**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00145186 Based on observation, interview, and record review the facility failed to follow professional standards of practice for nursing for 1 of 18 residents (R404) reviewed for significant medication errors resulting in R404 receiving another resident's medications including opioids, experienced respiratory failure, and sent to the hospital for life-sustaining treatment. Findings include: R404 According to the Minimum Data Set (MDS), dated [DATE], R404 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status). R7 According to the Minimum Data Set (MDS), dated [DATE], R7 scored 13 /15 (cognitively intact) on his BIMS (Brief Interview Mental Status). Review of R7's MAR/TAR dated 5/23/24 indicated at 8:00 AM, LPN WW indicated documented administration of: -Gabapentin 400 mg 1 capsule by mouth for neuropathy -methocarbamol 500 mg 2 tablets by mouth for muscle spasms/phantom pain -aspirin 81 mg by mouth for prophylaxis (preventative) -lotrel 5-20 mg 1 capsule by mouth for hypertension -Miralax17 grams by mouth for constipation -Apixaban (blood thinner) 5 mg 1 tablet by mouth for prophylaxis -hydromorphone HCL (dilaudid) 4 mg by mouth for chronic pain -levetiracetam 750 mg 2 tablets by mouth for seizure disorder -lidocaine External gel 4% topically for right shoulder pain Review of Licensed Practical Nurse (LPN) WW written statement by proxy of Nursing Home Administrator (NHA) A dated 5/23/24 at 1030 AM, indicated she had dispensed (prepped) and administered morning medications to R404 at approximately 7:30 AM. At approximately 7:45 AM LPN WW prepped R7's medications and handed the cup of medications to LPN XX and told him the room number. LPN WW stated she was unclear if she had given LPN XX the wrong room number or if he had heard her wrong but at approximately 8:35 AM R7 reported to her that he had not received his 8:00 AM medications. LPN WW informed R7 that he had received his medications, however, R7 continued to insist that he had not. LPN WW asked LPN XX if he had administered R7's to him and LPN XX stated, A bigger guy? LPN WW stated, No, that is not (R7). The medication error was reported to the former Unit Manager/Clinical Care Coordinator (UM/CCC) by both nurses, R404 had received R7's medications. Review of LPN XX written statement by proxy of NHA A dated 5/23/24 at approximately 11:45 AM, indicated he offered to run the medications for LPN WW. When LPN WW handed him the medications for R7 she told him These are for (R7's first name which was the same first name as R404) and when he asked for a room number. LPN XX stated when he entered the stated room, he spoke to a resident and asked if he was the man with the first name he was given. The resident responded to the name. LPN XX then informed R404 that he had his medications. During an interview on 7/11/24 at 3:35 PM, R404 stated, I was a resident at the facility in May (2024). I went to the room that was a lounge that morning, was given my medications by a lady, who said she was a nurse then I went back to my room. About 5 minutes later a man nurse came to my room and called out my first name. I said my first name. He did not ask me my last name. He said he had meds for me. I said I got my meds a short time ago by the lady nurse. He said the meds were mine. He said he had been a nurse for about 25 years and should know how to pass meds and that he knew they were my meds. He insisted he had my medications. I got tired of arguing with the nurse. He should have checked my ID. I still had the hospital bracelet on from the day before. I took the medications he insisted were mine. The next thing I knew I was in the hospital. I was told I was unresponsive. Review of LPN WW written statement by proxy of NHA A dated 5/23/24 at 2:27 PM, gave further clarification on the incident that happened earlier in the day involving R404 and other residents. LPN WW indicated she had prepped medications for three residents (R34, R353, and R49) with LPN XX administering them. LPN WW stated LPN XX had administered medications to the remainder of the residents on the 300 Hall. LPN WW stated all residents on the 400 Hall she had prepped medications and administered with LPN XX. During an interview on 7/10/24 at 3:38 PM, R7 stated, The facility overdosed the guy in the room across the hall from me a while back. The staff gave him my meds (medications). He was not my roommate. During an interview on 7/11/24 at 2:10 PM, LPN WW stated, I have been a nurse since 2002. I know the rights of medication (meds) administration. On May 23 rd (2024), I was passing meds with an agency nurse (LPN XX). We were working out of the same med cart. I gave (LPN XX) medications I had pulled to give to (R7) he gave the wrong person the wrong meds. Once (R7) came to the med cart and said he did not get his morning meds. (LPN XX) told me did not give the meds to (R7). I had been pulling meds that morning and (LPN XX) was giving them. I delegated the meds to (LPN XX). I knew I did wrong by pulling the medications and having the other LPN administer them. The meds were given by (LPN XX) around 8:30 AM. (R7) came to the med cart around 8:30 AM asking for his meds. I told him he already got them, and he argued with me. (LPN XX) said he gave the meds to a bigger guy (R404) and I told him that was not (R7). I gave (R404) his meds at 7:30 AM in the Garden Room. He was drowsy and laying across a bedside table. I had a hard time waking him, he took the meds, and went back to sleep. I left him there. He must have walked back to his room where (LPN XX) found him and gave him (R7's) meds. We went immediately to (Unit Manager (UM) VV) reporting the wrong meds had been given to the wrong person. I went back to passing meds at the same med cart. During an interview on 7/11/24 at 2:43 PM, LPN XX stated, I have been a nurse for 17 years. The first day I arrived, I was paired up (LPN WW) who was in her orientation process. We decided she would pull meds and I would pass them. (R404) was about the 4th resident we did this together. (LPN WW) would tell me the resident name and room number and I repeated it back to her and she would say yes. After the incident with (R404) we maybe did 5 more residents the same way. The Unit Manager told me to go sit with (R404) and do vital signs every 15 minutes. The second time VS were taken (R404) was slurring his speech and lethargic. The doctor came to the room, ordered Narcan, and it was administered. (R404) responded and then started to decline. A second Narcan was ordered and 911 was called. I do not know what the medications I gave him. I took the meds and went to what I thought was (R7's) room. (R404) responded when I went into the room. I did not pull the meds. I watched the MAR as (LPN WW) pulled meds and saw a first name but not a picture in the medical record. I watched the LPN pull a med out of the narcotic (controlled substance) drawer, but I did not look at what med it was or the name on the card. I do not know what meds were pulled. (R404) did not have on a wrist band, a name on the room door, or a picture in medical record. I know better than to administer medications the way I did. Review of R404's ED (Emergency Department) Provider Note dated 5/23/24, revealed, .Patient presented with unintentional medication overdose. Was given Dilaudid and Gabapentin. Was hypoxic (low level of oxygen in body tissues) and required Narcan (medication to treat narcotic overdose) in field. On arrival here, we did give him multiple doses of Narcan. Eventually started on Narcan drip. Was still sleepy. Noted to have hypercapnia (buildup of carbon dioxide in bloodstream). Did require hospitalization .Diagnosis: Acute hypercapnic respiratory failure . mistakenly given another patient's medication .At approximately 8:30 AM, he was given 4 mg of PO (by mouth) dilaudid and 800 mg Gabapentin that was intended for a different patient. Shortly thereafter he became unresponsive and desatted (blood oxygen levels dropped) to 70s Over the course of an hour (R404) became more somnolent (solemn state) and harder to arouse . gave him a total of 2 mg of Narcan .Toxicology was consulted in the emergency department. They recommended to start a Narcan drip Lab work was significant for a significant respiratory acidosis. The patient was evaluated by toxicology in the emergency department and recommended supportive measures and titratable Narcan in an effort to avoid intubation .Objective .in acute distress .cardiovascular rhythm irregular .Pulmonary .Tachypnea and accessory muscle usage present . Review of R404's Toxicology Consultation Note dated 5/23/24, revealed, Accidental narcotic ingestion .received total of 5 doses of Narcan and presently is on a Narcan drip .UA not known if the Narcan will be sufficient to return around his respiratory issues and he may require intubation . Review of facility policy, Medication Administration-General Guidelines dated 2/2019, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices .The Five Rights .Right Resident, Right Drug . are applied for each medication being administered. A triple check of these five Right Rights is recommended at three steps in the process of preparation of a medication for administration .B. Administration .5) The person who prepares the dose for administration is the person who administers the dose. 6) Residents are identified before medication is administered. Methods of identification include: a. checking a photograph attached to the medical record b. checking an identification band c. asking the resident to verify his/her name d. verifying resident identification with other facility personnel . 12. Medications supplied for one resident are never administered to another resident .the nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given .

This citation pertains to intake: MI00145580 Based on record review and interview, the facility failed to ensure residents recieved care in accordance with residents needs in 2 of 18 residents (Resident #27 and Resident #406) review for quality of care, resulting in Resident #27 not receiving appropriate assessment and treatment for a injury of unknown origin, and Resident #406 not attending follow up appts with surgeon following spinal fusion surgery. Findings include: Resident #27: Review of an admission Record revealed Resident #27 was a male with pertinent diagnoses which included dementia, abnormal posture (added 5/25/24), pain in right hip (added 6/25/24), pain in right knee (added 6/18/24), stroke, polyneuropathy (damage/disease affecting peripheral nerves on both sides of the body featuring weakness, numbness, and burning pain), dysphagia (damage to the brain responsible for production and comprehension of speech), dorsalgia (back pain), muscle weakness, unsteadiness on feet, lack of coordination, paralysis, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language) and fracture of right hip. Review of current Care Plan for Resident #27, revised on 3/9/23, revealed the focus, .I am at an increased risk for falls r/t (related to) orthostatic hypotension, muscle weakness, polyneuropathy, open area to left foot . with the intervention .Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance .Enable bar on right side of bed .Ensure that I am wearing non-skid footwear .I need a specialty wheelchair: Regr with pummel cushion and right-side lateral support, and left side arm rest to help reduce my risk for falls. A Device Assessment will be documented per policy to ensure proper use of such equipment (5/21/24) .PT/OT wheelchair /room evaluation .Reduce my risk for falling by cleaning up spills or clutter from my floor, provide glare-free lighting, accessible working call light, bed set at height deemed appropriate by PT/OT/Nurse (as applicable), my personal items within reach .Review information on past falls and attempt to determine cause of falls. Record possible root cause(s) and remove any potential causes as applicable .Staff to check and change resident and offer assistance to use toilet if awake .Fall Interventions: Offer to assist resident to get up in wheelchair for all meals. Bed against wall, enabler bar and fall mat to left side of bed (6/5/24) . Review of Nursing Progress Note dated 5/11/2024 at 7:00 PM, revealed, .Event occurred on 05/11/2024 at 6:50 PM. Resident fell out of wheelchair trying to propel self out of room into the hallway . Review of Nursing Progress Note dated 5/11/2024 at 11:19 PM, revealed, .Resident returned from (Local Hospital) ER department via stretcher by (Transport services). Head CT negative. Left eyebrow laceration glued together and covered with a bandaide. No new orders written, monitor laceration site for s/sx of infection . Review of Practitioner Progress Note dated 5/14/24 at 10:29 AM, revealed, .Pt is 67 y/o male with PMH significant for dementia, hx of CVA, anxiety, depression, HTN, HLD, hx of substance abuse and hemiparesis of L side. Pt is seen today by provider to follow up post ED visit for fall over the weekend. Nursing reports that patient fell out of his wheelchair trying to propel himself down the hallway. He did end up hitting his head and was evaluated in the ED. Pt did sustain a laceration to his left eye brow without need for sutures and head CT was negative for acute changes. Pt reports that he is feeling scared after the fall. He denies any pain or injuries as a result of the fall. I fell out of my wheelchair. He denies headache, neck pain, vision changes, or pain anywhere else. He continues to express that he feels scared as a result of the fall . Review of Nursing: Antigravity Team Note dated 5/15/2024 at 1:24 PM, revealed, .Root Cause(s) of Fall: IDT met and discussed residents most recent fall. Per resident's medical record the resident experienced a fall in the doorway of his room going into the hallway. Resident was unable to express what had happened however interview of staff notes that the resident will frequently use items in his environment to assist with propelling his w/c and it is felt that the resident had used the doorframe of his bedroom in an attempt to pull himself into the hallway ultimately pulling himself out of his w/c. Resident had on proper footwear, the call-light had not been activated due to the resident being in the doorway and the call-light being located on the bed. Assessment of the resident's w/c notes a standard w/c with a standard cushion. Review of resident's diagnoses note a diagnosis of embolic stroke with residual left sided weakness .New Interventions: - seating and positioning eval with noted addition of pummel cushion, right-side lateral support, left side arm rest . Review of Secure Conversation dated 6/14/24, revealed, .HI (first name of NP), resident has been complaining of pain on his right leg. No swelling or injury . Response: .Okay, thank you, please utilize prn (as needed) pain medicine. This is chronic . Review of Medication Administration Note dated 6/18/24 at 08:27 AM, .Give 2 tablets by mouth every 6 hours as needed for PRN (as needed) for pain .Resident requested for Right leg pain . Review of Medication Administration Note dated 6/18/24 at 12:53 PM, .Give 2 tablets by mouth every 6 hours as needed for PRN (as needed) for pain .PRN Administration was Ineffective . Review of Nursing Progress Note dated 6/18/24 at 9:10 PM, revealed, .Resident was slapping his right leg with his hand and yelling out throughout the morning. This nurse spoke with NP (nurse practitioner) in building and requested Right knee x-ray d/t (due to) resident nodding his head to feeling new and sharp pain in right thigh. X-ray resulted with -FINDINGS: Multiple views of the right knee show normal alignment without acute fractures or dislocations .Med staff notified of results and order Voltaren gel to Right knee TID (three times a day) for pain management. This nurse requested something different d/t (due to) resident rubbing leg constantly and being observed rubbing his face throughout the day. Med staff wished to continue with order. Resident declined lunch and dinner. Resident also declined any pain meds d/t him stating, they make me sleepy. This nurse spoke with med staff regarding his most recent return from hospital with no order for his Lyrica that he has been on in the past. Resident allowed this nurse to administer PRN Tylenol this morning with difficulty, with minimal effect. Resident allowed this nurse to apply Lidocaine patches to knee and thigh area of Right leg. This nurse assessed resident after dinner d/t CNA stating resident declined to eat dinner as well. Resident was observed Diaphoretic (sweating heavily), clammy, VS (vital signs) obtained with temp via forehead of 102.6, BP 161/84 P 108 O2 97% RA. Resident was able to be calmed down with reassurance by med staff. This nurse called on call med staff .spoke with her regarding the above and encouraged Voltaren gel be applied and then light weight pants so resident wouldn't touch his leg then his eye/face area. This nurse stated that resident is observed to be in pain r/t facial grimacing and moaning when med staff attempted to reposition him. Med staff ordered UA with C&S, Motrin and encourage ice packs as he allows. This nurse passed on the above to the oncoming nurse. Med staff stated, if he has any change in LOC (level of consciousness), increased pain or becomes non-verbal to call again and speak with on call . In an interview on 07/10/24 at 11:06 AM, Registered Nurse (RN) EE reported Resident #27 had a fall with a fracture of his right hip. Review of Incident Summary dated 6/25/24 at 5:20 PM, revealed, .NHA (Nursing Home Administrator) was notified at approximately 4:37pm that a resident has an intertrochanteric fracture (the area of the body where the hip and thigh meet) of unknown origin in his right hip. Resident was having complaints of pain, an x-ray was ordered, and a fracture was identified. Resident being sent out for further evaluation . Review of interview conducted by facility, revealed, .Spoke to (LPN TT) on 7/1/24 at approximately 1530. Per (LPN TT) she had been working with (CNA N) CENA on Tuesday 6/18/24 and (CNA N) reported that resident (Resident #27) had begun to complain of increased pain around the Thursday/Friday timeframe the week before and that he was experiencing even more pain today (6/18/24). Per (LPN TT), (CNA N) spoke to (NP YY) NP about this resident and (NP YY) assessed and ordered a knee x-ray and other pain interventions. When (LPN TT) was asked if the resident had had any abnormal occurrences or behaviors prior to this day (LPN TT) stated that she did not recall any but she did note that he began smacking his leg more and verbally complaining of increased pain on 6/18/24 . In an interview on 07/16/24 at 09:42 AM, Licensed Practical Nurse (LPN) TT reported Resident #27 had increased pain the last 4-5 days prior to 6/18/24, I went in there and he was hitting his leg. When she asked him about his pain, he indicated his leg hurt from his knee to his hip. LPN TT reported she reported the increase in pain to the nurse practitioner and the CNA reported to her as well. LPN TT reported she felt bad as he had a fractured hip and pain for a week and half at least and the staff were performing cares on him, turning him and attempting to get him up while he had a fractured hip. LPN TT reported he was getting aggressive with his behaviors with staff due to his increased pain. In an interview on 07/12/24 at 10:59 AM, CNA N reported she noticed his pain was more than his normal and reported to the nurse and reported it to the nurse practitioner too that from his knee to his hip was hurting him. CNA N reported she worked with the resident frequently and was familiar with him and she reported she could tell without asking him that he had increased pain by his response to the cares. CNA N reported she wanted him to be comfortable and his pain was not under control. CNA N reported now he had scheduled pain medications and the pain seem to be under better control. CNA N reported they just started the scheduled pain medications on Wednesday (7/10/24). Review of interview conducted by facility, revealed, .Spoke to (CNA N) on 6/28/24 at approximately 1430. Per (CNA N), (Resident #27) has a history of hitting his leg so this behavior was not abnormal for him however a couple of days before the x-ray was taken she had reported to the nurse that touching the residents leg resulted in him expressing a lot of pain. The following day (CNA N) reports that the resident continued to express the same thing however on this day the resident was insistent that he wanted to get up in his chair and they utilized the sit-to-stand to assist with the transfer and this was completed without concern. Per (CNA N), when she returned to work on Tuesday the resident was noted to be grinding his teeth and his facial expressions appeared as if the resident was experiencing increased pain. (CNA N) stated that she notified the NP, (NP YY), of her concern however the resident would not talk to her so (CNA N) asked the resident questions in the presence of (NP YY). (CNA N) asked the resident if his hip hurt and the resident nodded yes, she then asked if his knee hurt and he nodded yes and per (CNA N) she verified with (Resident #27) that he hurt from his hip to his knee and he nodded yes. Further interview of (CNA N) asking if there were any abnormal behaviors or occurrences since resident had returned from the hospital on 6/5/24 resulted in (CNA N) reporting that she had noted that the residents right foot kept dropping off the foot pedal which is new for this resident . Review of Practitioner Progress Notes dated 6/18/24 at 12:39 PM, revealed, .Pt is seen today by provider at the request of nursing. Nursing reports acute on chronic right knee and hip pain. Nursing reports chronic pain to his right thigh with worsening over the last day or so .Upon assessment, pt states that he is having right knee pain. He describes the right knee pain as new and sharp. He reports pain with palpation and movement. He denies recent injury, fall or hearing a popping noise recently. Nursing and nursing aide denies event of injury occurring . In an interview on 07/17/24 at 08:22 AM, Nurse Practitioner (NP) YY reported when she examined Resident #27 she did not perform palpation or assessment of the right hip area as he was seated in his broda chair. NP YY reported she had only performed range of motion on his right knee. When queried if the NP had staff lie the resident down in his bed for a more thorough examination she reported she did not have staff lie him down. NP YY reported she prescribed a lidocaine patch as well as re-prescribed Lyrica for Resident #25. Note: the medication was discontinued at the hospital and not re-prescribed when he returned from the hospital on 6/5/24. Review of interview during investigation revealed, .Spoke to (RN EE) RN on 7/1/24 at approximately 1715 (5:15 PM) via phone .Per (RN EE) she can only recall that staff have been reporting that the resident is noting to be more resistant to turning and that he is grabbing at their arms, being belligerent and agitated when care is being provided and that this started a couple of weeks ago. Resident has been more receptive to taking his medication when (RN EE) notifies him that his pain medications are in with the other medications, and this has been a change in the residents behaviors over the last 2 weeks as well . Review of Nursing Progress Note dated 6/23/24 at 10:15 AM, revealed, .This nurse was notified in shift-to-shift nurse report @0920 a.m. that resident's right knee is very red, warm to the touch and swollen. This writer called the on-call provider number and spoke with (Nurse Practitioner name) NP. Reviewed residents' history and recent right knee xray results as negative. New order received and noted for a uric acid level to be drawn in the a.m. tomorrow, 6/24/24, and administer prn Ibuprofen . Review of eMar - Medication Administration Note dated 6/23/24 at 10:15 AM, revealed, .Behaviors noted r/t (related to) pain . Review of Practitioner Progress Note dated 6/24/24 at 12:48 PM, revealed, .Chief complaint: R knee pain duration unknown .HPI: Pt says his right knee has been painful for 6 months. Worse with movement. Staff reported knee is red, warm and swollen. No fever. No hx gout. Uric acid level was drawn.Review of Systems: was not completed Poor historian .Musculoskeletal: Poor Strength, keep R knee flexed. Tender to palpation. no effusion. not red or warm. He wouldn't let me straighten the knee. no edema or calf tenderness .Diagnosis: M25. 561 - Pain in right knee: I don't see deformity or effusion. Cont. Ibuprofen and voltaren gel and observe for now. consider xray and CBC/WSR. Uric acid pending (ordered by on call provider) . Review of Practitioner Progress Notes dated 6/25/24 at 12:04 PM, revealed, .Chief complaint: Ongoing pain .HPI: Pt is 67 y/o male with PMH significant for dementia, hx of CVA, anxiety, depression, HTN, HLD, hx of substance abuse and hemiparesis of L side. Pt is seen today by provider to f/u to right knee and right hip pain. Uric acid ordered by on call provider resulted as normal at 4. 3. Nursing states that pain continues but ibuprofen does help his pain. Time spent reviewing with IDT. Pt is awaiting sign on to hospice, family is working on ppwk for this transition of care. Right knee xray revealed mild osteo arthritis. Suspect arthritis of right hip as well .Musculoskeletal: Poor Strength, No gross deformities, pain with palpation of right hip .M25. 561 - Pain in right knee: -continue prn ibuprofen and Voltaren gel .New diagnoses: M25. 551 - Pain in right hip .Plan: -suspect osteoarthritis of R hip, obtain xray of hip to r/o fx or dislocation. Low suspicion -continue prn ibuprofen -Add voltaren gel to right hip . Review of Nursing Progress Note dated 6/25/24 at 4:45 PM, revealed, .Resident had been experiencing pain since 6/14/24. Multiple assessments and diagnostic testing completed and 6/25/24 order for right x-ray ordered and noted to be positive .Immediate intervention implemented: Res transfer status changed to total lift, family requested to hospice . Review of Practitioner Progress Note dated 6/26/24 at 11:49 AM, revealed, Pt is seen today by provider to f/u (follow up) to positive hips xray. Pt has been experiencing increased pain to right leg, hip xray completed on 6/25/24 resulting as positive for fx (fracture) .He does endorse pain to right hip .Procedure: Hip RT (right) 2v (views): Findings: Intertrochanteric fracture is demonstrated on the right. Some displacement is seen. No dislocation is noted .Impression: Mildly displaced intertrochanteric fracture on the right .Plan: pt not a surgical candidate, goal to optimize pain and comfort . In an interview on 07/16/24 at 11:08 AM, CNA FFF reported she went to help another CNA with Resident #25. CNA FFF reported the other CNA informed her to be careful as he was in a lot of pain and to go easy on him when they turn him and move him. CNA FFF reported Resident #25 told CNA GGG he was still in pain, and to tell the nurse he had to go to the hospital as the pain was unbearable. CNA FFF reported she believed CNA GGG reported the pain and Resident #25's request to go the hospital but she was not sure what happened after as she was on the other hallway. This writer attempted to contact CNA GGG but was unable to reach them. Review of interview conducted by facility, revealed, .Per (CNA GGG) she could recall working with (CNA FFF) and providing care for (Resident #27) and he was grabbing at her arm and expressing increased pain with movement. (CNA GGG) believed that this increase in behavior and verbalization of pain had occurred around the June 20th timeframe. Per (CNA GGG) when she had asked the resident to rate his pain from 1-10 he stated it was a 20 and he was expressing that he was wanting to go to the hospital. (CNA GGG) stated that it was at this time that she noted that the residents hip was kind of swollen and she reported this to (RN AA), the nurse with the long dark hair. (CNA GGG) stated that she could recall (RN AA) stating that she was aware and working on getting an x-ray . Review of the provided schedule for 6/20/24 revealed, CNA GGG, CNA FFF, and RN AA worked that day. In an interview 07/17/24 at 10:14 AM, UM W reported LPN TT was walking up the hallway and she appeared upset, she was upset the provider did not want to do an xray on Resident #27's upper leg/hip as she did not feel it was clinically necessary. UM W reported she went to speak to the provider and NP YY reported to her she felt there was nothing to clinically support that she had examined him and did not see anything that would warrant further unnecessary testing. UM W reported the NP indicated him slapping his leg was not unusual for him. UM W reported when she went to examine Resident #27, who was in bed at this time, she attempted to straighten his leg a little bit and he said No and started slapping his leg. UM W reported she had maybe lifted it a couple of inches. UM W reported she did not observe the NP perform her examination on Resident #27. In an interview on 07/17/24 at 10:20 AM, Unit Manager (UM) W reported pain assessments were completed on every shift in the medication administration record (MAR). UM W reviewed the documented pain levels in mid-June 2024 for Resident #27's and his pain levels were documented in the range of 4-5 on a scale from 0-10 with 10 being the worst. UM W reported when she went to assess Resident #27 originally, she was barely able to lift his right leg up 2 inches and Resident #25 yelled No and appeared to be in extreme pain. UM W reported with the expression of his pain she observed the documentation of a range of 4-5 appeared to not be correct unless he was not moved at all when assessed and he had had pain medication administered. Resident #406: Review of an admission Record revealed Resident #406 was a female with pertinent diagnoses which included spinal stenosis (space inside the bones of the spine get too small), wedge compression fracture of fifth lumbar vertebra (spinal compression fracture that occurs when the front of a vertebra collapses, but the back does not), wedge compression fracture of first lumbar vertebra, fusion of spine (surgical procedure that permanently joins two or more vertebra together so there is no movement between them), muscle weakness, difficulty in walking, unsteadiness on feet, and lack of coordination. Review of Care Conference Summary dated 5/28/2024 at 2:59 PM, revealed, .Summary of Discussion: Initial care conference held to discuss admission, goals, and discharge planning. Resident admits into subacute rehabilitation post hospitalization at (Local Hospital) r/t spinal stenosis (L4-5) and compression fracture of L5. Resident is s/p orthopedic surgery and TOC states to follow up with OAM in 2 weeks . In an interview on 07/17/24 at 10:00 AM, Health Information Coordinator (HIC) M reported urogynecologist indicated they do not need to see Resident #406 with no explanation to this writer. HIC M was queried whether Resident #406 was scheduled to see a gastroenterologist and HIC M reported she was unsure and she would need to take a look and reported she was not scheduled to see the gastroenterologist. When queried whether Resident #406 was scheduled to see the spinal surgeon, HIC M reported she had contacted them on Monday (July 15, 2024) and today but had not returned a phone call back to her. When queried when the resident returned from the hospital, it was reported she returned on 7/2/24 and had been back in facility for approximately 2 weeks. When queried if it was HIC Ms responsibility to follow up on scheduling appointments for residents, she stated, Sure. When queried if Resident #406 had seen the spinal surgeon since her admission, HIC M reported she would have to refer to her notes and when she looked she did not have a note in reference to the appointment. When asked if she had scheduled an appointment for Resident #406 to see the spinal surgeon on 6/8/24 per the discharge instructions from the hospital she reported she did not schedule the appointment. In an interview on 07/17/24 at 12:01 PM, Therapy Director (TD) PP reported there was no order for changes to the spinal precautions and the staff should be following the precautions until otherwise changed by the spinal surgeon. The spinal surgeon would be the provider who would discontinue the precautions for Resident #406. In an interview on 07/17/24 at 12:17 PM, Director of Nursing (DON) B reported the HIC M would be the staff member to follow up and initiate the scheduling of appointments with the spinal surgeon and other discharge appointments.