**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to ensure Resident #331 received needed services and treatment for pain management of a right fractured hip by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. with instructions related to longstanding chronic pain management. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Abuse and Neglect - Clinical Protocol policy revised October 15, 2022 revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Definitions: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident(s) requires but fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. 4. Be familiar with the physiologic and behavioral (non-verbal) signs of pain. For example: a. Verbal expressions such as groaning, crying, whining: The following equipment and supplies will be necessary when performing this procedure; a. Explanation of pain scale severities of 0-10 or nonverbal indicators of pain scale; Steps in the Procedure 3. Conduct an abbreviated pain assessment if there has been not change of condition since the previous assessment . b. Verbal and non-verbal signs of pain; 5. Administer pain medications as ordered. Resident #331 was admitted to the facility on [DATE] with diagnoses, which included in part, other fracture of right femur, subsequent for closed fracture with routine healing, pain, depression, and anxiety disorder. Review of Resident #331's Nursing admission assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review of Resident #331's Nursing admission assessment dated [DATE] and baseline care plan revealed Resident #331 was totally dependent on staff for bed mobility, transfer, dressing and toilet use. Review of Resident #331's hospital records dated 05/28/2025 for surgical repair of right hip fracture revealed in part a discharge medication reconciliation for the continuation of Hydrocodone-acetaminophen 10-325 mg; take 1 tablet by oral route every 4 to 6 hours as needed for pain. Review of Resident #331's medical record failed to reveal ED hospital records from 05/29/2025 had been acquired by the facility. Review of Resident #331's ED hospital records dated 05/29/2025 obtained by surveyor revealed in part a history of present illness as: Resident #331 presents to the ED with c.o. (complaint of) right leg pain. EMS reports that they transported patient (Resident #331) from rehabilitation facility for uncontrolled pain. EMS states that patient (Resident #331) recently had hip surgery to the right side, and was discharged from the hospital yesterday. It (Resident #331) reports that she has only received Tylenol from the facility she has been with, but states that it has not been helping . Further review of Resident #331's ED hospital records dated 05/29/2025 revealed in part, Resident #331 had been prescribed longstanding chronic pain medication and last filled a 30 day supply of Hydrocodone-acetaminophen 10-325 mg on 04/30/2025. ED instructions included in part for Resident #331's family to bring Resident #331's bottle of pain medication to the facility to be administered. Review of S13Medical Director's 2025 Standing Orders revealed in part: admission Orders: 1. Continue all orders from hospital including meds, if there are questions, contact NP (Nurse Practitioner)/AP (Advanced Practitioner). PRN Medications: c. Pain/minor complaints/fever: Tylenol 650 mg q 6 hours prn, notify NP if not effective after 2 doses. Review of Resident #331's Physician orders failed to reveal an order for narcotic pain medication until 06/02/2025 when Hydrocodone-acetaminophen tablet 10-325 mg; give 1 tablet by mouth every 4 hours as needed for pain was ordered via an original hard copy prescription (hard script) signed by S19NP. Review of Resident #331's May and June 2025 MARs (Medication Administration Record) revealed in part, on a pain intensity scale of 1 to 10, a pain level of 8 on 05/28/2025's night shift; a pain level of 2 on 05/31/2025's dayshift; and a pain level of 8 on 06/02/2025's evening shift had been documented. Further review of May and June 2025 MARs failed to reveal Tylenol 650 mg or Hydrocodone-acetaminophen 10-325 mg pain medication had been administered. Review of Resident #331's paper Narcotic Administration Record revealed Resident #331 received an initial dose of Hydrocodone-acetaminophen 10-325 mg on 06/02/2025 at 9:00 a.m. Review of Resident #331's Interdisciplinary notes revealed in part, standing order pain medication was administered on 05/28/2025 at 10:02 p.m. and 05/29/2025 at 10:19 p.m. Further review of Resident #331's Interdisciplinary notes revealed a note by S14LPN (Licensed Practical Nurse) on 05/29/2025 at 1:09 a.m. which read in part: Writer (S14LPN) assessed Resident #331 at beginning of shift. Resident alert and oriented x 3. Complained of right hip pain of an 8 on pain scale. Writer (S14LPN) informed Resident #3 that her pain medication has been ordered but did not come in and offered Tylenol. Tylenol 650 mg administered per S13Medical Director's standing orders. Resident took medication without difficulty . Writer (S14LPN) went to room and Resident #331 was on phone with a 911 (Emergency Medical Services) . Resident #331 stated she needs something for pain because the Tylenol is not helping . Further review of Resident #331's Interdisciplinary notes revealed Resident #331 received Tramadol and Norco in the ED prior to returning to the facility on [DATE] at 4:09 a.m. Further review revealed the Pharmacy was notified of non-delivery of narcotic medication on 05/29/2025 at 10:27 p.m. and a hard script request was faxed to S13Medical Director's office on 05/29/2025 at 10:42 p.m. During an interview on 06/02/2025 at 8:00 a.m., Resident #331 reported she was in severe pain all over and had not received her pain medicine because the facility was out of her medicine. During an interview on 06/03/25 08:08 a.m., Resident #331 reported facility did not have her prescription pain medicine until yesterday, 06/02/2025. Resident #331 further reported she had been given Tylenol and stated it did not help. During an interview on 06/04/2025 at 9:30 a.m. Resident #331 reported she was told by her nurses the facility did not have her pain medication and she felt she was getting the run around. Resident #331 reported her hip pain became unbearable so she called EMS (on 05/29/2025) to come get her. During an interview on 06/04/2025 at 11:00 a.m., S15CNA (Certified Nursing Assistant) reported she took care of Resident #331 on 05/29/2025 and stated Resident #331's pain was through the roof. S15CNA further stated Resident #331 was crying and would scream when staff touched or turned her. During an interview on 06/04/2025 at 11:10 a.m., S16LPN reported the process for a new admit needing pain medication, was for the discharging hospital to send a hard script for the narcotic to be filled by the pharmacist. S16LPN further reported the facility had not received a hard script for Resident #331's narcotic pain medication upon admission and had to wait on S13Medical Director to provide one in order for Resident #331 to receive her pain medication. During an interview on 06/04/2025 at 12:20 p.m., S18PT (Physical Therapist) reported he evaluated Resident #331 on 05/29/2025 for a closed right hip fracture. S18PT further reported Resident #331 exhibited a high level of pain when touched and was unable to participate at the time. During a telephone interview on 06/04/2025 at 1:00 p.m. S14LPN reported she worked the 11-7 shift beginning 05/28/2025 and was informed by the evening nurse a request for hard copy script for pain medication had been sent to S13Medical Director. S14LPN reported Resident #331 had received Tylenol but called EMS to take her to the ED because she was in pain. S14LPN further reported at this time Resident #331 was at an 8 pain level. S14LPN stated I truly believe she was in pain or she wouldn't have called EMS. S14LPN confirmed she was not able to administer Norco without a hard copy script even if available in the emergency back-up system. During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining Narcotics for a new admit was for the nurse to fax the hard script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give Narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard copy script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported he had been notified numerous times via fax to his phone by the facility regarding Resident #331 needing a hard script for narcotic pain medication. S13Medical Director reported he was out of town and was informed by S19NP Resident #331 was out of the facility on 05/29/2025. S13Medical Director reported he had not been informed of Resident #331's return to the facility. S13Medical Director acknowledged Resident #331 was admitted to the facility on [DATE] and did not receive narcotic pain medication until 06/02/2025 and should have. S13Medical Director reported Resident #331 would have been in significant pain related to her fracture. S13 Medical Director further reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotic. During a telephone interview on 06/04/2025 at 3:45 p.m., S19NP reported there had been a misunderstanding of Resident #331 being in the facility on 05/29/2025. S19NP reported on the morning of 05/29/2025 he was informed by staff of a new admit from the 05/28/2025 evening shift who had been sent out by EMS. S19NP reported he assumed Resident #331 had been admitted to the hospital and failed to clarify. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:00 a.m., S12LPN reported the first day she was assigned to take care of Resident #331 was 06/02/2025. S12LPN further reported upon initial morning assessment, Resident #331 reported a 10 out of 10 pain. S12LPN further reported Resident #331 informed her she had been asking for pain medication since she was admitted and had not received any narcotic pain medication. S12LPN reported she checked the medication cart and discovered Resident #331 did not have a Norco blister package of doses in the medication cart. S12LPN further reported a request for a hard script for Norco was then faxed to S13Medical Director. During an interview on 06/05/2025 at 9:15 a.m., S19NP confirmed Resident #331 was in the facility on 05/29/2025 when he rounded. S19NP acknowledged he failed to see Resident #331 and provide a hard script for Norco. During an interview on 06/05/2025 at 9:30 a.m., Resident #331 reported she quit asking for pain medicine because she felt like no one was helping her. Resident #331 stated I'm [AGE] years old and I knew Tylenol was not going to work for this kind of pain. Resident #331 reported yesterday, 06/04/2025 was the first day she could tolerate getting out bed to go to therapy. During an interview on 06/05/2025 at 10:45 a.m., S3DON reported she was aware Resident #331 called EMS to get pain medicine and the issue was discussed in the morning meeting on 05/29/2025. S3DON reported S4ADON (Assistant Director of Nursing) was responsible for admit orders and ensuring medications are received and should have taken care of the issue regarding Resident #331's pain medication. S3DON reported she did not follow up and should have. During an interview on 06/05/2025 at 10:50 a.m., S4ADON reported she was aware Resident #331 did not receive ordered pain medication and S5Unit Manager was responsible for obtaining hard script. During an interview on 06/05/2025 at 11:00 a.m. S5Unit Manager reported she was aware resident #331 still did not have pain medication on 06/02/2025 and S4ADON was responsible to ensure a hard script was received. S5Unit Manager further reported she notified the S19NP on 06/02/2025 when she realized Resident #331's Norco had never been delivered. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication by failing to obtain a hard copy script for Norco. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by noncompliance. Staff did not obtain hard script for ordered narcotic pain medication at the time of admission or for 4 days after for Resident #331. Medication audit performed on 06/02/2025 by Administrative nurses to ensure all ordered narcotic medications were on the medication cart and available for residents. On 06/04/2025 all medication cars were audited again by QI (Quality Improvement) Nurse/DON and Administrative nurses and all narcotic medications were present. Medication orders for controlled substance prescriptions policy and procedure will be implemented 06/05/2025 by QI Nurse. To ensure residents are free from neglect and provided with the necessary goods and services of ordered narcotic pain medication DON and LPN/MDS (Minimum Data Set) nurse will be in-serviced on the Medication Orders Controlled Substance Prescriptions policy and procedure by RN (Registered Nurse)/QI Nurse. All other Administrative Nurses and staff nurses will be in-serviced on this policy and procedure by RN DON and/or LPN/MDS. In-service will be completed on 06/05/2025 for all staff nurses currently working on shift. Nurses unavailable for in-service on 06/05/2025 will be unable to work until training has been completed. Nursing administration will review 24 hour report, which includes resident change in conditions and new physician orders, during morning meeting five days a week x 4 weeks to ensure any pain is addressed and neglect is not present. Any concerns identified will be addressed immediately with parties responsible for correction and reported to the Quality Assurance Committee. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director to review Plan of Removal. The DON will complete Narcotic Audit tool on a monthly basis and report findings to QAPI team along with any concerns identified in monitoring for this Plan of Removal monthly times 3 then as directed by the QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide pain management consistent with professional standards of practice for a resident, following a fractured right hip, for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. Nursing staff failed to ensure severe pain was managed for Resident #331 by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Pain Assessment and Management policy revised March 2025 revealed in part: Purpose: The purposes of this procedure are to help the staff identify pain in the residents, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Definitions of different pain include: Acute Pain refers to pain that is usually sudden in onset and time-limited with a duration of less than 1 month and often is caused by injury, trauma, or medical treatments such as surgery . 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, whining. Assessing Pain: b. Characteristics of pain: (1) Intensity of pain (Pain scale 0-10 or nonverbal pain). 2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: (4) Fractures; and (2) Surgical incision. Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. 4. Be familiar with the physiologic and behavioral (non-verbal) signs of pain. For example: a. Verbal expressions such as groaning, crying, whining: The following equipment and supplies will be necessary when performing this procedure; a. Explanation of pain scale severities of 0-10 or nonverbal indicators of pain scale; Steps in the Procedure 3. Conduct an abbreviated pain assessment if there has been not change of condition since the previous assessment . b. Verbal and non-verbal signs of pain; 5. Administer pain medications as ordered. Resident #331 was admitted to the facility on [DATE] with diagnoses, which included in part, other fracture of right femur, subsequent for closed fracture with routine healing, pain, depression, and anxiety disorder. Review of Resident #331's Nursing admission assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review of Resident #331's Nursing admission assessment dated [DATE] and baseline care plan revealed Resident #331 was totally dependent on staff for bed mobility, transfer, dressing and toilet use. Review of Resident #331's hospital records revealed in part a discharge medication reconciliation dated 05/28/2025 for the continuation of Hydrocodone-acetaminophen 10-325 mg; take 1 tablet by oral route every 4 to 6 hours as needed for pain. Review of S13Medical Director's 2025 Standing Orders revealed in part: admission Orders: 1. Continue all orders from hospital including meds, if there are questions, contact NP (Nurse Practitioner)/AP (Advanced Practitioner). PRN Medications: c. Pain/minor complaints/fever: Tylenol 650 mg q 6 hours prn, notify NP if not effective after 2 doses. Review of Resident #331's Physician orders failed to reveal an order for narcotic pain medication until 06/02/2025 when Hydrocodone-acetaminophen tablet 10-325 mg; give 1 tablet by mouth every 4 hours as needed for pain was ordered via an original hard copy prescription (hard script) signed by S19NP. Review of Resident #331's May and June 2025 MARs (Medication Administration Record) revealed in part, on a pain intensity scale of 1 to 10, a pain level of 8 on 05/28/2025's night shift; a pain level of 2 on 05/31/2025's dayshift; and a pain level of 8 on 06/02/2025's evening shift had been documented. Further review of May and June 2025 MARs failed to reveal Tylenol 650 mg or Hydrocodone-acetaminophen 10-325 mg pain medication had been administered. Review of Resident #331's paper Narcotic Administration Record revealed Resident #331 received an initial dose of Hydrocodone-acetaminophen 10-325 mg on 06/02/2025 at 9:00 a.m. Review of Resident #331's Interdisciplinary notes revealed in part, standing order pain medication was administered on 05/28/2025 at 10:02 p.m. and 05/29/2025 at 10:19 p.m. Further review of Resident #331's Interdisciplinary notes revealed a note by S14LPN (Licensed Practical Nurse) on 05/29/2025 at 1:09 a.m. which read in part: Writer (S14LPN) assessed Resident #331 at beginning of shift. Resident alert and oriented x 3. Complained of right hip pain of an 8 on pain scale. Writer (S14LPN) informed Resident #3 that her pain medication has been ordered but did not come in and offered Tylenol. Tylenol 650 mg administered per S13Medical Director's standing orders. Resident took medication without difficulty . Writer (S14LPN) went to room and Resident #331 was on phone with a 911 (Emergency Medical Services) . Resident #331 stated she needs something for pain because the Tylenol is not helping . Further review of Resident #331's Interdisciplinary notes revealed Resident #331 received Tramadol and Norco in the ED prior to returning to the facility on [DATE] at 4:09 a.m. During an interview on 06/02/2025 at 8:00 a.m., Resident #331 reported she was in severe pain all over and had not received her pain medicine because the facility was out of her medicine. During an interview on 06/03/25 08:08 a.m., Resident #331 reported facility did not have her prescription pain medicine until yesterday, 06/02/2025. Resident #331 further reported she had been given Tylenol and stated it did not help. During an interview on 06/04/2025 at 9:30 a.m. Resident #331 reported she was told by her nurses the facility did not have her pain medication and she felt she was getting the run around. Resident #331 reported her hip pain became unbearable so she called EMS (on 05/29/2025) to come get her. During an interview on 06/04/2025 at 11:00 a.m., S15CNA (Certified Nursing Assistant) reported she took care of Resident #331 on 05/29/2025 and stated Resident #331's pain was through the roof. S15CNA further stated Resident #331 was crying and would scream when staff touched or turned her. During an interview on 06/04/2025 at 11:10 a.m., S16LPN reported the process for a new admit needing pain medication, was for the discharging hospital to send a hard script for the narcotic to be filled by the pharmacist. S16LPN further reported the facility had not received a hard script for Resident #331's narcotic pain medication upon admission and had to wait on S13Medical Director to provide one in order for Resident #331 to receive her pain medication. During an interview on 06/04/2025 at 12:20 p.m., S18PT (Physical Therapist) reported he evaluated Resident #331 on 05/29/2025 for a closed right hip fracture. S18PT further reported Resident #331 exhibited a high level of pain when touched and was unable to participate at the time. During a telephone interview on 06/04/2025 at 1:00 p.m. S14LPN reported she worked the 11-7 shift beginning 05/28/2025 and was informed by the evening nurse a request for hard copy script for pain medication had been sent to S13Medical Director. S14LPN reported Resident #331 had received Tylenol but called EMS to take her to the ED because she was in pain. S14LPN further reported at this time Resident #331 was at an 8 pain level. S14LPN stated I truly believe she was in pain or she wouldn't have called EMS. S14LPN confirmed she was not able to administer Norco without a hard copy script even if available in the emergency back-up system. During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining narcotics for a new admit was for the nurse to fax the hard copy script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotics. During a telephone interview on 06/04/2025 at 3:45 p.m. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:00 a.m., S12LPN reported the first day she was assigned to take care of Resident #331 was 06/02/2025. S12LPN further reported upon initial morning assessment, Resident #331 reported a 10 out of 10 pain. S12LPN further reported Resident #331 informed her she had been asking for pain medication since she was admitted and had not received any narcotic pain medication. S12LPN reported she checked the medication cart and discovered Resident #331 did not have a Norco blister package of doses in the medication cart. During an interview on 06/05/2025 at 9:30 a.m., Resident #331 reported she quit asking for pain medicine because she felt like no one was helping her. Resident #331 stated I'm [AGE] years old and I knew Tylenol was not going to work for this kind of pain. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by noncompliance. Staff did not assure that hard script for pain medication was available upon admission and during the first four days of stay. Processes and systems for improvement include admission and administrative follow-up for narcotic availability for all admitting residents. The admission's director will forward hospital discharge orders to all administrative nurses, including the DON. Once hospital discharge orders are received, the ADON will request that copies of hard scripts for all narcotics be emailed to our admission's director and forwarded to administrative nurses. The DON or designee will ensure that all hard scripts are received prior to admission. If the hard script is not received, the DON or designee will contact the medical director to request a hard script for any narcotic order. The DON or designee will communicate with charge nurse, who is assigned to the admitting resident, until the prescribed narcotics are delivered to facility. Training for all nurses began immediately. Nurses in attendance on 06/05/2025 will be educated/in-serviced on the Medication Orders: Controlled Substance Prescriptions Policy and Procedures. All nurses will also be in- serviced on medication availability and proper notification to DON when medications, including narcotics, are not available. Nurses who are unavailable for training on this date will not be allowed to return to work until all training is complete. RN (Registered Nurse) DON and LPN MDS (Minimum Data Set) will provide education/training. Monitoring by the DON will be in place for receipt of hard scripts and narcotic medications for all admitting patients. The nursing administration will review 24-hour reports which include resident changes of conditions, new physician orders, and any documented indications of pain, during the morning meeting for five days weekly for four weeks. Any concerns identified during the morning meeting will be addressed immediately to the parties responsible for correction and the QA (Quality Assurance) committee. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director, facility administrator, director of nursing, and social worker to review the plan of removal. The DON will complete the nursing audit tool monthly and report the findings to the QAPI team along with any concerns identified in monitoring for this plan of removal monthly times three then as directed by QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to have an effective system in place to obtain and provide pain management for Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. with instructions related to longstanding chronic pain management. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings, Cross reference F600 and F697: During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining Narcotics for a new admit was for the nurse to fax the hard script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give Narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard copy script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported he had been notified numerous times via fax to his phone by the facility regarding Resident #331 needing a hard script for narcotic pain medication. S13Medical Director reported he was out of town and was informed by S19NP Resident #331 was out of the facility on 05/29/2025. S13Medical Director reported he had not been informed of Resident #331's return to the facility. S13Medical Director acknowledged Resident #331 was admitted to the facility on [DATE] and did not receive narcotic pain medication until 06/02/2025 and should have. S13Medical Director reported Resident #331 would have been in significant pain related to her fracture. S13 Medical Director further reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotic. During a telephone interview on 06/04/2025 at 3:45 p.m., S19NP reported there had been a misunderstanding of Resident #331 being in the facility on 05/29/2025. S19NP reported on the morning of 05/29/2025 he was informed by staff of a new admit from the 05/28/2025 evening shift who had been sent out by EMS. S19NP reported he assumed Resident #331 had been admitted to the hospital and failed to clarify. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:15 a.m., S19NP confirmed Resident #331 was in the facility on 05/29/2025 when he rounded. S19NP acknowledged he failed to see Resident #331 and provide a hard script for Norco. During an interview on 06/05/2025 at 10:45 a.m., S3DON reported she was aware Resident #331 called EMS to get pain medicine and the issue was discussed in the morning meeting on 05/29/2025. S3DON reported S4ADON (Assistant Director of Nursing) was responsible for admit orders and ensuring medications are received and should have taken care of the issue regarding Resident #331's pain medication. S3DON reported she did not follow up and should have. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication by failing to obtain a hard copy script for Norco. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by lack of administrative oversight. Administrator did not ensure that the staff obtained hard script for ordered narcotic pain medication at the time of admission or for 4 days after for Resident #331. The DON did not ensure that nursing responded appropriately for Resident #331's complaints of pain and ensure medication was available. RN (Registered Nurse) QI (Quality Improvement) nurse implemented medication orders for controlled substance prescriptions policy and procedure on 06/05/2025. Administrator will attend the clinical morning meeting with the administrative nurses and DON twice weekly to ensure the 24 hour report was reviewed and pain addressed timely and neglect is not present. Corporate QI RN will in-service Administrator on 06/05/2025 on validating that 24 hour report was reviewed and pain addressed timely and neglect is not present. Corporate QI RN will in-service DON or nursing responsibilities and staff oversight regarding ordering of pain medication. Corporate QI RN will provide oversight that the Administrator has attended the clinical morning meeting and reviewed the morning clinical QA (Quality Assurance) meeting form which includes the 24 hour report review by the DON to ensure accuracy and any issues were followed up on timely and neglect is not present. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director, facility Administrator, Director of Nursing and Social Services Director to review the Plan of Removal. The Administrator will complete the clinical meeting audit tool (which will ensure the 24 hour report was reviewed by DON) weekly times 4 weeks and report findings to QAPI team along with any concerns identified in monitoring for this Plan of Removal monthly times 3 then as directed by QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.