**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital documentation review, review of a facility investigation, review of video footage, policy review and interviews, the facility failed to timely and comprehensively assess, notify a physician, and provide timely and necessary care and services to Resident #22 after she complained of hip pain as a result of a dislocated right hip. This resulted in Immediate Jeopardy and Actual Harm beginning on 07/21/25 at 1:10 A.M. when Resident #22 voiced complaints of pain and staff continued to provide personal care, assisting the resident into her bathroom and transferred the resident to bed without first assessing the resident. Licensed Practical Nurse (LPN) #113 administered a dose of as needed narcotic pain medication but failed to comprehensively assess the resident related to the pain. On 07/21/25 at 2:01 A.M. review of video footage revealed staff entered Resident #22's room to attempt to place a hip abductor wedge at which time the resident yelled out in pain upon movement of her leg. Staff exited the room and per video footage they did not return until 5:05 A.M. Video footage revealed Resident #22 was yelling out and at 5:11 A.M., Certified Nursing Assistant (CNA) #168 removed blankets from Resident #22, who had a visibly severe internal rotation to her leg, and began to undress the resident as the resident was screaming in pain. CNA #168 did not stop undressing Resident #22 and proceeded to re-dress her as Resident #22 was observed on video screaming in pain. At 5:18 A.M., CNA #169 and LPN #113 entered Resident #22's room and assisted CNA #168 to stand-pivot Resident #22 to her wheelchair as the resident was screaming. Resident #22 remained out of her room in the wheelchair until 10:56 A.M., when CNA #145, Physical Therapist (PT) #260, and Certified Occupational Therapy Assistant (COTA) #250 transferred Resident #22 from her wheelchair into her bed using a gait belt and attempted a stand/pivot transfer. Resident #22 was briefly seated at the edge of bed while crying out. An x-ray was subsequently ordered. On 07/21/25 at 1:51 P.M. Radiology Technician (RT) #400 expressed concern about the image captured (noting the dislocation of the resident's hip). Emergency Medical Transportation (EMT) was called and arrived at 2:58 P.M. Resident #22 left the facility at 3:16 P.M. to be taken to the hospital where she was diagnosed with a dislocated right hip requiring surgical intervention. This affected one resident (#22) of four residents reviewed for falls. The facility census was 86. On 08/19/25 at 3:03 P.M., the Administrator, Director of Nursing (DON) #141 and #185, Regional Clinician (RC) #300 were notified Immediate Jeopardy began on 07/21/25 at 1:10 A.M. when Resident #22 voiced complaints of hip pain that was not comprehensively or adequately assessed and treated. Between 1:10 A.M. and 10:56 A.M. Resident #22 continued to complain of severe pain to the hip area captured on video footage of the resident screaming and crying out due to the pain while staff proceeded to manipulate/move the leg providing routine care. An x-ray was not obtained until 1:51 P.M. which confirmed the hip dislocation. The resident was not transferred to the hospital until 07/21/25 at 3:16 P.M. The Immediate Jeopardy was removed on 07/21/25 and the deficiency subsequently corrected on 07/26/25 when the facility implemented the following corrective actions. On 07/21/25 at 2:40 P.M., preliminary results of Resident #22's x-ray were reported to Physician #230 by Registered Nurse (RN) #127. Physician #230 ordered Resident #22 to be transferred to the hospital for evaluation and treatment. Physician #225 was updated by RN # 127. The resident was transferred to the hospital on [DATE] at 3:16 P.M. and did not return to the facility following the hospitalization. On 07/21/25 at 2:40 P.M. Resident #22's family/responsible party was notified by RN #127. On 07/22/25 at 4:00 P.M. CNA #168 was immediately re-educated by the Administrator and DON #141 regarding performing activity of daily living (ADL) care to residents with increased pain or signs of distress ensuring stopping ADL care and notifying nursing staff with s/s of pain, distress or changes in functioning. On 07/22/25 at 4:30 P.M. (via phone) LPN #113 was immediately re-educated by the Administrator and DON #141 regarding conducting timely and thorough assessments with change in condition and notification to physician. On 07/22/25 at 6:00 P.M. (via phone) CNA #169 was immediately re-educated by the Administrator and DON #141 regarding performing ADL care to residents with increased pain or signs of distress ensuring stopping ADL care and notifying nursing staff with s/s of pain, distress or changes in functioning. On 07/22/25 at 10:00 P.M. a skin sweep was completed by DON #185 and facility wound nurse for possible injuries and changes in condition for current residents unable to be interviewed and all other current residents were interviewed for potential changes in condition warranting interventions. 82 residents were assessed. On 07/22/25 the facility Change in Condition Policy was reviewed by the Administrator, DON #185, and DON #141. No changes were made to the policy. By 7/25/25, 18 RN's, 13 LPN's and 40 CNAs were re-educated by the DON and Administrator on ensuring proper identification and assessment (e.g. vital signs, ROM, visual alignment and or deformity, palpation of joint/area and verbal interview, etc.) of residents with any changes in condition following injuries, complaints of severe pain, or suspected fractures/dislocations; on ensuring notification to physician of findings and prompt notification to responsible party; and on following the proper chain of command if a nurse fails to respond promptly, staff will escalate notifications to the DON/Administrator. On 07/22/25, the Administrator, DON#185, and DON #141 reviewed the Pain Management Policy. No changes were made to the policy. By 7/25/25, 18 RN's, 13 LPN's and 40 CNAs were re-educated by DON #141, DON #225 and the Administrator on ensuring nursing staff were assessing pain as needed and assessing for possible causes; on providing non-pharmacological pain remedies and pain medications and monitoring for effectiveness; and on ensuring new complaints or worsening complaints of pain are reported to physician and updating family. On 07/23/25 at 1:00 P.M. DON #141 reviewed current residents with an orthopedic surgical intervention or injury within last 14 days who were at risk for complications, ensuring orders were in place for assessing area every shift for two weeks or as directed by the physician. One (1) resident was identified, and an order was put in place for monitoring on 07/23/25 to monitor right hip/femur surgical site for signs and symptoms (s/s) of infection, proper alignment, or s/s of displacement and notify physician with any abnormalities. On 07/24/25 at 2:00 P.M. an Ad hoc quality assurance (QA) committee meeting was held to review investigation and findings of initial audits, as well as, the ongoing audit plan and education action plan. Meeting consisted of Administrator, DON # 185, DON # 141, RN # 204, RN # 170, HR # 153 and Physician #153. By 07/25/25, 18 RNs, 13 LPNs and 40 CNAs were re-educated by DON #141, DON # 185, and the Administrator on ensuring direct care staff stop ADL care and notify nursing staff when a resident was showing signs of discomfort, distress or increased pain (e.g., yelling out, crying, grimacing guarding, restlessness, decreased ROM or functioning etc.); ensuring nursing staff perform an assessment to identify cause of pain (e.g., vital signs, ROM, interview, palpation of site, and visualize location of pain identified ) before proceeding with care; and ensuring notification of the physician and the responsible parties as indicated. By 0/25/25, 18 RNs, 13 LPNs and 40 CNAs were re-educated by DON #141, DON # 185, and the Administrator on expectations for monitoring new surgical sites. This re-education included that nursing would assess for signs/symptoms of dislocation, increased pain, deformity, and/or misalignment and notify the physician of relative abnormalities; and that a resident with suspected fracture/dislocation must be assessed immediately by a nurse and physician notified without delay. Beginning on 07/26/25, five (5) residents were reviewed weekly for two (2) weeks by DON #141 and or LPN #132, on ensuring proper identification and assessment (e.g. vital signs, ROM, verbal interview, etc.) of residents with any changes in condition following injuries, complaints of severe pain, or suspected fractures/dislocations; on ensuring notification to physician of findings and prompt notification to responsible party; and on following the proper chain of command if a nurse failed to respond promptly. No irregularities were noted and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with monthly random interviews, ongoing, until further direction from the committee and ongoing education for new hires of facility policy on change in condition and proper identification and assessment of the change in condition. Beginning on 07/26/25, five (5) residents were interviewed weekly for two (2) weeks by DON # 141 and or LPN # 132, to ensure pain is being controlled and interventions are in place to manage pain levels. No irregularities were noted and the results were reported to the QA committee for review and recommendations on 08/13/25. QA committee recommended to continue with ongoing education to new hires ensuring understanding of facility policy for pain management and intervening with signs of increased pain, and to continue monthly random interviews, until further direction from the committee. Beginning on 07/26/25, three (3) CNAs were interviewed weekly for two (2) weeks by DON #141 and or LPN #132 to ensure verbal understanding of stopping ADL care and notify nursing staff when resident is showing signs of discomfort, distress or increased pain (e.g., yelling out, crying, guarding, etc.). No irregularities were noted and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with ongoing education with new hires on ensuring understanding of stopping ADL care and notifying nursing staff with s/s of pain, and continuing ongoing monthly interviews, until further direction from the committee. Beginning on 07/26/25, audits were conducted weekly for two (2) weeks by DON #141 and or DON # 185, on process for assessing new orthopedic surgical procedures ensuring order to monitor site q shift is in place and that the nurse assessed for s/s of dislocation, increased pain, deformity, and or misalignment and that relative abnormalities were reported to the physician. No irregularities were noted, and the results were reported to the QA committee for review and recommendations on 8/13/25. QA committee recommended to continue with ongoing education of new nursing hires ensuring understanding for new facility process for assessing new orthopedic surgical procedures and continuing monthly audits, until further direction from the committee. DON #185 was identified as being responsible for implementation and monitoring of this plan. Nurse Managers RN # 204 and LPN #132 were responsible to ensure staff adherence on their units. Findings include:Closed record review revealed Resident #22 originally was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses including unspecified intracapsular fracture of right femur, muscle wasting and atrophy, and need for assistance with personal care. Review of a care plan dated 05/07/25 revealed Resident #22 was at risk for alteration in comfort related to disease process, generalized pain, impaired mobility, diagnosis of osteoarthritis, low back pain, and fracture with surgical intervention. The goal was to decrease Resident #22's pain to an acceptable level for the resident which would allow for participate in activities of daily living (ADLs), activities, therapy, treatment, and etcetera. Interventions included administer medications as ordered, maintain proper body alignment, monitor for effectiveness of interventions, notify physician for review or for change in pain medications if needed, pain assessment per facility policy, and therapy referral as needed. Review of an order by Medical Director/Physician (MD) #225 dated 06/06/25 revealed Resident #22 was on hip precautions each shift. Review of an order by MD #225 dated 06/11/25 revealed Resident #22 was to have an abductor pillow between legs which could be removed for care and transfers. Skin integrity to be checked each shift and physician to be notified of any decline every shift for hip precautions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had impaired cognition, no behaviors, was dependent on staff for transfers, and had occasional pain of five. Review of an order by MD #225 dated 06/30/25 revealed Resident #22 was to receive cyclobenzaprine oral tablet give milligrams (mg) one tablet by mouth every 12 hours as needed (PRN) for muscle spasms. The resident also had an order on this date for tramadol 50 mg one tablet by mouth every 12 hours as needed (PRN) for pain level of four to six (on a scale of one to 10). Review of an occupational therapy note dated 07/18/25 at 1:35 P.M. by Certified Occupational Therapy Assistant (COTA) #250 revealed Resident #22 completed dynamic stand balance activities with reaching and bending forward while engaging core, maintaining forward flexion attention to task and safety cues with fair balance until resident became fatigued. Functional sit to stand with hand placement upright posture completed with an engaged core, maintained balance with minimum assist and multimodal cues to perform the task. Resident #22 tolerated well and required minimum assistance to perform. Resident #22 was able to stand and pivot to and from the toilet utilizing a walker with minimum assistance and multimodal cues to complete the task. Review of a physical therapy note dated 07/18/25 at 2:22 P.M. by Physical Therapy Assistant (PTA) #240 revealed Resident #22 performed sit to stand transfers with verbal and tactile cues given on hand placement, done for seven reps to increase in bilateral lower extremity strength and activity tolerance, done with minimum assistance for safety, pivot transfers with minimum assistance with cues given on walker placement with understanding demonstrated, ambulation done for 35 feet two times to increase mobility and activity tolerance, and postural cues given to keep center of gravity over base of support with understanding demonstrated. Once fatigued, posterior lean noted. Review of a nursing note dated 07/21/25 at 12:25 A.M. by LPN #113 revealed Resident #22 had no cognitive impairment, a skin assessment was completed with no changes noted, and observation of neuro musculoskeletal status was completed with no new changes. Review of video footage provided by Resident #22's family revealed the following on 07/21/25:- 1:10 A.M. to 1:12 A.M.: Resident #22 was brought into her room in a standard wheelchair by CNA #168 and CNA #169. Resident #22 began to cry in pain and staff asked where it hurt at. CNAs #168 and #169 then took Resident #22 into the bathroom and LPN #113 entered to assist. (There was no evidence Resident #22 was assessed in regard to her complaints of pain). - 1:18 A.M. to 1:23 A.M.: Resident #22 was taken out of her bathroom while still in a standard wheelchair by CNA #168 and CNA #169. LPN #113 entered the room again and CNA #169 stated, she keeps saying it hurts. LPN #113 went to speak with Resident #22 who requested as needed pain medication. LPN #113 exited the room to retrieve the medication. CNAs #168 and #169 stand/pivot assisted Resident #22 into bed while she was observed whimpering in pain. CNA #168 attempted to place a hip abductor wedge between Resident #22's legs and she began to cry out in pain. CNAs #168 and #169 asked Resident #22 where she was hurting but Resident #22 provided no clear answer. Resident #22 was in bed with a pillow propping her up in a seated position with her legs out in front of her; her left leg was bent at the knee with her foot flat on the bed and her right leg was flat on the bed with an inward rotation. Resident #22 repeatedly stated, Oh it hurts. LPN #113 entered the room to administer medication. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 1:25 A.M.: LPN #113 had administered medication and was talking to Resident #22 while CNAs #168 and #169 were still present in the room. LPN #113 attempted to have Resident #22 describe where the pain was located by instructing her to place her hand where she was hurting. Resident #22 was noted to be grabbing the back of her right leg. CNA #168 approached the bed to place covers over Resident #22 as resident was repeatedly stating, don't. CNA #168 reassured Resident #22 they weren't going to touch her and she could go to sleep. CNA #168 adjusted the bed position and Resident #22 cried stating, Oh it's burning. CNA #168 stated Resident #22 had been grabbing her hip but hadn't really been paying attention to how the hip looked. CNA #168 could be heard stating, I wanted to check that hip but she started whining that it was hurting. Resident #22 was trying to go to sleep so staff exited the room and turned off the lights. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 2:00 A.M.: CNA #168 entered the room and attempted to place a hip abductor wedge between Resident #22's legs after asking if she felt better. When CNA #168 went to separate the resident's left leg from her right, Resident #22 stated, Oh, no, no, no. CNA #168 covered Resident #22 back up and left the room. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). - 5:05 A.M.: CNA #169 was observed on video footage standing next to Resident #22's bed, Resident #22's blanket was slightly removed from her right side. Resident #22 stated, go away, go away, go away now, I can't, I can't, no, no, no. CNA #169 left the room. - 5:11 A.M. to 5:13 A.M.: CNA #168 entered the room to change Resident #22. Resident #22 was still crying and stated something undecipherable. CNA #168 got Resident #22's clothing ready and began to lift the bed for care. Resident #22 stated, Oh my God, and CNA #168 replied, what? - 5:14 A.M. to 5:18 P.M.: CNA #168 removed bolsters from the right side of the bed. Resident #22 was visibly leaning away from the right side, grabbing her right hip and sobbing. Resident #22 had a pained facial expression, appeared to be in pain and was visibly crying. CNA #168 proceeded to remove the covers from Resident #22 revealing her left leg was bent at the knee and her right leg had a severe inward rotation, bent at the knee and tucked under the left leg. CNA #168 removed Resident #22's brief from her while the resident continued to cry in pain. Resident #22's right leg was still bent at the knee and tucked under her left leg to the point where her right knee was touching the bed. Resident #22 was laying on her back with a pillow tucked under her and leaning to the left slightly. CNA #168 grabbed Resident #22's knees and pulled them apart to try to separate her legs while Resident #22 screamed in pain. CNA #168 attempted to separate the resident's legs multiple times to apply a new brief, but Resident #22 kept pulling her legs back together while screaming out in pain, with her head thrown back and visibly in pain. CNA #168 proceeded with care and applied a new brief and pants as Resident #22 continued crying out. Once Resident #22's pants were up to the top of her legs below her buttocks, CNA #168 used a walkie talkie to request assistance to transfer Resident #22 from her bed into her wheelchair. CNA #168 attempted again to pull Resident #22's right leg from below her left leg to place her knees together for better alignment. Resident #22 screamed in pain. CNA #169 walked into the room while Resident #22 was still crying and stated, I told you she's complaining of pain in here, while gesturing to her own inner right thigh because that's where she was grabbing a minute ago. LPN #113 entered the room and CNA #169 asked Resident #22 multiple times where she was hurting, Resident #22 stated everywhere, and CNA #169 stated, where does your leg hurt at? (There was no evidence the LPN assessed the resident in regard to her continued complaints of pain). - 5:19 A.M. to 5:27 A.M.: Resident #22 was observed on video still lying in bed grabbing her right hip while CNAs #168 and #169 and LPN #113 stood in the room to prepare to transfer her from bed to her wheelchair. LPN #113 stated, do you think if I braced her hips and then we sat her up that would help? LPN #113 applied gloves than approached Resident #22 stating, (insert name), I'm going to grab right here, and we are going to sit you up. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain or prior to attempting to move her). - 5:28 A.M. to 5:34 A.M.: LPN 113 had a hold of Resident #22's hips while CNAs #168 and #169 worked on sitting her up in bed. Resident #22 immediately began screaming. Staff got the resident seated at the edge of the bed while the resident was screaming, then proceeded to stand her to finish pulling up her pants. Resident #22 was unable to bear weight so CNA #168 and LPN #113 lifted her off the ground while CNA #169 moved the wheelchair into place. While in the air, Resident #22's legs were turned in at abnormal angles. Once seated in wheelchair, Resident #22 stopped crying. CNA #168 took Resident #22's shirt off to help her finish getting ready and redressed her. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). Review of a Medication Administration Record (MAR) for July 2025 revealed Resident #22 received a dose of as needed tramadol 50 mg at 1:22 A.M. on 07/21/25 which was documented as effective. However, there was no evidence a comprehensive assessment of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor was completed related to the use of the as needed narcotic pain medication was completed at that time. Review of an Occupational Therapy note dated 07/21/25 at 10:44 A.M. by COTA #250 revealed nursing reported Resident #22 had complaints of right hip pain, therapy staff attempted to stand Resident #22 three times with resistance and complaints of hip pain with pulling hip up and holding up and they were unable to get her to stand completely upright. Resident #22 completed motor activities with strengthening tasks to improve ADLs and balance with bilateral upper extremity strengthening and core strengthening. CNA staff asked for help to lay Resident #22 down, transfer completed with max pain, Resident #22 laid in bed and nurse was aware of the pain. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain). Review of a nursing note dated 07/21/25 at 10:44 A.M. by RN #127 revealed Resident #22 was yelling out complaining of pain to right hip. Resident #22 was refusing to stand and having difficulties with transfers due to increased pain. Medical Director (MD) #225 was notified and new orders were received. Review of a video on 07/21/25 revealed from 10:56 A.M. to 11:01 A.M. CNA #145, PT #260 and COTA #250 were in Resident #22's room to transfer her from her wheelchair to the bed. Resident #22 can be heard repeatedly saying, oh my land. PT #260 and COTA #250 used a gait belt to stand/pivot transfer Resident #22 into bed, as the resident was crying out. Resident #22 was seated at the edge of bed and crying in pain. The staff moved the resident to a position laying down and CNA #145 attempted to place a pillow between Resident #22's legs which did cause her to cry in pain, however once she was no longer moving, was not crying out in pain. Resident #22 was saying oh my goodness. Review of physician orders revealed an order dated 07/21/25 for Resident #22 to receive a right hip x-ray with two views stat for right hip pain, previous fracture. The x-ray was to be portable due to physical limitations. Review of a MAR for July 2025 revealed Resident #22 received a dose of as needed tramadol 50 mg at 11:00 A.M. on 07/21/25 which was documented to be effective. However, there was no evidence a comprehensive assessment of the resident's pain to include location, quality, intensity, onset, duration, aggravating/alleviating factor was completed related to the use of the as needed narcotic pain medication was completed at that time. Review of continued video footage from 07/21/25 between 11:03 A.M. and 11:04 A.M. revealed Resident #22 was resting in her bed repeatedly stating, I don't wanna die. Review of video dated 07/21/25 at 11:08 A.M. revealed RN #127 entered Resident #22's room and attempted to lay down the head of the resident's bed. Resident #22 stated, oh, no, no, no, don't do that. Resident #22 indicated she wanted the head of the bed back up and RN #127 placed the bed in a more comfortable position for Resident #22. (There was no evidence Resident #22 was assessed in regard to her continued complaints of pain at this time). Review of a physical therapy note dated 07/21/25 at 12:54 P.M. by Physical Therapy Assistant (PTA) #240 revealed Resident #22 completed sit to stand transfers with maximum assistance of two staff and moderate cueing for correct sequencing and attention to task. Resident #22 performed standing at walker with maximum assistance of one to two staff and maximum cueing up to one minute with poor balance with posterior and lateral loss of balance (LOB). Patient performed lower extremity exercises seated in a chair including marching, hip adduction, hip abduction, ankle pumps, heels raises, and glute sets 15 reps each with maximum cueing for correct sequencing and attention to task. Resident #22 complained of right hip pain and discomfort during session, reported to nursing, nursing stated Resident #22 had complained of pain since midnight and had gotten medication several times. (However, there was no evidence Resident #22 was actually assessed in regard to her continued complaints of pain). Review of video footage dated 07/21/25 from 1:51 P.M. to 1:56 P.M. revealed Radiology Technician (RT) #401 entered the resident's room to perform x-rays. RT #401 gently slid an x-ray plate under Resident #22 between her pelvis and the bed. Resident #22 was heard saying, they hurt like the dickens. Resident #22 was positioned on her back with a tilt to the left, her left leg was bent at the knee with her foot resting flat on the bed and her right leg was also bent at the knee, completely rotated inward and tucked under her left leg with her right knee touching the bed. RT #401 requested an aide to help reposition the bed once she took one x-ray, she stated she would not be moving the resident to get other views. RT #401 showed RN #127 the image of the first x-ray. CNA #145 was in the room with RT #401 and stated Resident #22 had not allowed them to put a pillow between her knees and RT #401 responded she wanted her right leg tucked under her left leg because it made it feel better. CNA #145 then stated, when I got here this morning, she was in her chair. RT #401 bewildered, responded, How? and CNA #145 stated, I have no idea. Review of a nursing note dated 07/21/25 at 2:40 P.M. by RN #127 revealed Orthopedic Surgeon (OS) #230's office was notified of Resident #22's severe pain and possible displacement of right hip. OS #230 recommended Resident #22 be transferred to the emergency department. MD #225 was notified and gave new orders to transfer Resident #22 to the emergency department for evaluation and treatment. Resident #22 and her family were made aware. Review of an order dated 07/21/25 revealed it was medically necessary to send Resident #22 to the emergency room. Review of a nursing note dated 07/21/25 at 2:55 P.M. by RN #127 revealed 911 had been called to transport Resident #22 to the emergency department. A follow-up note at 3:16 P.M. revealed Resident #22 had left the facility via stretcher enroute to the emergency department. Resident #22's family was made aware. Review of video footage dated 07/21/25 from 2:58 P.M. to 3:03 P.M. revealed EMTs arrived to take Resident #22 to the emergency department. RN #127 told the EMTs Resident #22 had been in severe pain all day. When Resident #22 was uncovered and her legs were visible, one EMT says a surprised, Oh! Once loaded on the cot, Resident #22 left the building. Review of an x-ray dated 07/21/25 at 4:28 P.M. revealed Resident #22 had a single view of the pelvis with legs crossed. The right hip arthroplasty was dislocated; the femoral head component was projecting six to seven centimeters superolateral to the acetabular component. Review of a nursing note dated 07/21/25 at 9:15 P.M. by RN #127 revealed Resident #22 was admitted to the hospital. Review of a Brief Operative Note dated 07/22/25 by OS #130 revealed Resident #22 had a right hip dislocation status post total hip arthroplasty and would require a closed reduction under anesthesia. The note included the closed reduction was completed with some difficulty. Interview on 08/14/25 at 12:05 P.M. with Resident #22's responsible party (RP) revealed she had concerns about the complete disregard of Resident #22's pain while the resident could be observed on video screaming and her leg was bent at an odd angle. RP brought footage from a camera located in Resident #22's room to show the incident. RP had a hard time listening to the footage and would not look at the camera (due to the pain the resident was in and demonstrated). RP stated her mother was screaming in pain and felt staff neglected her. RP stated she spoke with OS #230 who stated it would have taken a lot of effort to dislocate the hip. Interview on 08/15/25 at 12:44 P.M. with OS #230 revealed Resident #22 already had a broken hip with a partial, then full replacement. OS #230 stated he was not sure of the mechanism that would've caused the dislocation. OS #230 stated it was fairly hard to dislocate a hip because you had to really twist the leg around somehow to get it to come out. OS #230 stated Resident #22 does have dementia, so she could've had an unwitnessed event which was the cause of the dislocation (however, the exact circumstance of how the dislocation had occurred could not be determined). OS #230 stated people with dementia express their pain in different ways or sometimes can't at all, but it would be a painful injury for most people to have. Interview on 08/18/25 at 1:20 P.M. with RN #127 revealed she worked with Resident #22 often during the resident's stay in the facility. Resident #22's baseline was confused and did not have a lot of behaviors. RN #127 stated she recalled 07/21/25 and when she came in that morning, nightshift staff were reporting the resident had yelled out in pain all night and pain medication had been administered but did not seem to be effective. RN #127 stated she asked about the right hip and the nurse (LPN #113) had stated she thought it looked aligned to her, but it had taken three staff to get her out of bed (which was not the resident's normal). RN #127 inquired about how therapy went and was told Resident #22 would scream and had to be sat down. RN #127 stated while Resident #22 was sitting in her wheelchair, she was fine and did not have signs of distress. The only time Resident #22 was transferred during RN #127's shift was to lay her down for the x-ray. RN #127 stated she called the resident's RP and let her know Resident #22 was having pain and did not do well in therapy. RN #127 stated when the x-ray tech was present, she asked her to come to Resident #22's room to see the picture and they were able to tell the right hip was out. RN #127 stated she obtained orders to send Resident #22 to the emergency [TRUNCATED]