need to notify by phone utilizing the on-call medical provider service. The order was given to obtain an x-ray for Resident O's hand on 1/30/22. An interview was conducted with LPN 10 on 3/11/22 at 11:18 a.m. She indicated she was the nurse that had taken care of Resident O at that time of her fall. After the fall, she had assessed the resident with no injuries that she had observed. LPN 10 had then written the fall incident in the medical provider book due to the resident did not have an injury. She had not notified the medical provider via phone about the fall. Later on in the evening, the CRCA 12 had reported to her the resident's left hand was bruised, swollen, and she had complaints of pain. LPN 10 at that time applied ice to the resident's left hand, but did not notify the medical provider. She believed at that time, the resident did not have any major injury to her left wrist. The resident had landed on her left side, and she believed the hand was just bruised from the fall. LPN 10 had administered scheduled pain medication, but had not provided any additional pain medication that evening. She had worked on the unit until 10:00 p.m. LPN 13 was the night shift nurse that took over Resident O's care at 10:00 p.m., that night. LPN 13 was going to notify the medical doctor to have an x-ray ordered for the resident's left hand. An interview was conducted with LPN 13 on 3/11/22 at 3:33 p.m. She indicated she had taken over Resident O's care after LPN 10 at 10:00 p.m. to 6:00 a.m. She had also been working that evening on a different hallway, and was aware Resident O had fallen that evening. After assessing the resident's hand when she had taken over her care, the resident's left hand was observed to be visibly swollen, bruised, and the resident had complaints of pain if the extremity was touched. The resident would draw up her arm and verbalize an ow if the left extremity was touched. The resident's verbal and physical reactions were apparent to LPN 13 the resident's arm was causing her pain. She believed she had administered pain medication that night to Resident O. She had notified the medical provider about the resident's condition. It was not the end of her shift, but it was later on in her shift when she notified the medical provider. After notification, an x-ray was ordered by the provider. An interview was conducted with CRCA 12 on 3/11/22 at 3:20 p.m. She indicated she had worked on the evening of 1/29/22 and was providing care to Resident O until 10:00 p.m. She had notified LPN 10 Resident O had fallen on the floor in her room. Later on in the evening, she had reported to LPN 10 she had noticed the resident's left hand was blue, swollen and she was hollering out in pain. The resident does normally yell out when the staff turn her, but it was different that time. She was in real pain. She had taken care of Resident O all evening and kept checking on the resident in bed through out her shift due to concerns of the resident's hand. She had not observed any ice that had been applied to the resident's hand that evening. CRCA 12 then had notified LPN 13, the night nurse that took over the resident's care that the resident had fallen and something was wrong with her left hand. LPN 13 had stated she agreed with CRCA 12 something was wrong with the resident's hand. An interview was conducted with LPN 11 on 3/11/22 at 11:34 a.m. She had indicated she had taken over the care of Resident O on the morning of 1/30/22. She had observed the resident in the hallway prior to getting report and had already observed the resident's hand was bruised and swollen twice the size of her other hand. She had indicated to the night staff Resident O's hand does not look right. LPN 13 had reported she had called the doctor and received an order to get an x-ray. The lab would be coming out to obtain. The lab team was late getting to the facility and had come around lunch time to obtain the x-ray. The resident was unable to voice her pain utilizing a numeric pain scale due to her cognitive status. The resident would verbalize a no if the staff tried to touch her arm during care and/or she would guard her arm bringing it close to her body. The x-ray was challenging to obtain due to the resident did not like her hand to be touched due to pain. She could tell the resident was in pain, because she grimaced or verbalize Oh, Ow, and No if anyone touched her arm. After receiving the x-ray results the medical provider was notified. LPN 11 had received an order to send the resident to the emergency room due to the results indicated a fracture. The resident was then sent out approximately around 2:00 p.m. - 3:00 p.m. A nursing progress note dated 1/31/22 indicated Resident O returned from hospital.Resident has fractured L wrist with splint and elevated on a pillow. Resident to have follow up appointment with ortho in one week . A fall management policy was provided by the Executive Director on 3/10/22 at 10:15 a.m. It indicated Procedure: 2. Should the resident experience a fall the attending nurse shall complete the 'Fall Event' .3. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified . 3. a) The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses included, but were not limited to, chronic kidney disease and dementia. She was discharged to the hospital on 2/20/22 after a fall and readmitted to the facility from the hospital on 2/24/22. The 2/20/22 to 2/24/22 hospital notes read, SIRS [systemic inflammatory response syndrome] criteria/Leukocytosis/tachycardia. Unclear source. BP [Blood pressure] stable Tachycardic with HR [heart rate] up to 130s. Fever of 103.1 in ED [emergency department.] WBC [white blood cell] of 15.1, lactic acid 2.3 Started on sepsis protocol with broad spectrum antibiotics with vanc [vancomycin]/merrem, given fluids Continue on antibiotics and IV [intravenous] fluids. The discharge medication list indicated to start taking clindamycin 75 mg/5 mL solution, 10 mLs by mouth, 3 times daily for 5 days. The 2/25/22 IDT (Interdisciplinary Team) note read, IDT review of infection event. Resident admitted to campus with new orders for antibiotic therapy related to dx [diagnosis] of sepsis. Resident to continue with antibiotic per orders. The February, 2022 and March, 2022 MARs (medication administration records) indicated Resident W never received the ordered antibiotic medication after returning from the hospital. The 2/27/22 nurse's note read, Called pharmacy to follow up on why ABX [antibiotic] Cleocin has not yet been received .they are unable to fill the script [prescription] written as is. Recommended change is to 150 mg capsules (which can be opened). Will place in triage book for MD/NP [nurse practitioner] reorder. The 2/28/22 nurse's note read, Still awaiting ABT [antibiotic] order clarification. The 3/1/22 nurse's note read, Awaiting ABT order clarification. NP/MD aware. The 3/2/22 nurse's note read, Awaiting order clarification for ABT. The 3/7/22 nurse's note read, Still awaiting clarification on ABT orders. The 3/8/22 nurse's note read, Awaiting clarification on ABT orders. An interview was conducted with the NM (Nurse Manager) on 3/10/22 at 2:39 p.m. She indicated Resident W never received the Clindamycin (Cleocin) antibiotic she was ordered when discharged from the hospital. It appeared the pharmacy was not able fill the prescription as written. Nursing attempted to contact the physician about it. They put it in the triage book and sent the order to hospice. The pharmacy was unable to fill it in liquid form and suggested the pill form instead, but have been unable to get the order from anyone. They have NP 22, their medical director, and hospice available to them, and between those 3, I still cannot get an order. She stated, I saw [name of NP 22] on Tuesday. I said I need you to give me an order, please, and he said, 'We'll take a look at it,' and I still don't have one. An interview was conducted with NP 22 on 3/11/22 at 9:45 a.m. He indicated he gave permission to start the antibiotic yesterday, 3/10/22. He stated, I think I was first notified yesterday that she had the order. Resident W was on hospice, so he was not the primary provider. He stated, Obviously it would have been optimal for it to have started sooner. Whenever you don't start an order there's always a risk for further progression of why it wasn't started. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she was made aware yesterday, 3/10/22, about the Clindamycin order from the hospital. When their admission nurse, Hospice Nurse 16, came to the facility upon Resident W's readmission, she would have been the one made aware of the order. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the admitting hospice nurse when Resident W was readmitted to the facility on [DATE]. She asked the facility for her current orders, not the hospital orders. She just assumed all medications she was on when discharged from the hospital would have been included. She was unaware she did not receive the Clindamycin as ordered. 3. b) The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses included, but were not limited to, chronic kidney disease and dementia. The 2/2/21 hospice care plan, last revised 1/17/22, indicated approaches were to communicate with hospice when any changes were indicated to the plan of care; to coordinate care with the provider; and to collaborate with all team members including Medical NP, hospice NP, family and staff. An interview was conducted with the NM on 3/11/22 at 12:44 p.m. She indicated they did not have access to Resident W's hospice notes at the facility and had to request them to be sent. An interview was conducted with the NM on 3/14/22 at 10:30 a.m. She indicated their preferred communication method with hospice was to call them. There was a hospice binder with hospice information like names, phone numbers, etc. at the nurse's station, but they did not include notes. If hospice came in and wrote a new order, they would have to verbalize it to the nurse, because hospice did not have access to their electronic health record. Resident W had a fall the evening of 2/14/22 and the morning of 2/15/22. The 2/15/22, 3:45 p.m. IDT (interdisciplinary team) note read, Review of fall on 2/15/22. Resident noted with witnessed fall onto hallway floor by nurses station while trying to reach for something. Resident noted with increased restlessness observed. No other injuries noted at this time per staff nurse assessment. Resident assisted to bed et [and] resting. Family/MD made aware. Hospice called & notified. New intervention noted for hospice to evaluate anti-anxiety medication. The 2/16/22, 12:20 p.m. nurse's note, written by the NM (Nurse Manager) read, Spoke with [name of Resident W's hospice company] regarding most recent falls and interventions. Hospice nurse to evaluate anti-anxiety medication upon next scheduled visit. An interview was conducted with the NM on 3/14/22 at 10:14 a.m. She indicated she remembered discussing having hospice evaluate Resident W's anti-anxiety medications and writing it in the 2/16/22 note, but didn't see any verification it was done. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she didn't remember if she was asked to evaluate Resident W's anti-anxiety medications after her 2/15/22 fall. Perhaps the on call hospice nurse, Hospice Nurse 16, would know, as she was the nurse who spoke with the facility after her 2/14/22 and 2/15/22 falls. After reviewing the notes, there was no information about an anti-anxiety medication review. Hospice Nurse 14 came to the facility later on 2/15/22 to visit Resident W. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the on call nurse when Resident W fell. When they called her, Resident W had already been monitored since the fall. Her vital signs were stable, and there were no signs or symptoms of injury. The facility informed her they would call, if they had any other concerns. She was not notified of any other concerns and was never informed of any intervention of reviewing her anti-anxiety medications. She was uncertain if Hospice Nurse 14 was made aware of the intervention, but I definitely wasn't made aware of it by the facility. The 2/15/22 Hospice Staff Collaboration Log indicated Hospice Nurse 14 visited on 2/15/22 as a follow up for 2 falls. The section entitled Was The Care Plan Changed? read, Will order Broda Chair. The 2/15/22 hospice note, written by Hospice Nurse 14, read, Late entry for PRN [as needed] visit today at 3:34 p.m Writer spoke with staff nurse, [name of CRMA 20,] who confirmed that patient fell last night. [Name of CRMA 20] also reports that patient fell from her wheel chair this morning. Nurse stated that perhaps patient was attempting to pick something up off the floor and lost her balance Broda Chair requested by facility nurse. An interview was conducted with the NM on 3/14/22 at 11:12 a.m. She indicated she wrote the order for the Broda chair on 3/3/22, so that was when she got it. There was a care plan meeting on 2/25/22, where they discussed the Broda chair, positioning, and what would be most comfortable for her. Hospice was there via phone. She was unaware of the 2/15/22 hospice note about the Broda chair and did not recall discussing it prior to the 2/25/22 care plan. She thought the family chose Resident W's hospice company. She let families know which companies were available, but encouraged them to do their own research and make the decision. She stated, I guess I'm going to have to read this binder everyday. Clearly, this collaboration with [name of hospice company] is not working. Resident W had another fall on 2/20/22 and was sent to the hospital. She returned to the facility on 2/24/22. The hospice contract between the facility and Resident W's hospice company was provided by the NM on 3/14/22 at 12:00 p.m. It read, Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a resident with adequate assistance of 2 staff members for bed mobility. This resulted in a fall with a fractured rib for 1 of 4 residents reviewed for accidents and failed to ensure fall interventions were implemented per the plan of care for 2 of 4 residents reviewed for falls. (Resident H, Q, W). Findings include: 1. The clinical record for Resident H was reviewed on 3/9/22 at 12:40 p.m. The Resident's diagnosis included, but were not limited to, polyosteoarthritis (arthritis in multiple joints) and contracture of her r knee. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/21, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. A physical therapy Discharge summary, dated [DATE], indicated that she continued to require maximum assistance of 2 staff members for side rolling in bed. The care givers had been provided education on positioning she was laying supine (laying on her back), proper body mechanics and on safety with bed mobility. A Quarterly MDS Assessment, completed 1/25/22, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. A care plan, last reviewed on 1/28/22, indicated she verbalized discomfort and or pain during ADL (Activities of Daily Living) care. The goal was for her ADL care to be completed successfully without discomfort or pain. The approaches, initiated 1/28/2019, were to evaluate effectiveness of pain medications as needed and utilized 2 care givers for ADL care. A fall event, dated 2/7/22, indicated that on 2/7/22 at 7:53 p.m., she was being turned in bed and had a witnessed fall. She experienced moderate pain (distressing or miserable) and a suspected fracture. She was transferred to an acute care hospital for evaluation. The IDT (Interdisciplinary Team) had reviewed the fall on 2/8/22 at 11:38 a.m., as she had been being changed in bed, the air bed had fluctuated, and she had rolled out of bed. She had complaints of pain all over and wanted to go the emergency room. She had voiced it was an accident and that the girl was just attempting to help clean her up when she fell. An Emergency Department Providers noted, dated 2/7/22 at 10:41 p.m., indicated she had been brought to the emergency department after a fall. She was having her brief changed when she fell to the ground. She was complaining of right hip and knee pain. A chest x-ray, completed at the emergency department on 2/7/22 at 11:20 p.m., indicated there was at least 1 rib lower left rib fracture. A care plan, revised on 2/8/22, indicated that she had a history of falls related to weakness, paralytic (abnormal) gait, and dizziness. The goal was that she would remain free from injuries. The approaches included to provide her with toileting assistance, initiated 1/28/19, to transfer her using a mechanical lift and assist of 2 staff members, initiated 1/28/19, and to use a 2-person approach to care, initiated 2/8/22. During an interview on 3/9/22 at 12:17 p.m., Resident H indicated she had rolled out of bed and had a fall. She went to the hospital and had a fracture. During an interview on 3/10/22 at 2:20 p.m., CRCA (Certified Resident Care Assistant) 1 indicated she used 2 staff members to assist with Resident H's bed mobility. She had always used 2 staff members, even prior to the fall, for safety. During an interview on 3/10/22 at 2:21 p.m., CRCA 2 indicated prior to the fall on 2/7/22, she had turned her in bed by herself. Since the fall she had been instructed to always use 2 staff members when turning her. During an interview on 3/11/22 at 12:46 p.m., CRCA 4 indicated she was present when Resident H fell on 2/7/22. She was attempting to turn her to while providing incontinent care and she slid out of the bed. She normally turned and repositioned her in bed or during incontinent care by herself. She had not been told to use 2 staff members for bed mobility or incontinent care until after the fall. During an interview on 3/14/22 at 9:54 a.m., PTA (Physical Therapy Assistant) 5 indicated she had provided treatments for Resident H. She had needed maximum assistance of 2 staff members for turning in bed throughout most of her time residing at the community. Upon discharge from therapy 11/23/21, she had required maximum assistance of 2 staff members for turning side to side in bed and for providing brief changes. On 3/10/22 at 10:15 a.m., the Executive Director provided the Falls Management Program Guidelines Policy, reviewed 5/22/18, which read .to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures intensive efforts will be directed toward minimizing or preventing injury Care plan interventions should be implemented that address the resident's risk factors 3. The clinical record for Resident Q was reviewed on 3/9/22 at 2:00 p.m. The diagnoses for Resident Q included, but were not limited to, dementia, difficulty in walking, unsteadiness on feet, lack of coordination and repeated falls. A care plan dated 1/23/19 indicated .Resident is at risk for falling. Requires assist of staff with transfers/mobility. Has dx [diagnosis] of dementia .Approach: remind resident of asking for assistance. antirollbacks to wheelchair. place non-skid strips in bathroom in front of toilet. add non skid strips to bathroom floor . A fall event dated 12/29/21 indicated Resident Q had unwitnessed fall in her room. The resident had transferred herself. A nursing progress note dated 12/31/21 indicated IDT [interdisciplinary team] Review: Resident was found on floor next to bed. Had attempted to transfer self from wheelchair to bed without proper footwear and slipped and fell. Resident interventions in place of que signs, non skid strips and bed in lowest position. Resident is supposed to keep her shoes on for transfers. Due to dx resident is non compliant with interventions and continues to do transfers and toileting by herself and non compliant with asking staff for assistance .No injuries noted from fall. IDT recommends to place anti-rollbacks on resident wheelchair. MD and family notified and care plan updated. A fall event dated 1/8/22 indicated Resident Q had an unwitnessed fall in her bathroom. The resident was transferring herself to toilet. An IDT Review dated 1/10/22 indicated .Resident was found on floor in bathroom. Resident stated that she was transferring back to wheelchair and forgot to lock her brakes .Resident reminded to ask for assistance from staff for safety. Resident recently initiated therapy for strength training. Will continue to remind resident of asking for assistance. An observation was made of Resident Q in her room with Nurse Support 10 on 3/10/22 at 3:10 p.m. There was no observation of anti-tippers on her wheelchair nor non-skid strips on her bathroom floor per the plan of care. An interview was conducted with the Nurse Manager on 3/11/22 at 2:30 p.m. She indicated the anti-tippers were missed and had not been placed on Resident Q's wheelchair. The facility no longer places non-skid strips on the flooring. The resident's care plan will need to be revised. This Federal Tag relates to complaint IN00373313. 3.1-45(a)(2) 2. The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses included, but were not limited to, chronic kidney disease. The fall care plan, last revised 3/11/22, indicated the goal was for her to remain free from falls with major injury. An approach was for hospice to evaluate anti-anxiety medication, with a start date of 2/15/22. The 2/14/22, 9:48 p.m. nursing note read, Fell out of wheel chair at 9:20 p.m. 2/14/22 nurse notified. Minor knot on back of head. The 2/14/22, 10:43 p.m. nurse's note read, Unwitnessed fall in [NAME] hallway. Resident was sitting in WC [wheel chair] and fell to floor and hit head on side of WC on wheel. Noted a small hematoma on the left side. No bruising noted, skin is closed. No dizziness, h/a [head ache,] or nausea seen. Unable to determine pupil size, but both are sluggishly reactive and equal. ROM [range of motion] intact and normal for resident's baseline. VSS [vital signs stable.] .Resident kept awake for monitoring in a 1:1 with aide or nurse. Will continue to monitor and observe. The 2/15/22, 4:48 a.m. nurse's note read, Resident was given 1 dose of PRN [as needed] ordered Ativan [anti-anxiety medication] for restlessness once placed in bed The 2/15/22, 9:45 a.m. nurse's note read, Witnessed fall observed & reported. Res [Resident fell out of w/c onto hallway floor by nurses station while trying to reach for something. Res laying on her left side, with BLE [bilateral lower extremity] flexed at the knees. HTN [Hypertension] noted. Increased restlessness observed. No other injuries noted at this time. Res laid down in bed & is sleeping at this time . On 3/15/22 at 2:25 p.m., an interview was conducted with CRMA (Certified Resident Medication Aide) 20, who witnessed Resident W's fall on 2/15/22. She indicated Resident W was reaching for something and fell by the medication cart in front of the nurse's station. CRMA 20 was behind the desk at the time and was unaware Resident W was placed on 1:1 monitoring for a fall the previous night. The 2/15/22, 3:45 p.m. IDT (interdisciplinary team) note read, Review of fall on 2/15/22. Resident noted with witnessed fall onto hallway floor by nurses station while trying to reach for something. Resident noted with increased restlessness observed. No other injuries noted at this time per staff nurse assessment. Resident assisted to bed et [and] resting. Family/MD made aware. Hospice called & notified. New intervention noted for hospice to evaluate anti-anxiety medication. The 2/16/22, 12:20 p.m. nurse's note, written by the NM (Nurse Manager) read, Spoke with [name of Resident W's hospice company] regarding most recent falls and interventions. Hospice nurse to evaluate anti-anxiety medication upon next scheduled visit. An interview was conducted with the NM on 3/14/22 at 10:14 a.m. She indicated she remembered discussing having hospice evaluate Resident W's anti-anxiety medications and writing it in the 2/16/22 note, but didn't see any verification it was done. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she didn't remember if she was asked to evaluate Resident W's anti-anxiety medications after her 2/15/22 fall. Perhaps the on call hospice nurse, Hospice Nurse 16, would know, as she was the nurse who spoke with the facility after her 2/14/22 and 2/15/22 falls. After reviewing the notes, there was no information about an anti-anxiety medication review. Hospice Nurse 14 came to the facility later on 2/15/22 to visit Resident W. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the on call nurse when Resident W fell. When they called her, Resident W had already been monitored since the fall. Her vital signs were stable, and there were no signs or symptoms of injury. The facility informed her they would call, if they had any other concerns. She was not notified of any other concerns and was never informed of any intervention of reviewing her anti-anxiety medications. She was uncertain if Hospice Nurse 14 was made aware of the intervention, but I definitely wasn't made aware of it by the facility. The 2/15/22 Hospice Staff Collaboration Log indicated Hospice Nurse 14 visited on 2/15/22 as a follow up for 2 falls. The section entitled Was The Care Plan Changed? read, Will order Broda Chair. The 2/15/22 hospice note, written by Hospice Nurse 14, read, Late entry for PRN [as needed] visit today at 3:34 p.m Writer woke with staff nurse, [name of CRMA 20,] who confirmed that patient fell last night. [Name of CRMA 20] also reports that patient fell from her wheel chair this morning. Nurse stated that perhaps patient was attempting to pick something up off the floor and lost her balance Broda Chair requested by facility nurse. There was no information in the clinical record to indicate Resident 20 was provided with a Broda chair until 3/3/22. An interview was conducted with the NM on 3/14/22 at 11:12 a.m. She indicated she wrote the order for the Broda chair on 3/3/22, so that was when she got it. There was a care plan meeting on 2/25/22, where they discussed the Broda chair, positioning, and what would be most comfortable for her. Hospice was there via phone. She was unaware of the 2/15/22 hospice note about the Broda chair and did not recall discussing it prior to the 2/25/22 care plan. The 2/20/22, 5:28 p.m. nursing note read, Writer was alerted by CRCA [Certified Resident Care Assistant] that resident fell at the nurses station. Res [Resident] has laceration to left eye and a hematoma forming over left eyebrow. Res in pain, speech mumbled, pupils react slowly. Vitals 157/107 T [Temperature] 98.2 P [Pulse] 71 02 [Oxygen saturation] 95%. Laceration to left eye cleansed and dry dressing applied. Res given prn pain meds. Daughter notified. NP [Nurse Practitioner] notified. Res sent out to ER for further eval [evaluation.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical record for Resident H was reviewed on 3/9/22 at 12:40 p.m. The Resident's diagnosis included, but were not limited to, polyosteoarthritis (arthritis in multiple joints) and contracture of her r knee. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/21, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. She had frequent pain, which limited her daily activities. The pain was a 5 on a pain scale of 1 through 10 and she had received scheduled pain medications. She had also received as needed pain medications and non-pharmacological interventions to help with pain. A physician's order, dated 12/20/21, indicated she was to receive 2 tablets of hydrocodone- acetaminophen (narcotic pain medication) 5-325 mg (Milligram) by mouth twice daily. A Quarterly MDS Assessment, completed 1/25/22, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. She had frequent pain, which limited her daily activities. She described the pain as moderate and received scheduled pain medications. She had not received as needed pain medications or non-pharmacological intervention to help with pain. A care plan, last revised on 1/28/22, indicated she was at risk for pain related to arthritis and osteoporosis. She had a bone spur in her right ankle. The goal was for her to voice pain relief within 1 hour of any intervention that had been provided. The approaches, with start dates of 1/28/19, were to administer medications as ordered. To monitor and record effectiveness and report adverse side effects to the physician. Encourage support of family and significant others. To evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge. Monitor and record any complaints of pain, including location, frequency, effect on function, intensity, alleviating factors, and aggravating factors. To monitor for any non-verbal signs of pain such as crying, guarding, moaning, restlessness, grimacing, diaphoresis (sweating), withdrawal. To offer non-medicated pain relief measures such as biofeedback, application of heat or cold, massage, physical therapy, stretching and strengthening exercises, acupuncture, excreta, and monitor effectiveness. A fall event, dated 2/7/22, indicated that on 2/7/22 at 7:53 p.m., she was being turned in bed and had a witnessed fall. She experienced moderate pain (distressing or miserable) and a suspected fracture. She was transferred to an acute care hospital for evaluation. An Emergency Department Providers noted, dated 2/7/22 at 10:41 p.m., indicated she had been brought to the emergency department after a fall. She was complaining of right hip and knee pain. A chest x-ray, completed at the emergency department on 2/7/22 at 11:20 p.m., indicated there was at least 1 rib lower left rib fracture. A physician's order, dated 2/17/22, indicated she could receive 1 tablet of hydrocodone- acetaminophen 5-325 mg 3 times a day PRN (as needed) for pain. The February 2022 MAR (Medication Administration Record) indicated she received her scheduled dose of hydrocodone- acetaminophen as ordered for the month of February and her PRN dose on the following days, with the effectiveness of the medication for pain relief as documented: 2/17/22 at 8:20 p.m. for pain with somewhat effective results, 2/18/22 at 1:49 p.m. for pain, which was not effective, 2/20/22 at 1:38 p.m. for pain, which was effective, and 2/24/22 at 1:54 p.m. for pain which was effective. The Controlled Drug Use Record for her hydrocodone- acetaminophen 5-325 mg indicated that she had also received a PRN dose on the following days, which were not recorded on the February MAR and did not indicate the effectiveness of the medication: 2/21/22 at 3 p.m., 2/22/22 at 12:30 p.m., 2/23/22 at 3 p.m., and 2/26/22 at 3:30 p.m. The PRN dose of hydrocodone- acetaminophen was discontinued on 2/26/22. A physician's order, dated 3/3/22, indicated she could receive 1 tablet of hydrocodone- acetaminophen 5-325mg 5 times daily PRN for pain. A physician's order, dated 3/4/22, indicated she was to have a right knee x ray done. A nursing progress note, dated 3/4/22 at 11:29 p.m., indicated the right knee x-ray results showed she had a fracture of the distal femur (lower end of thigh bone) and proximal tibia (upper end of shin bone). NP (Nurse Practitioner) 22 had been notified and had given an order to send her to the ED (Emergency Department). She had refused to go the ED and NP 22 was informed of her refusal. A pain event IDT (Interdisciplinary Team) note, dated 3/7/22 at 10:58 a.m., indicated she had 2 fractures noted on the right knee x-ray. She had refused treatment at any hospital and that treatment options were being discussed with her family. She continued to receive scheduled pain medication and had PRN pain medication available. On 3/10/22 at 3:24 p.m., the NM (Nurse Manager) provided the March MAR, which indicated she had received her scheduled hydrocodone- acetaminophen, as ordered, and her PRN dose on the following days, with the effectiveness of the medication for pain relief as documented: 3/3/22 at 1:04 p.m. for pain, which was effective, 3/4/22 at 11:02 a.m. for pain, which was effective, 3/8/22 at 12:57 p.m. for pain, which was effective, and 3/9/22 at 2:00 p.m. for pain which was effective. The Controlled Drug Use Record for her hydrocodone- acetaminophen 5-325 mg indicated that she had also received a PRN dose on the following days, which were not recorded on the March MAR and did not indicate the effectiveness of the medication: 3/3/22 at 1:30 p.m., 3/5/22 at 2:00 p.m., 3/6/22 at 2:00 p.m., and 3/7/22 at 3:00 p.m. On 3/9/22 at 12:14 p.m., Resident H was observed laying in her bed. She was grimacing and moaning. She indicated that she sometimes had to wait for pain medication. During an interview on 3/10/22 at 2:20 p.m., CRCA (Certified Resident Care Assistant) 1 indicated Resident H had started complaining about her right leg hurting after the fall she had in February. She complained about the pain each time she was turned in bed. She had let the nurses know about the increased pain when she turned her. During an interview on 3/11/22 at 9:11 a.m., NP 22 indicated that he had ordered the PRN hydrocodone- acetaminophen on 2/17/22 due to Resident H complaining to him about rib pain. She was usually vocal about her pain and let him know if there was any new pain or issues. He had ordered the right knee x-ray due to her complaining of increased pain and he had noted some redness when he examined her right knee. He would expect to be notified if a resident's pain was disproportional to their normal status. During an interview on 3/11/22 at 2:31 p.m., LPN (Licensed Practical Nurse) 7 indicated that when she administered a PRN pain medications, she would usually wait around 30 to 40 minutes, and then check to see how effective it was, and then document the effectiveness on the MAR. She did not document the effectiveness of the routine pain medications she gave. If a CRCA informed her that a resident was in pain, she would do a pain assessment on the resident to determine where the pain was and the pain level. She would then administer a PRN pain medication, if the resident had one, or she would inform the physician about the pain. Resident H usually had a pain level of about 8 of 10 when she received PRN pain medications and her pain level would generally be decreased to around a 4 of 10. The 2 hydrocodone- acetaminophen she received routinely were more effective for her pain than the PRN medication was. She verbally informed the physician or the nurse practitioner of how the pain medication were doing. On 3/10/22 at 10:15 a.m., the Executive Director provided the Guidelines for Pain Observation and Management Policy, revised 5/23/17, which read .Purpose To ensue each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual . 3. Initiate a Plan of care related to chronic, acute or breakthrough pain .4. If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate changes and care plan updated. a. Observe the resident for a condition that would indicate that pain might be expected (injury, surgery, procedure) 5. Educate the resident /[sic] family/[sic]/ care givers on the pain management interventions and importance of notifying staff of changes in pain status. 6. Implement the care plan approaches to assist with pain management. 7. Evaluate the effectiveness of pain management interventions and modify as indicated . 3.1-37(a) Based on observation, interview and record review, the facility failed to ensure residents' pain were adequately assessed, monitored and addressed for 1 of 1 residents reviewed for pain management, 1 of 1 residents reviewed for tube feeding and 1 of 4 residents reviewed for falls. This resulted in a resident transferred to hospital with a fracture in pain. (Resident H, O and P) Findings include: 1. The clinical record for Resident O was reviewed on 3/9/22 at 12:00 p.m. The diagnoses for Resident O included, but were not limited to, fracture of the lower end of left radius and wrist, Alzheimer's disease, and dementia with behavioral disturbances. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident O was cognitively impaired. She was extensive assistance with 1 staff person for bed mobility, transfer and dressing. A care plan dated 12/27/20 indicated At risk for pain r/t [related to]: decreased mobility, need for staff assistance with bed mobility, transfers and toileting, dx [diagnosis] of Alzheimer's disease and dementia. Goal: Resident's pain will be at a tolerable level with interventions. Interventions: Administer medications as ordered and notify MD [Medical doctor] for any side effects observed or lack of effectiveness. Attempt non-pharmacological interventions. notify MD of increased pain. Observe for and record verbal and non-verbal signs of pain. Reposition as needed . An observation was made of Resident O on 3/10/22 at 9:32 a.m. Resident O was observed sitting in her wheelchair with a brace on her left arm. A fall event dated 1/29/22 at 3:30 p.m., indicated Resident O had an unwitnessed fall in her room. She was observed and assessed by LPN 10 at that time. The resident was observed not wearing appropriate footwear, range of motion to all extremities and was not in any pain. A nursing progress note written by License Practical Nurse (LPN) 10 dated 1/29/22, indicated Writer notified by the CRCA [Certified Resident Care Assistant]12 that resident (O) was on the floor. Writer entered [Resident O's room number] and noted resident lying on L [left] side the floor next to bed, (+) [had] ROM [range of motion] x [times] 4 extremities, no in/outward or length difference of BLE [bilateral lower extremities], no visual injuries, up with assist x 2 [staff members]. Resident A&O [alert and oriented] x 1, unable to tell what happened. Resident was laying in bed before incident . A bruise event written by LPN 10 dated 1/29/22 at 6:39 p.m., indicated Resident O's left hand and distal forearm was blue in color and her hand had swelling. The resident was experiencing pain at level of 3 using the following pain scale: 0-no pain, 1-mild pain, 2, 3, 4-moderate pain distressing/miserable, 5, 6, 7-severe pain-horrible/intense, 8, 9, 10-Excruciating pain - worst possible -interferes with ability to carry on with daily routines, socialization or sleep. The event indicated a progress note dated 1/29/22 at 6:45 p.m., after putting resident to bed the CRCA [12] noted L hand and distal forearm was bruise (blue) and nursing swollen. Writer noted bruises and applied ice, bruising from previous fall today-resident rolling out of low bed, will cont. to monitor . A physician order dated 12/27/20 indicated Resident O was to receive 500 milligrams of Tylenol twice a day. A physician order dated 4/23/21 indicated Resident O was to receive 325 milligrams of Tylenol every 6 hours for pain as needed. A physician order dated 4/23/21 indicated the resident was to receive .25 milliliters of morphine every 3 hours for pain as needed. A physician order dated 1/29/22 indicated Resident O's pain should be assessed every shift for 72 hours after fall incident. The January 2022 Medication Administration Record (MAR) indicated Resident O's pain was assessed on the following days, shifts, pain location and pain level: 1/29/22 = 2:00 p.m. - 10:00 p.m., resident had no pain assessed by LPN 10, 1/29/22 = 10:00 p.m.- 6:00 a.m., location of the pain was left wrist and the pain level was 4 out of 10 assessed by LPN 13, and 1/30/22 = 6:00 a.m. - 2:00 p.m., location of pain was left wrist and hand and pain level was 5 out of 10 assessed by LPN 11. The MAR indicated 500 milligrams of scheduled Tylenol was administered on 1/29/22 between 6:00 a.m. - 10:00 a.m., by LPN 11, 1/29/22 between 6:00 p.m. -10:00 p.m. by LPN 10, and 1/30/22 between 6:00 a.m. - 10:00 a.m. by LPN 11. The MAR did not indicate any as needed pain medication was administered on 1/29/22 nor 1/30/22. The clinical record did not indicate Resident O's pain was addressed nor continued monitoring of the resident's pain was conducted by staff after the fall; that included non-pharmacological interventions, as needed pain medication administrations, or assessing effectiveness of the scheduled pain medications. A nursing progress note written by LPN 11 dated 1/30/22 indicated Resident L hand and distal forearm bruising, swelling, and severe pain indicated by Nursing extreme guarding of area; assessment revealed need for x-ray ordered by NP (Nurse Practitioner) on call. X-ray completed this day at 11am (sic) that confirmed an acute fracture of the distal radius of left extremity. Nurse notified on-call NP of findings and new orders given to send resident to ER (emergency room) for further evaluation and treatment. Resident [family] notified. Resident being transported to [name of hospital] via ambulance. A physician order dated 1/30/22 at 6:00 a.m., indicated Resident O was to have an x-ray of her left wrist. A lab report dated 1/30/22 indicated an acute fracture to Resident O's left wrist was reported to the facility at 12:30 p.m. An interview was conducted with LPN 10 on 3/11/22 at 11:18 a.m. She indicated she was the nurse that had taken care of Resident O at that time of her fall. After the fall, she had assessed the resident with no injuries that she had observed. LPN 10 had then written the fall incident in the medical provider book due to the resident did not have an injury. She had not notified the medical provider via phone about the fall. Later on in the evening, the CRCA 12 had reported to her the resident's left hand was bruised, swollen, and she had complaints of pain. LPN 10 at that time applied ice to the resident's left hand, but did not notify the medical provider. She believed at that time, the resident did not have any major injury to her left wrist. The resident had landed on her left side, and she believed the hand was just bruised from the fall. LPN 10 had administered scheduled pain medication, but had not provided any additional pain medication that night. She had worked on the unit until 10:00 p.m. An interview was conducted with LPN 13 on 3/11/22 at 3:33 p.m. She indicated she had taken over Resident O's care after LPN 10 at 10:00 p.m. to 6:00 a.m. She had also been working that evening on a different hallway, and was aware Resident O had fallen that evening. After assessing the resident's hand when she had taken over her care, the resident's left hand was observed to be visibly swollen, bruised, and the resident had complaints of pain if the extremity was touched. The resident would draw up her arm and verbalize an ow if the left extremity was touched. The resident's verbal and physical reactions were apparent to LPN 13 the resident's arm was causing her pain. She believed she had administered Tylenol that night to Resident O. She had notified the medical provider about the resident's condition. It was not the end of her shift, but it was later on in her shift when she notified the medical provider. An interview was conducted with CRCA 12 on 3/11/22 at 3:20 p.m. She indicated she had worked on the evening of 1/29/22 and was providing care to Resident O until 10:00 p.m. She had notified LPN 10 Resident O had fallen on the floor in her room. Later on in the evening, she had reported to LPN 10 she had noticed the resident's left hand was blue, swollen and she was hollering out in pain. The resident does normally yell out when the staff turn her, but it was different that time. She was in real pain. She had taken care of Resident O all evening and kept checking on the resident in bed through out her shift due to concerns of the resident's hand. She had not observed any ice that had been applied to the resident's hand that evening. An interview was conducted with LPN 11 on 3/11/22 at 11:34 a.m. She had indicated she had taken over the care of Resident O on the morning of 1/30/22. She had observed the resident in the hallway prior to getting report and had already observed the resident's hand was bruised and swollen twice the size of her other hand. She had indicated to the night staff Resident O's hand does not look right. LPN 13 had reported she had called the doctor and received an order to get an x-ray. The lab would be coming out to obtain. The lab team was late getting to the facility and had come around lunch time to obtain the x-ray. The resident was unable to voice her pain utilizing a numeric pain scale due to her cognitive status. The resident would verbalize a no if the staff tried to touch her arm during care and/or she would guard her arm bringing in close to her body. The x-ray was challenging to obtain due to the resident did not like her hand to be touched due to pain. She could tell the resident was in pain, because she grimaced or verbalize Oh, Ow, and No if anyone touched her arm. LPN 11 indicated she had administered Tylenol to Resident O that day, but can not recall if it was scheduled or as needed. The Hospital Records was provided by the Nurse Manager on 3/10/22 at 3:14 p.m. It indicated Resident O was brought in to the emergency room and seen on 1/30/22 at 4:30 p.m.Chief complaint: Patient presents with arm injury. left arm fracture from fall out of bed yesterday evening .X-ray today showed radial fx [fracture]. Splinted by medics . The records indicated the resident had pain in arm and hip. A physician note dated 1/31/22 indicated .Chief Complaint/Nature of Presenting Problem: 1/31: Resident is being seen today for follow up rounds for recent hospital leave Resident [P] was found on the floor lying on her side. L hand and distal forearm bruising, swelling and severe pain. X ray ordered showing acute fx of the distal radius of the left extremity. Pt [patient] sent to ED [emergency department] for further evaluation .Plan: .left forearm/radius fracture: 1/31/22: Splint in place .Pain management. ortho follow up . 2. The clinical record for Resident P was reviewed on 3/9/22 at 11:00 a.m. The diagnoses for Resident P included malignant neoplasm of upper-outer quadrant of right female breast, secondary neoplasm of bone, and gastrostomy. A care plan for Resident P dated 9/17/20 indicated Risk for pain r/t: terminal dx of breast cancer, decreased mobility, dx of malnutrition, GERD [gastroesopheal reflux disease], presence of pressure ulcers .Goal: Resident's pain will be at a tolerable level with interventions .Approach: Administer medications as ordered and notify MD for side effects observed or lack of effectiveness. Attempt non-pharmacological interventions. notify MD of increased pain. Observe for and record verbal and non-verbal signs of pain. Reposition as needed. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident P was moderately cognitively impaired. A physician order dated 3/2/22 indicated to wash area about g-tube site and dry. apply thin layer of bacitracin ointment and cover with split gauze twice a day . This order was discontinued on 3/9/22. A physician order dated 3/11/22 indicated Cleanse gtube insertion site with normal saline. Apply mupirocin ointment. Cover with split sponge and secure. Change daily and as needed. A physician order dated 12/7/21 indicated staff was to administer 0.5 milliliters of dilaudid four times a day as needed. A physician order dated 12/7/21 indicated the resident was to receive 10 milligrams of methadone twice a day. A March 2022 Methadone Narcotic count sheet indicated on 3/11/22 at 7:45 a.m., LPN 7 had administered 10 milligrams of methadone to Resident P. The resident received another dose of methadone on 3/11/22 at 7:50 p.m. A Narcotic dilaudid count sheet indicated Resident P had not received any dosages of dilaudid on 3/11/22. A nursing progress notes dated 3/3/22 indicated .PEG [gtube] site cleaned with NS [normal saline]. Noted to be unchanged from this nurse previous assessment. [NAME] purulent drainage noted. Very painful to palpation, though now to the superior of the PEG tube insertion site. Edema and erythema around insertion site. Also noted bloody drainage with cleaning of site. Resident reports it is painful. NP aware. Will continue to monitor, clean and observe. An observation was made of Resident P's gtube site with LPN 7 on 3/11/22 at 11:00 a.m. LPN 7 had indicated the resident's gtube site has been very aggravated. The resident was scheduled to have removal, because she had been eating. At that time, the resident's site was observed with a brown substance around the site. LPN 7 asked Resident P at that time if she was in any pain. She utilized a scale of 1 being the least amount of pain and 10 being the most amount of pain. Resident P responded her pain was an 8. LPN 7 then continued to provide care to the resident's gtube site. An interview was conducted with Resident P on 3/11/22 at 2:15 p.m. She indicated her pain level was still an 8 out of 10. She had not received any additional pain medication nor any care was provided for pain relief. The gtube site was tender by touching it. An interview was conducted with LPN 7 at 3/11/22 at 2:25 p.m. LPN 7 indicated she had given Resident P her scheduled methadone around 10:00 a.m., that morning. The resident had to wait 4 hours before she was able to give her anything else for pain. She had delivered the resident's lunch earlier, and she had not reported to her any other concerns about pain. The scheduled pain medication she had given her earlier that day had probably wore off, and she was able at that time to have something else. A nursing progress note written by LPN 7 dated 3/11/22 at 11:14 a.m., indicated Res [resident] seen for wound/irritation around g-tube site this a.m. Res c/o [complaints] pain around site on a scale of 8/10. Res was given scheduled pain meds this morning, pain meds were somewhat effective, Nurse made aware that site was starting to bother res again around 2:30 pm (sic) after report, nurse made QMA [qualified medication aide] assisting aware to continue with PRN [as needed] med orders. Res also c/o of sore irritate throat and was given PRN throat drops . An interview was conducted with CRCA 9 (Certified Resident Care Assistant) on 3/14/22 at 10:00 a.m. CRCA 9 indicated Resident P has had complaints of stomach pain for weeks. An interview was conducted with the Nurse Manager on 3/14/22 at 10:10 a.m. She indicated if staff recognized by facial expressions or verbal responses that the residents' are in pain, the nursing staff will then proceed to treat by utilizing his or her pain orders or call the doctor for pain medication orders.