**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from neglect for one (Resident #1) of 8 residents reviewed for resident neglect. The facility failed to ensure Resident #1 was free from neglect by RN A on 05/31/25. RN A failed to perform an assessment on 05/31/25 when Resident #1 reported he needed to go to the hospital complaining of leg pain. RN A failed to notify and follow-up to ensure Resident #1 was sent to the hospital. RN A failed to notify the physician or any licensed nurse of Resident #1 requesting to go to the hospital. RN A called 911 to report Resident #1's behavior, but RN A failed to report Resident #1 wanted to go to the hospital on [DATE]. When police arrived at the facility on 05/31/25, RN A did not notify the police of Resident #1 wanting to go to the hospital or assist in sending Resident #1 to the hospital. The local police called EMS and Resident #1 was transferred to the emergency room. Resident #1 was admitted to the hospital on [DATE] and placed on a heparin drip as a precaution until test results were completed to rule out a DVT. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25 at 8:15 PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for serious injuries, abuse, serious harm, and death. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition where blood vessels outside the heart and brain are affected, reducing blood flow to the limbs). Resident #1 was his own responsible party. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required set up assistance to independent with ADLs. Review of Resident #1's Comprehensive Care Plan reflected the following: -dated 04/21/25 Resident will call [transportation] to go to the hospital wanting IV pain medication. Even when offering his pain medication he has on hand. -dated 06/02/25 high probability of [deep vein thrombosis] to lower extremities. Refuses to take any type of anticoagulant. Intervention included to notify provider and send resident to ER when [complaint of shortness of breath]. -dated 06/02/25 Risk for deep vein thrombosis. Interventions include evaluate legs for swelling and monitor legs for changes in skin color, temperature. Review of Resident #1's Nurse progress note by RN A dated 05/31/25 reflected the following: [LVN D] notified this nurse that resident wanted to talk. when this nurse arrived at resident room. resident stated, I said to that other nurse that when I need to go he hospital . I need to go. this nurse said, alright you can go then, resident interrupted nurse and stated, you know what get out of here. now! get the hell out of here. this nurse said OKAY and stared walking down the hall. Resident followed this nurse down the hall and became aggressive and started yelling at this nurse, you f****** bitch I will destroy you. I will ruin you. f*** you. resident waving hands in the air. This nurse left and went to shelter in 300 unit, then police were called. nurse asked the police to speak to resident because of the potential for scalation and that, he might physically attack this nurse later. this nurse also asked the police to request resident to delete the videos on his phone that he have been recording of this nurse on the previous morning in the lobby area of this facility. resident left facility via EMS. nurse was not notified of this. Review of local police call record dated 05/31/25 at 6:14 PM a call for a welfare check at the facility reflected patient is being aggressive towards staff with caller as the RN Nurse for night shift who is concerned for her safety. The caller reported patient verbally assaulted the caller. At 6:34 PM police arrived to the facility and 6:45 PM a request for EMS for patient transport possible blood clot. EMS notified. EMS transport one at 7:00 PM. Review of Resident #1's EMS record dated 05/31/25 reflected Patient was noted to be sitting on the edge of the bed with the left leg swollen. Patient stated that he was having some sudden trouble breathing with leg pain as well. Patient stated that he has history of blood clots and that today it was getting worse. Patient states that it's gotten even more unbearable for the last 45 minutes when his shortness of breath started. Patient stated that he tried telling the nurse staff but they would not take him seriously. Patient then stated he got irritated and raise his voice at the staff and law enforcement was called .Medic 2 transported one patient code [emergent] to [hospital] without incident. Review of Resident #1's hospital records reflected Resident #1 was admitted to the hospital on [DATE] from nursing home with a history of factor V Leiden deficiency (inherited disorder that increases the risk of developing blood clots) with a history of chronic bilateral lower extremity DVTs .who was brought to the [emergency department] from the nursing nurse via EMS with a chief complaint of worsening of his lower extremity edema with pain associated with worsening dyspnea over the last 2 days .He became concerned for new DVT probably [pulmonary embolism] because of his shortness of breath, requested EMS .In the [emergency department] venous dopplers currently ordered but are pending. CT angiogram of the chest revealed no pulmonary embolism .Labs include a CBC that revealed a mild normocytic anemia .Patient was initially on a heparin drip pending the venous doppler. He is being admitted for further management . Observation and Interview on 06/03/25 at 9:59 AM with Social Worker revealed Resident #1 was in his room sitting on his bed. Resident #1 stated he wanted the social worker to stay in the room. Resident #1 stated on 05/31/25 he asked to speak to RN A. He stated RN A came to his room and he told her he needed to go to the hospital for shortness of breath and leg pain. Resident #1 stated RN A refused to send him to the hospital on [DATE] at the beginning of her shift and RN A did not care what happened to me. He stated he did get upset yelled at RN A. He stated the police were called to the facility by staff. He stated the police called EMS for him noticing he was short of breath. He stated the EMTs took me to the hospital for possible blood clot. He stated he was complaining of shortness of breath and leg pain. He stated on 05/31/25 he told CNA C about RN A refusing to send him to the hospital. He stated RN A would not even print off his face sheet so he could have it when EMTs transporting him to the hospital. He stated he tried to do the right thing by letting RN A know he needed to go to the hospital. He stated he returned back to the facility from the hospital yesterday on 06/02/25. He stated the Administrator was aware of the allegation and he was told by Administrator that RN A would not be returning back to the facility. Interview on 06/03/25 at 10:35 AM with DON revealed she received a phone call on 05/31/25 from RN A about not wanting to take care of Resident #1 anymore because he was being verbally aggressive towards me and asked if LVN B could take care of him. DON stated she advised RN A to inform LVN B to take care of Resident #1 for the rest of the shift. DON stated it was not reported to her of Resident #1 wanting to go to the hospital. She stated at 6:38 pm she spoke to CNA C about RN A calling the police on Resident #1 but did not know why RN A called the police. DON stated she reached out to RN A who told her Resident #1 was being aggressive towards her and she was afraid of Resident #1. DON stated she was not notified about Resident #1 wanting to go to the hospital. She further stated she was not informed Resident #1 was sent to the hospital. She stated she should have been notified of Resident #1 being sent to the hospital. DON stated she did not find out Resident #1 had been sent to the hospital or in the hospital until 06/02/25 when she was at the facility. She stated she reached out to Resident #1 on 06/02/25 via telephone who reported to her about RN refusing to send him to the hospital on [DATE] when he reported having trouble breathing and needing to go to the hospital. She stated she immediately reported the neglect allegation to the Administrator. She stated Administrator reached out to RN A who was suspended pending investigation on 06/02/25. Interviews on 06/03/25 at 1:11 PM with CNA C revealed on 05/31/25 Resident #1 was concerned about leg pain and swollen leg thought he might have a blood clot. She stated Resident #1 reported to her he wanted to be sent to hospital CNA C stated Resident #1 told her that he tried to do it their way by notifying RN A of needing to go to the hospital so they can send him to hospital but Resident #1 stated RN A blew him off. CNA C stated she did not have an opportunity to report Resident #1 wanting to be send to the hospital to LVN B because she got distracted when the police arrived to the facility. She stated she contacted the DON via telephone on 05/31/25 about police in the facility and RN A had called the police on Resident #1. CNA C stated Resident #1 was walking slowly and was flustered with RN A. She stated Resident #1 went back to his room and police contacted EMT to send him to the hospital. She stated she did not know if LVN B was aware of Resident #1 wanting to go to the hospital. CNA C stated Resident #1 had issues with RN A but RN A was still Resident #1's nurse. She stated RN A would ask LVN B to give Resident #1 his medications. She stated her last in-service on abuse/neglect was about a couple weeks ago to maybe a month ago. She stated she had not been in-serviced on 05/31/25 or after on abuse/neglect policy including reporting. She stated she had not spoke to Administrator or DON to give them a statement about the incident on 05/31/25 with Resident #1. Interview on 06/04/25 at 8:09 PM with CNA C revealed she reported to the DON about RN A not sending Resident #1 to the hospital when she reported to DON about RN A calling the police on Resident #1. She stated she should have called the Administrator who is the abuse coordinator immediately to report the allegation of neglect of Resident #1 reporting RN A did not send him to the hospital. She stated she was verbally counseled for failure to report the allegation to the Administrator immediately. She stated RN A worked the rest of her shift on 05/31/25 and worked on 06/01/25 night shift until 6 AM on 06/02/25. Interview on 06/03/25 at 2:52 PM with Social Worker revealed Resident #1 reported on 05/31/25 to RN A he was short of breath and was concerned about a possible blood clot. She was not aware of RN A refusing to send him to the hospital until 06/03/25. Social Worker stated RN A had an attitude problem and Resident #1 reported to her RN A was mouthy to him. Interview on 06/04/25 at 11:05 AM with Police Officer H revealed the police officer who was dispatched to the facility on [DATE] worked the night shift. He stated he would leave a message to call surveyor. He stated based on his review of the report it reflected on 05/31/25 a nurse from the facility called to report Resident #1 having a verbal altercation with nurse. He reviewed the call details report reflecting Resident #1 complained of leg pain when police arrived at the facility and police notified EMTs to send Resident #1 to the hospital. Interview on 06/04/25 at 8:44 PM with LVN D revealed she had been administering Resident #1's medications to Resident #1 when RN A was assigned as his nurse for the last couple of weeks She stated RN A told her that she could not administer medications to Resident #1 and DON was aware of it. She stated she did not follow up with DON or the Administrator about RN A not administering Resident #1's medications on her shifts and requesting her to give Resident #1 his medications. She stated she was not asked to be Resident #1's charge nurse on 05/31/25. She stated the police officer asked her to print off Resident #1's face sheet but did not understand why RN A was not more involved in Resident #1 being sent to the hospital. She stated she did not know why Resident #1 was sent to the hospital. She stated she did not make any notifications of Resident #1 going to the hospital since he was RN A's resident on 05/31/25. She stated she heard Resident #1 cussing right after shift change but she did not really think anything of it since it stopped. She stated Resident #1 did verbally cuss out staff. She stated as the charge nurse if a resident reports to her wanting to go to the hospital, she would assess, find out more information about what was going on with resident and take vitals. She stated residents have a right to go to the hospital if he or she wants to. She stated she would contact the physician to report her assessment of the resident and what was going on with resident. She stated if a resident wants to go to the hospital she would report it to physician and DON. Interview on 06/05/25 at 9:14 AM with DON revealed RN A called the police on Resident #1. She stated RN A told her Resident #1 was cussing and yelling at her. DON stated RN A told her she was in fear for her life so this is why she called the police. DON stated she expected the nurse to assess resident including head to toe, vital, and asking to find out more about resident's change of condition. She stated RN A should have notified the physician and if resident wanted to be sent out to the hospital to send resident out to the hospital. She stated Resident #1 was his own responsible party. She stated if she had known on 05/31/25 of RN A refusing to send Resident #1 to the hospital she would have reported an allegation of abuse/neglect to the Administrator immediately. She stated prior to this incident there had been customer service complaints of RN A's tone being rude. She stated Resident #1 did not like her. She was not aware of RN A not giving Resident #1 her medications when she was his charge nurse and having other nurses administer his medications. She stated Resident #1 was admitted to the hospital on [DATE]. She stated Resident #1 had a history of DVT in a previous hospitalization. Interview on 06/05/25 at 9:33 AM with Resident #1's MD revealed he could not recall if he was notified about Resident #1 being sent to the hospital on [DATE]. He stated he expected the nurse to assess the resident including taking vitals and listening to lungs. He expected the nurse to find out more information of why Resident #1 wanted to be sent to the hospital. Resident #1's MD stated should call the on-call physician to notify of Resident #1 symptoms and change of condition. He stated Resident #1 had a history of calling Uber to go to hospital. He stated if resident wanted to go to the hospital, the nurse will contact EMS for transportation. He stated the risk to the resident could be potential risk of pulmonary embolism or heart attack. Interview on 06/05/25 at 10:17 AM with LVN D revealed Resident #1 told her he needed to talk to RN A but did not tell him what was going on. She reported to RN A at shift change which was 6:00 PM on 05/31/25 that Resident #1 wanted to talk to him. LVN D stated she was not informed Resident #1 wanted to go to the hospital and was not aware of any change of condition. Interview on 06/07/25 at 11:18 AM with RN A revealed LVN D reported to her Resident #1 wanted him to go see him at beginning of her shift at 6 PM. She stated she found it odd he wanted to talk to her because she stated she stayed out of his room, she did not like to deal with him and if he walking down the hall I go the other way. She stated when she entered Resident #1's room. RN A stated he told he needed to go to the hospital and she told him you can go. RN A stated Resident #1 started yelling at her, told her to get the hell out of his room. She stated she left his room and he followed her down the hall saying who the hell are you, I am going to destroy you. RN A stated she did not know what Resident #1 was complaining of and did not have a chance to ask any questions. She stated she did not have a chance to assess him or ask him more questions to find out what he wanted to go to the hospital. LVN D stated she went to shelter on the secure unit and called the police to inform of Resident #1's aggression towards her. She stated she needed to administer her medications to the residents on his hall and was afraid he might attack me so she called the police. RN A stated she called the police after she sheltered on the secure unit and it took like 20 to 30 minutes for them to arrive. She stated she did not inform the police about Resident #1 wanting to go to the hospital. She did not inform anyone about Resident #1 wanting to go to the hospital. She stated the police called for Resident #1 to be sent out to the hospital. She stated she had 2 incidents with Resident #1 when giving him his medications prior to 05/31/25 and Resident #1 got upset at her for opening the door and waking him up for his medications. She stated Resident #1 followed her and yelled at her by cussing her out. She stated she gave the other nurse on her shift to have the other nurse administer his medications. She stated she would follow-up with other nurse to see if it was given and documented it was given. She stated the DON called me on 05/31/25 to find out why I called the police. She stated she did not inform anyone about Resident #1 going to the hospital. She stated Resident #1 did have chronic DVT history. She stated when she was contacted by the facility on 06/02/25 she told them she quit because she knew Resident #1 would back at the facility. Interview on 06/05/25 at 12:10 PM with Administrator revealed Resident #1 did have past issues with nurses about wanting to get medications on time. He stated Resident #1 did have history of being verbally aggressive to staff. DON reported to him on 06/02/25 of Resident #1 reporting RN A refused to send him to the hospital and police had to call EMS to send him to the hospital. The Administrator stated this was an allegation of neglect and possibly abuse so he reported it to HHSC. He stated he initiated the investigation and contacted RN A to suspend her pending investigation. He stated RN A refused to give a witness statement for the incident on 05/31/25 and RN A told him F*** this facility and F*** those residents. He stated he was not aware of RN A not giving Resident #1 his medications on her shift as the charge nurse and having the other nurse give the medications to Resident #1. He stated CNA C should have immediately notified me as the abuse coordinator on 05/31/25 of RN A refusing to send Resident #1 to the hospital. He stated RN A should have assessed Resident #1 and/or tell other nurse about Resident #1 wanting to go to hospital. He stated the failure to immediately report abuse or neglect to me could place residents at risk for resident abuse/neglect to continue and not be aware of abuse/neglect. He stated this placed the residents at risk for further abuse and neglect with allowing RN A to continue to work and could possibly do it to someone else. Interview on 06/05/25 at 7:14 PM with Local Police Officer G revealed he did come out to the facility on [DATE]. He stated based on interviews with facility staff it seemed like Resident #1 did not seem to get along with RN A. He stated Resident #1 requested to the police to go to the hospital on [DATE] per a possible blood clot. He stated he called EMS and Resident #1 was sent out to the hospital. Review of RN A's timecard for 05/31/25 reflected RN A worked from 05/31/25 at 5:43 PM to 6:14 AM on 06/01/25. On 06/01/25 at 5:43 PM to 6:21 PM on 06/02/25. Review of facility's policy last revised September 2022 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reflected All reports of resident abuse (including injuries of unknown origin, neglect, exploitation or theft/misappropriation of property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting allegations to the Administrator and Authorities 1. If resident abuse, neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines .6. Upon receiving any allegations of abuse, neglect .the administrator is responsible for ensuring what actions (if any) are needed for the protection of residents .12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . On 06/05/25 at 5:10 PM, the Administrator and ADON were informed in person with DON and Regional VP on the phone of an IJ situation. The Administrator was provided the IJ template at this time. The facility's plan of removal was accepted on 06/06/25 at 10:44 AM and reflected the following: The facility failed to protect Resident #1's right to be free from neglect when RN A decided she would not provide care to resident #1 when she was assigned to the resident. This failure could place residents at risk for not having measures I place to protect them from serious harm, mental anguish, neglect or death. The facility medical director was notified of the Immediate Jeopardy by the Facility Administrator on 06/05/2025. Resident #1 was sent to the ER for evaluation and treatment on 5/31/25 and returned to the facility on [DATE]. RN A was suspended, pending investigation, by the DON and Facility Administrator on 6/2/25 and terminated from her position by the DON and Administrator on 6/3/25. All staff were in-serviced on Abuse, Neglect, and Exploitation, Patient care assignments, resident change in condition, resident rights, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on June 2nd, 2025, and were completed on 06/05/2025. In-services were completed per the Director of Nursing. No staff or agency staff will be allowed in the facility until they are in-serviced by the ADON/ADMIN on Abuse, Neglect, and Exploitation and all other in-service requirements. Staff were in-serviced that it is a resident right to go to the hospital when they want. Staff were also in-serviced that they must assess patients prior to send them out. Staff were in-serviced by ADON that the MD must be notified on any change of condition immediately. DON/ADON will monitor and be responsible moving forward. The facility DON began in-services for all nursing staff regarding resident care assignments and the responsibilities included in resident care assignments for nursing staff, notification to the physician if residents request to go to the hospital, notification to DON and Administrator if law enforcement are called to the facility, and resident assessment on 6/5/2025. All nursing staff will be in-serviced by the DON prior to the start of their next shift. DON and Administrator will interview 3 staff daily related to their understanding of the inservice education provided, for the next 4 weeks. Admin/ADON conducted safe surveys with alert residents on 6/3/25 An Ad Hoc QAPI was held by the Regional VP of Operations, Facility Administrator, Director of Nursing, Regional Nurse Consultant, (medical director), and Asst. Director of Nurses on 06/05/2025 to review the alleged deficiency and plan. Review of the IJ monitoring for the facility's plan of removal reflected the following: Review of RN A's termination dated 06/02/25 reflected RN A was placed on suspension for neglect allegation and said she wasn't going to do that and stated she quit .[RN A] was very antagonistic towards the residents and other staff. Interviews from 06/06/25 at 2:25 PM to 7:40 PM with four nurses from different shifts (LVN I, RN O, LVN Q and Agency LVN S) they had been in-serviced on abuse/neglect policy. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. Interviews from 06/06/25 at 2:42 PM to 7:20 PM with eight CNAs from different shifts (CNA J, CNA K, CNA L, CNA M, CNA N, CNA P, CNA R, and CNA T) revealed they had been in-serviced on abuse/neglect policy, resident rights and patient care responsibility. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. All CNAs were aware of resident rights including resident right to go to the hospital. All stated if CNA became aware of allegation of nurse not sending a resident to the hospital or assessing a resident for a change of condition they would immediately notify the Administrator of the allegation. The CNAs stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interviews from 06/06/25 at 3:40 PM to 7:26 PM with three facility staff (Activity Director, Dietary [NAME] U and Dietary Aide V) reflected they were in-serviced on abuse/neglect, reporting requirements of allegations and resident rights. All three staff were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. They were aware of resident rights including resident right to go to the hospital. They stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interview on 06/06/25 at 3:53 PM with Administrator revealed staff have been in-serviced from different shifts on abuse/neglect policy and reporting requirements. He stated all staff who have been in-serviced should be aware to notify him immediately of any allegations of abuse/neglect. He stated CNA C and LVN B have been in-serviced on abuse/neglect and reporting requirements to immediately report any allegations to him. He stated any staff who have not been in-serviced will be unable to work until in-serviced. Interview on 06/06/25 at 4:41 PM with ADON revealed staff had been in-serviced on abuse/neglect. She was knowledgeable of types of abuse/neglect and would report any allegations to Administrator immediately once the resident was safe. She was knowledgeable of resident right. She stated LVN B had been in-serviced but she was unavailable to contact due to being on personal leave at this time. She stated LVN B would be in-serviced in person again to ensure her understanding of all the in-services when she returns back to work from her leave. Review of In-services for Abuse/Neglect dated 06/02/25 to 06/05/25 reflected staff were in-serviced on abuse/neglect policy and reporting requirements. Review of 2 of 2 resident clinical records (Resident #2 and #3) for change of condition and hospitalization revealed no concerns with abuse or neglect. Review revealed CNA C and LVN B were verbally counseled for not reporting an allegation of abuse/neglect signed by employees on 06/04/25. Review of Reporting of Abuse and Neglect dated 06/05/25 reflected if you feel, see or even think abuse or neglect is happening, immediately do the following: Get the resident or residents to safety. Immediately call the abuse coordinator [Administrator] with phone number provided. An IJ was identified on 06/05/25. The IJ template was provided to the Administrator and ADON on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm to ensure the effectiveness of the training and plan of removal components.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for one, (Resident #1) of eight residents reviewed for resident neglect. The facility failed to report a potential allegation of neglect to the Abuse Coordinator when RN A failed to provide care and treatment for Resident # 1, who was in her care assignment. LVN B and CNA C were aware that RN A did not provide care to Resident #1. RN A was allowed to work on 05/31/25 to 06/02/25 after she failed to provide care and treatment when Resident # 1 requested to go the hospital on [DATE]. Police notified EMS of Resident #1's request to go to the hospital for a possible blood clot on 05/31/25. RN A was suspended on 06/02/25 by the Abuse Coordinator. An identification of an Immediate Jeopardy (IJ) on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25 at 8:15 PM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition where blood vessels outside the heart and brain are affected, reducing blood flow to the limbs). Resident #1 was his own responsible party. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #1 required set up assistance to independent with ADLs. Review of Resident #1's Comprehensive Care Plan reflected the following: -dated 04/21/25 Resident will call [transportation] to go to the hospital wanting IV pain medication. Even when offering his pain medication he has on hand. -dated 06/02/25 high probability of [deep vein thrombosis] to lower extremities. Refuses to take any type of anticoagulant. Intervention included to notify provider and send resident to ER when [complaint of shortness of breath]. -dated 06/02/25 Risk for deep vein thrombosis. Interventions include evaluate legs for swelling and monitor legs for changes in skin color, temperature. Review of Resident #1's Nurse progress note by RN A dated 05/31/25 reflected the following: [LVN D] notified this nurse that resident wanted to talk. when this nurse arrived at resident room. resident stated, I said to that other nurse that when I need to go he hospital . I need to go. this nurse said, alright you can go then, resident interrupted nurse and stated, you know what get out of here. now! get the hell out of here. this nurse said OKAY and stared walking down the hall. Resident followed this nurse down the hall and became aggressive and started yelling at this nurse, you f****** bitch I will destroy you. I will ruin you. f*** you. resident waving hands in the air. This nurse left and went to shelter in 300 unit, then police were called. nurse asked the police to speak to resident because of the potential for scalation and that, he might physically attack this nurse later. this nurse also asked the police to request resident to delete the videos on his phone that he have been recording of this nurse on the previous morning in the lobby area of this facility. resident left facility via EMS. nurse was not notified of this. Review of local police call record dated 05/31/25 at 6:14 PM a call for a welfare check at the facility reflected patient is being aggressive towards staff with caller as the RN Nurse for night shift who is concerned for her safety. The caller reported patient verbally assaulted the caller. At 6:34 PM police arrived to the facility and 6:45 PM a request for EMS for patient transport possible blood clot. EMS notified. EMS transport one at 7:00 PM. Review of Resident #1's EMS record dated 05/31/25 reflected Patient was noted to be sitting on the edge of the bed with the left leg swollen. Patient stated that he was having some sudden trouble breathing with leg pain as well. Patient stated that he has history of blood clots and that today it was getting worse. Patient states that it's gotten even more unbearable for the last 45 minutes when his shortness of breath started. Patient stated that he tried telling the nurse staff but they would not take him seriously. Patient then stated he got irritated and raise his voice at the staff and law enforcement was called .Medic 2 transported one patient code [emergent] to [hospital] without incident. Review of Resident #1's hospital records reflected Resident #1 was admitted to the hospital on [DATE] from nursing home with a history of factor V Leiden deficiency (inherited disorder that increases the risk of developing blood clots) with a history of chronic bilateral lower extremity DVTs .who was brought to the [emergency department] from the nursing nurse via EMS with a chief complaint of worsening of his lower extremity edema with pain associated with worsening dyspnea over the last 2 days .He became concerned for new DVT probably [pulmonary embolism] because of his shortness of breath, requested EMS .In the [emergency department] venous dopplers currently ordered but are pending. CT angiogram of the chest revealed no pulmonary embolism .Labs include a CBC that revealed a mild normocytic anemia .Patient was initially on a heparin drip pending the venous doppler. He is being admitted for further management . Observation and Interview on 06/03/25 at 9:59 AM with Social Worker revealed Resident #1 was in his room sitting on his bed. Resident #1 stated he wanted the social worker to stay in the room. Resident #1 stated on 05/31/25 he asked to speak to RN A. He stated RN A came to his room and he told her he needed to go to the hospital for shortness of breath and leg pain. Resident #1 stated RN A refused to send him to the hospital on [DATE] at the beginning of her shift and RN A did not care what happened to me. He stated he did get upset yelled at RN A. He stated the police were called to the facility by staff. He stated the police called EMS for him noticing he was short of breath. He stated the EMTs took me to the hospital for possible blood clot. He stated he was complaining of shortness of breath and leg pain. He stated on 05/31/25 he told CNA C about RN A refusing to send him to the hospital. He stated RN A would not even print off his face sheet so he could have it when EMTs transporting him to the hospital. He stated he tried to do the right thing by letting RN A know he needed to go to the hospital. He stated he returned back to the facility from the hospital yesterday on 06/02/25. He stated the Administrator was aware of the allegation and he was told by Administrator that RN A would not be returning back to the facility. Interview on 06/03/25 at 10:35 AM with DON revealed she received a phone call on 05/31/25 from RN A about not wanting to take care of Resident #1 anymore because he was being verbally aggressive towards me and asked if LVN B could take care of him. DON stated she advised RN A to inform LVN B to take care of Resident #1 for the rest of the shift. DON stated it was not reported to her of Resident #1 wanting to go to the hospital. She stated at 6:38 pm she spoke to CNA C about RN A calling the police on Resident #1 but did not know why RN A called the police. DON stated she reached out to RN A who told her Resident #1 was being aggressive towards her and she was afraid of Resident #1. DON stated she was not notified about Resident #1 wanting to go to the hospital. She further stated she was not informed Resident #1 was sent to the hospital. She stated she should have been notified of Resident #1 being sent to the hospital. DON stated she did not find out Resident #1 had been sent to the hospital or in the hospital until 06/02/25 when she was at the facility. She stated she reached out to Resident #1 on 06/02/25 via telephone who reported to her about RN refusing to send him to the hospital on [DATE] when he reported having trouble breathing and needing to go to the hospital. She stated she immediately reported the neglect allegation to the Administrator. She stated Administrator reached out to RN A who was suspended pending investigation on 06/02/25. Interviews on 06/03/25 at 1:11 PM with CNA C revealed on 05/31/25 Resident #1 was concerned about leg pain and swollen leg thought he might have a blood clot. She stated Resident #1 reported to her he wanted to be sent to hospital CNA C stated Resident #1 told her that he tried to do it their way by notifying RN A of needing to go to the hospital so they can send him to hospital but Resident #1 stated RN A blew him off. CNA C stated she did not have an opportunity to report Resident #1 wanting to be send to the hospital to LVN B because she got distracted when the police arrived to the facility. She stated she contacted the DON via telephone on 05/31/25 about police in the facility and RN A had called the police on Resident #1. CNA C stated Resident #1 was walking slowly and was flustered with RN A. She stated Resident #1 went back to his room and police contacted EMT to send him to the hospital. She stated she did not know if LVN B was aware of Resident #1 wanting to go to the hospital. CNA C stated Resident #1 had issues with RN A but RN A was still Resident #1's nurse. She stated RN A would ask LVN B to give Resident #1 his medications. She stated her last in-service on abuse/neglect was about a couple weeks ago to maybe a month ago. She stated she had not been in-serviced on 05/31/25 or after on abuse/neglect policy including reporting. She stated she had not spoke to Administrator or DON to give them a statement about the incident on 05/31/25 with Resident #1. Interview on 06/04/25 at 8:09 PM with CNA C revealed she reported to the DON about RN A not sending Resident #1 to the hospital when she reported to DON about RN A calling the police on Resident #1. She stated she should have called the Administrator who is the abuse coordinator immediately to report the allegation of neglect of Resident #1 reporting RN A did not send him to the hospital. She stated she was verbally counseled for failure to report the allegation to the Administrator immediately yesterday. She stated RN A worked the rest of her shift on 05/31/25 and worked on 06/01/25 night shift until 6 AM on 06/02/25. She was knowledgeable of different types of abuse/neglect policy and reporting requirements and was in-serviced yesterday. Interview on 06/03/25 at 2:52 PM with Social Worker revealed Resident #1 reported on 05/31/25 to RN A he was short of breath and was concerned about a possible blood clot. She was not aware of RN A refusing to send him to the hospital until 06/03/25. Social Worker stated RN A had an attitude problem and Resident #1 reported to her RN A was mouthy to him. Interview on 06/04/25 at 11:05 AM with Police Officer H revealed the police officer who was dispatched to the facility on [DATE] worked the night shift. He stated he would leave a message to call surveyor. He stated based on his review of the report it reflected on 05/31/25 a nurse from the facility called to report Resident #1 having a verbal altercation with nurse. He reviewed the call details report reflecting Resident #1 complained of leg pain when police arrived at the facility and police notified EMTs to send Resident #1 to the hospital. Interview on 06/04/25 at 8:36 PM with CNA E revealed on 05/31/25 she did not know why Resident #1 was being sent to the hospital but saw him on the EMS stretcher. She stated the Administrator is the abuse coordinator. She stated RN A could be condescending and act like she is better than anyone else. Interview on 06/04/25 at 8:44 PM with LVN D revealed she had been administering Resident #1's medications to Resident #1 when RN A was assigned as his nurse for the last couple of weeks. She stated RN A told her that she could not administer medications to Resident #1 and DON was aware of it. She stated she did not follow up with DON or the Administrator about RN A not administering Resident #1's medications on her shifts and requesting her to give Resident #1 his medications. She stated she was not asked to be Resident #1's charge nurse on 05/31/25. She stated the police officer asked her to print off Resident #1's face sheet but did not understand why RN A was not more involved in Resident #1 being sent to the hospital. She stated she did not know why Resident #1 was sent to the hospital. She stated she did not make any notifications of Resident #1 going to the hospital since he was RN A's resident on 05/31/25. She stated she heard Resident #1 cussing right after shift change but she did not really think anything of it since it stopped. She stated Resident #1 did verbally cuss out staff. She stated as the charge nurse if a resident reports to her wanting to go to the hospital, she would assess, find out more information about what was going on with resident and take vitals. She stated residents have a right to go to the hospital if he or she wants to. She stated she would contact the physician to report her assessment of the resident and what was going on with resident. She stated if a resident wants to go to the hospital she would report it to physician and DON. Interview on 06/05/25 at 9:14 AM with DON revealed RN A called the police on Resident #1. She stated RN A told her Resident #1 was cussing and yelling at her. DON stated RN A told her she was in fear for her life so this is why she called the police. DON stated she expected the nurse to assess resident including head to toe, vital, and asking to find out more about resident's change of condition. She stated RN A should have notified the physician and if resident wanted to be sent out to the hospital to send resident out to the hospital. She stated Resident #1 was his own responsible party. She stated if she had known on 05/31/25 of RN A refusing to send Resident #1 to the hospital she would have reported an allegation of abuse/neglect to the Administrator immediately. She stated prior to this incident there had been customer service complaints of RN A's tone being rude. She stated Resident #1 did not like her. She was not aware of RN A not giving Resident #1 her medications when she was his charge nurse and having other nurses administer his medications. She stated Resident #1 was admitted to the hospital on [DATE]. She stated Resident #1 had a history of DVT in a previous hospitalization. Interview on 06/05/25 at 9:33 AM with Resident #1's MD revealed he could not recall if he was notified about Resident #1 being sent to the hospital on [DATE]. He stated he expected the nurse to assess the resident including taking vitals and listening to lungs. He expected the nurse to find out more information of why Resident #1 wanted to be sent to the hospital. Resident #1's MD stated should call the on-call physician to notify of Resident #1 symptoms and change of condition. He stated Resident #1 had a history of calling Uber to go to hospital. He stated if resident wanted to go to the hospital, the nurse will contact EMS for transportation. He stated the risk to the resident could be potential risk of pulmonary embolism or heart attack. Interview on 06/05/25 at 10:17 AM with LVN D revealed Resident #1 told her he needed to talk to RN A but did not tell him what was going on. She reported to RN A at shift change which was 6:00 PM on 05/31/25 that Resident #1 wanted to talk to him. LVN D stated she was not informed Resident #1 wanted to go to the hospital and was not aware of any change of condition. Interview on 06/07/25 at 11:18 AM with RN A revealed LVN D reported to her Resident #1 wanted him to go see him at beginning of her shift at 6 PM. She stated she found it odd he wanted to talk to her because she stated she stayed out of his room, she did not like to deal with him and if he walking down the hall I go the other way. She stated when she entered Resident #1's room. RN A stated he told he needed to go to the hospital and she told him you can go. RN A stated Resident #1 started yelling at her, told her to get the hell out of his room. She stated she left his room and he followed her down the hall saying who the hell are you, I am going to destroy you. RN A stated she did not know what Resident #1 was complaining of and did not have a chance to ask any questions. She stated she did not have a chance to assess him or ask him more questions to find out what he wanted to go to the hospital. LVN D stated she went to shelter on the secure unit and called the police to inform of Resident #1's aggression towards her. She stated she needed to administer her medications to the residents on his hall and was afraid he might attack me so she called the police. RN A stated she called the police after she sheltered on the secure unit and it took like 20 to 30 minutes for them to arrive. She stated she did not inform the police about Resident #1 wanting to go to the hospital. She did not inform anyone about Resident #1 wanting to go to the hospital. She stated the police called for Resident #1 to be sent out to the hospital. She stated she had 2 incidents with Resident #1 when giving him his medications prior to 05/31/25 and Resident #1 got upset at her for opening the door and waking him up for his medications. She stated Resident #1 followed her and yelled at her by cussing her out. She stated she gave the other nurse on her shift to have the other nurse administer his medications. She stated she would follow-up with other nurse to see if it was given and documented it was given. She stated the DON called me on 05/31/25 to find out why I called the police. She stated she did not inform anyone about Resident #1 going to the hospital. She stated Resident #1 did have chronic DVT history. She stated when she was contacted by the facility on 06/02/25 she told them she quit because she knew Resident #1 would back at the facility. Interview on 06/05/25 at 12:10 PM with Administrator revealed Resident #1 did have past issues with nurses about wanting to get medications on time. He stated Resident #1 did have history of being verbally aggressive to staff. DON reported to him on 06/02/25 of Resident #1 reporting RN A refused to send him to the hospital and police had to call EMS to send him to the hospital. The Administrator stated this was an allegation of neglect and possibly abuse so he reported it to HHSC. He stated he initiated the investigation and contacted RN A to suspend her pending investigation. He stated RN A refused to give a witness statement for the incident on 05/31/25 and RN told him Fuck this facility and Fuck those residents. He stated he was not aware of RN A not giving Resident #1 his medications on her shift as the charge nurse and having the other nurse give the medications to Resident #1. He stated CNA C should have immediately notified me as the abuse coordinator on 05/31/25 of RN A refusing to send Resident #1 to the hospital. He stated RN A should have assessed Resident #1 and/or tell other nurse about Resident #1 wanting to go to hospital. He stated the failure to immediately report abuse or neglect to me could place residents at risk for resident abuse/neglect to continue and not be aware of abuse/neglect. He stated this placed the residents at risk for further abuse and neglect with allowing RN A to continue to work and could possibly do it to someone else. Interview on 06/05/25 at 7:14 PM with Local Police Officer G revealed he did come out to the facility on [DATE]. He stated based on interviews with facility staff it seemed like Resident #1 did not seem to get along with RN A. He stated Resident #1 requested to the police to go to the hospital on [DATE] per a possible blood clot. He stated he called EMS and Resident #1 was sent out to the hospital. Review of RN A's timecard for 05/31/25 reflected RN A worked from 05/31/25 at 5:43 PM to 6:14 AM on 06/01/25. On 06/01/25 at 5:43 PM to 6:21 PM on 06/02/25. Review of facility's policy last revised September 2022 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reflected All reports of resident abuse (including injuries of unknown origin, neglect, exploitation or theft/misappropriation of property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting allegations to the Administrator and Authorities 1. If resident abuse, neglect .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines .6. Upon receiving any allegations of abuse, neglect .the administrator is responsible for ensuring what actions (if any) are needed for the protection of residents .12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . On 06/05/25 at 5:10 PM, the Administrator and ADON were informed in person with DON and Regional VP on the phone of an IJ situation. The Administrator was provided the IJ template at this time. The facility's plan of removal was accepted on 06/06/25 at 10:44 AM. Review of facility's Plan of Removal for F609 reflected the following: The facility failed to report a potential allegation of neglect to the Abuse Coordinator when RN A failed to provide care and treatment for Resident #1, who was in her care assignment. The facility medical director was notified of the Immediate Jeopardy by the Facility Administrator on 06/05/2025. Resident #1 was sent to the ER for evaluation and treatment on 5/31/25 and returned to the facility on [DATE]. RN A was suspended on 06/02/2025 by the DON and Administrator and terminated from her position at the facility on 06/03/2025 by the DON and Facility Administrator/Abuse Coordinator. LVN B and CNA C were in-serviced by the DON and Administrator on 6/3/25 regarding immediately reporting potential Abuse, Neglect, and Misappropriation. Both employees were given written disciplinary action related to not reporting immediately, by the DON on 06/04/2025. All staff were in-serviced by ADON/DON on Abuse, Neglect, and Exploitation, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on June 2nd 2025 and were completed on 06/05/2025. ADMIN or designee will monitor and be responsible moving forward. In-services were completed per the Director of Nursing. Any new staff or agency staff will be in-serviced by the DON on Abuse, Neglect, and Exploitation policy before the start of their first shift. DON and Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. Admin and ADON conducted safe surveys with alert residents on 6/3/25. Review of the IJ monitoring for the facility's plan of removal reflected the following: Interviews from 06/06/25 at 2:25 PM to 7:40 PM with four nurses from different shifts (LVN I, RN O, LVN Q and Agency LVN S) they had been in-serviced on abuse/neglect policy,. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. Interviews from 06/06/25 at 2:42 PM to 7:20 PM with eight CNAs from different shifts (CNA J, CNA K, CNA L, CNA M, CNA N, CNA P, CNA R, and CNA T) revealed they had been in-serviced on abuse/neglect policy,. All were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who was the abuse coordinator once the resident was safe. They were all knowledgeable of where to find contact information for the abuse coordinator. Interviews from 06/06/25 at 3:40 PM to 7:26 PM with three facility staff (Activity Director, Dietary [NAME] U and Dietary Aide V) reflected they were in-serviced on abuse/neglect, reporting requirements of allegations and resident rights. All three staff were knowledgeable of types of abuse/neglect and would report any allegations immediately to Administrator who is the abuse coordinator once the resident was safe. They were aware of resident rights including resident right to go to the hospital. They stated they would notify the DON and Administrator if resident rights were violated. They were all knowledgeable of where to find contact information for the abuse coordinator. Interview on 06/06/25 at 3:53 PM with Administrator revealed staff have been in-serviced from different shifts on abuse/neglect policy and reporting requirements. He stated all staff who have been in-serviced should be aware to notify him immediately of any allegations of abuse/neglect. He stated CNA C and LVN B have been in-serviced on abuse/neglect and reporting requirements to immediately report any allegations to him. He stated any staff who have not been in-serviced will be unable to work until in-serviced. Interview on 06/06/25 at 4:41 PM with ADON revealed staff had been in-serviced on abuse/neglect. She was knowledgeable of types of abuse/neglect and would report any allegations to Administrator immediately once the resident was safe. She stated LVN B had been in-serviced but she was unavailable to contact due to being on personal leave at this time. She stated LVN B would be in-serviced in person again to ensure her understanding of all the in-services when she returns back to work from her leave. Review of In-services for Abuse/Neglect dated 06/02/25 to 06/05/25 reflected staff were in-serviced on abuse/neglect policy and reporting requirements including CNA C and LVN B. Review of 2 of 2 resident clinical records (Resident #2 and #3) revealed no concerns with abuse or neglect. Review revealed CNA C and LVN B were verbally counseled for not reporting an allegation of abuse/neglect signed by employees on 06/04/25. Review of Reporting of Abuse and Neglect dated 06/05/25 reflected if you feel, see or even think abuse or neglect is happening, immediately do the following: Get the resident or residents to safety. Immediately call the abuse coordinator [Administrator] with phone number provided. An IJ was identified on 06/05/25. The IJ template was provided to the Administrator and ADON on 06/05/25 at 5:10 PM. While the IJ was removed on 06/06/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm to ensure the effectiveness of the training and plan of removal components.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of six residents reviewed for pain management. 1. The facility failed to ensure Resident #1 was assessed, monitored and received effective pain management by LVN A after Resident #1 was found on the floor with indications of pain when mumbling and grumbling during transfer at time of unwitnessed fall on 02/24/24 at 12:17 AM. Resident #1 received no pain management from LVN A. 2. The facility failed to ensure Resident #1 received pain medication until after a 9 hour delay after the an unwitnessed fall. Resident #1 exhibited increasing signs of pain indicated by facial grimacing, moaning and holding her left hip. LVN B failed to follow Resident #1's prn physician order of administering Tylenol 500 mg before the 4 hours and failed to notify the physician of Resident #1's pain medication not being effective. 3. The facility failed to ensure effective pain management was provided to Resident #1 resulting in increased indicators of pain which resulted in 911 being called after Resident #1's POA intervention to contact Physician. Resident #1 was admitted to the hospital (19 hour delay since pain onset) for a left displaced hip fracture and had surgery to repair the fracture An Immediate Jeopardy (IJ) was identified on 07/17/24. The IJ Template was provided to the facility on [DATE] at 12:15 PM. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on pain management. These failures placed residents at risk of experiencing significant pain, discomfort and hospitalization. Findings include: Review of Resident #1's face sheet dated 07/16/24 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had diagnoses of traumatic brain injury (form of acquired brain injury occurs when a sudden trauma causes damage to the brain), hypertension (high blood pressure), unsteadiness on feet, cognitive communication deficit, anxiety disorder (persistent feelings of worry or fear) and depression disorder (episodes of persistently sad moods) and a BIMS score of 00 (severely impaired cognition). Review of Resident #1's comprehensive care plan last revised on 06/11/24 revealed resident had experienced multiple falls and included a fall on 02/24/2024 but did not indicate injury of hip fracture. Interventions included floor mats next to bed when resident was in bed, ensure her nonskid socks are on, and check frequently to make sure resident was not self-transferring, and to monitor pain during task. Review of Event Report for Resident #1 by LVN A with an event date of 02/24/2024 at 12:17 AM, dated recorded 02/24/2024 at 06:18 AM and closed date of 02/26/2024 at 1:38 PM by the DON reflected an unwitnessed fall in resident room. Resident seen lying on her right side on the floor in her room. Resident confused, pacing around in hallway & room. Resident re-directed & repositioned back to bed several times but prove abortive. CNA called [Charge Nurse] that resident is on the floor, resident seen lying on her right side on the floor close to the door. When asked, resident unable to explain, Resident mumbling & grumbling during transfer. Vital signs Blood pressure: 129/73, Pulse :68, Respirations:18, 02:96% [room air], T:97.4. No skin tear noted. Stat xray to bilateral hip ordered. Resident's POA, Supervisor & MD notified. Neuro checks initiated. Resident's pain was noted to be a 1 out of 10 (mild) and had painful and/or limited range of motion in her lower extremities. She was responsive to her name and to pain and was able to perceive her environment clearly and responded appropriately to stimuli. Review of Post Fall Observation report with an observation date of 02/24/2024 at 12:21 AM and completed dated of 02/24/2024 at 6:24 AM by LVN A reflected Resident #1 was previously in her bed and had an unwitnessed fall and was seen lying on her left side in her room. LVN A documented that Resident #1 had an agitated and confused mental status prior to the fall, and a pain level of 3 of 10 at 06:26 AM. Review of Resident #1's nurse's progress note dated 02/24/2024 at 1:48 AM by LVN A revealed resident had an unwitnessed fall and the Physician, supervisor, and resident's representative were notified and a STAT x-ray to both hips were ordered. Review of Resident #1's nurse's progress note dated 02/24/2024 at 10:11 AM by LVN B reflected 9am Resident has facial grimacing and has been holding her left hip. [Physician C] notified ordered [Tylenol] 500mg tablet one q 4hrs prn pain.[Tylenol] 500mg tab one given for pain inital [sp] dose given for pain for pain level of 5. Repositioned in bed with both legs in straight alignment using pillows to keep legs straight align ment.10am good results from pain med.(1) 1011am Phone call made to [X-ray Company N] and they said he will be here shortly. Review of Resident #1's nurse's progress note dated 02/24/2024 at 12:27 PM by LVN B revealed at 12:24 PM [x-ray company N] had arrived to x-ray resident's hips and resident was observed moaning and holding her left hip and was given a Tylenol 500 mg for a pain level noted as a 4 and was turned and repositioned with pillows. Review of Resident #1's nurse's progress note date 02/24/2024 at 7:21 PM by LVN B revealed Resident #1's family had visited and were told the x-ray results were not in yet and staff had called x-ray services and they stated it would be awhile until results were ready. LVN B documented that the POA wanted Physician C called to ask for an order to transfer Resident #1 to the hospital via ambulance to be evaluated by the emergency room doctor. LVN B documented that Physician C gave orders to send Resident #1 to the hospital and Resident #1 was being transported via ambulance at 5:00 PM and DON notified at 5:09 PM. Review of Resident #1's Physician Orders for February 2024 reflected a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain. Record review of February 2024 MAR for 02/01/2024-02/29/2024 revealed an order for a pain evaluation every shift, 6:00 AM- 6:00 PM (day shift) and 6:00 PM to 6:00 AM shift (night shift). Review of resident pain level on the night shift of 02/23/2024 showed entry, initialed by LVN A, that noted resident's pain was a 0. The following morning shift on 02/24/2024 initialed by LVN B recorded a pain of 5. Review of Resident #1's MAR for February 2024 revealed a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain with blank spaces for 02/24/2024. Review of Hospital EMS record dated 02/24/24 reflected EMS received a phone call on 02/24/24 at 5:02 PM from facility. Resident #1 was transported from facility to local hospital for a possible hip fracture. Patient was having right hip pain secondary to a fall she sustained at 0100 this morning. Nursing staff stated they called for transport due to the patient not getting better. Patient was transported supine and immobilized the right hip area. Patient also has a history of [traumatic brain injury] due to a fall and hitting her head on a marble coffee table as stated by family in the room .Patient complains of pain on the left side during any movement .Lower extremities-patient had pain on left side with shortening of the left leg The EMS record reflected Resident #1 had chief complaint of hip hurting for 16 hour duration. Review of Hospital paperwork for Physician documentation dated 02/24/24 from Emergency Doctor reflected Resident #1 diagnosis of fracture of unspecified part of neck of left femur bone ( hip fracture). Resident #1 presented to ER with complaints of hip injury .coming into the emergency room with left hip pain after she had a fall at the nursing home patient denies any other injuries, she does have deformity on the left hip.X-ray shows a femoral neck fracture on the left side. Review of Hospital paperwork of Admitting History and Physical dated 02/24/24 reflected Resident #1 was a [AGE] year-old female nursing home resident with history of dementia, coronary artery disease, hypertension, type 2 diabetes and seizure disorder .She continued to have pain in left hip area after the fall at nursing home .Evaluation revealed left femoral neck (hip) fracture .It is relieved with oral hydrocodone .Pain with any movement of left hip .Plan.1. Left femoral neck fracture: Patient will be admitted to the hospital. IV morphine will be given as needed for pain control .orthopedic surgery was consulted. Plan to have surgical open reduction internal fixation tomorrow . Review of Hospital X-rays CR for pelvis and left hip with pain with traumas/injury dated 02/24/24 reflected Resident #1 had an acute left displaced subcapital femoral neck fracture (hip fracture). Review of Resident #1's X-ray by X-ray Company N of bilateral hips with pelvis dated 02/24/24 signed at 7:55 PM reflected an acute transverse fracture of the left of the neck femur (hip fracture). Review of Email dated 02/24/24 at 7:59 PM reflected DON and ADON were emailed to indicate a critical finding was flagged for patient [Resident #1], service date 02/24/24. Observation on 07/16/2024 at 9:40 AM of Resident #1 revealed she was asleep in bed on low position and with floor mats and interview with resident revealed she was confused, pleasant, and did not remember falling. Interview on 07/16/24 at 2:09 PM with resident's POA revealed on 02/24/2024 she was notified by the night nurse (LVN A) in the middle of the night that Resident #1 had a fall and was found on the floor with her blankets tangled around her legs and x-ray was ordered for Resident #1. She had another call later in the morning by LVN B about Resident #1 had been in bed all day and had a little discomfort and crying and was given Tylenol for pain and were awaiting x-ray to come. The POA and another family member visited Resident #1 on 02/24/24 in the late afternoon and resident was in bed with a pillow propped under her knee. POA said it seemed like the resident could not get comfortable because when she would make any movement with the left leg she would cry and grab it. She stated Resident #1 did not typically have pain and she was concerned that the fall had occurred in the middle of the night but there were still no x-ray results and resident was crying with any little movement and said it hurt. The POA stated she told the nurse (LVN B) that she was going to call 911 and have resident transported to ER and nurse said they needed to call the doctor to get an order and that the nurse would call. The POA checked a few minutes later and the nurse was helping a different resident and the POA and family member stated they would call 911 and nurse said no, she would do it immediately. The POA stated that she was frustrated that it seemed to take another 45 minutes before they had the call from Physician C to send resident to hospital via ambulance. The POA stated that the resident ended up having a fracture and had hip surgery. The POA stated she called the Administrator the following day and expressed her frustration about the delay in getting the resident to the hospital and x-ray results. The POA stated that the Administrator stated she knew and understood and had turned it in [to HHSC]. Interview on 07/16/2024 at 2:42 PM via phone with Physician C revealed he was notified in the middle of the night on 02/24/2024 that Resident #1 had a fall with some pain with movement and he ordered a STAT x-ray. He stated he thought he was called again later in the morning about the resident having some pain and he ordered Tylenol 500 mg every 4 hours as needed and asked about the status of the x-ray and was told they were waiting for x-ray to arrive. He stated he did not know Resident #1 was experiencing increasing pain until later into the evening when he was contacted by facility and informed that the family requested Resident #1 be sent to the emergency room (ER) due to her pain levels. He instructed that Resident #1 be sent to the hospital for an evaluation due to the level of pain resident had and the results of the x-ray were still pending. Physician C stated he reviewed the nurse's progress notes and did not know why Resident #1 received Tylenol 500 mg on 02/24/2024 at 9 am and then at 12:24 pm because it was too soon for another dose that if contacted he would have ordered a Tylenol #3 which is slightly stronger to manage the pain. Physician C stated that his expectation was if a resident's pain was not controlled then he would be called and he would either order stronger pain medication or send the resident to the hospital. Physician C stated that he expected the nurses to use their judgement and if a resident fell, and there was a suspicion of injury or the resident had uncontrolled pain, then they can send her to the ER themselves. He stated Resident #1 had injury of hip fracture. Interview on 07/16/2024 at 3:12 PM via phone with LVN A revealed on 02/24/24 resident was up and pacing the halls that evening which was typical for her and she was put back to bed a number of times. LVN A stated the CNA alerted LVN A that Resident #1 had fallen and she observed the resident lying on right side on the floor in her room next to her bed. LVN A stated that she assessed Resident #1 and she didn't seem to be in much pain but only mumbled and grumbled during transfer back into bed. She states she notified the doctor and the POA and an x-ray was ordered STAT by physician due to resident having some pain. LVN A stated she did not remember giving any pain medication to Resident #1 on her shift. LVN A stated she noticed later into her shift that Resident #1 was having more pain and discomfort when moving her lower extremities. She stated she contacted x-ray company about the STAT x-ray by phone but could not recall when she called the STAT x-ray in. LVN A stated she notified LVN B at shift change of Resident #1 had a fall and x-ray ordered for Resident #1. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/17/2024 at 5:09 PM via phone with LVN B revealed she was familiar with Resident #1 and that she had falls in the past but never had a serious injury until February 2024. She stated Resident #1 typically walked up and down the halls and it was common for her to cry, ask for family members, to lash out and throw things, hit or kick. LVN B stated that Resident #1 was able to indicate that she had pain verbally and would point to the area or say hurt. LVN B stated that on 02/24/2024 during the night to day shift change, LVN A informed her that Resident #1 had experienced a fall around the middle of the night- the POA and physician had been contacted, and an order for a STAT X-ray had been ordered. LVN B stated that during her shift Resident #1 did not display her typical behavior, she was in bed, displayed signs of pain such as facial grimacing and holding her left leg which appeared slightly turned out and was painful to touch. LVN B stated she thought Resident #1 had broken her hip. LVN B stated that she called Physician C around 9:00 AM to ask for pain medication because the resident did not have any orders pain medication and he prescribed Tylenol 500 mg as needed every 4 hours for pain and asked if the x-ray results were in yet. LVN A stated she told him they were not in yet and she would call about the x-ray status. LVN B stated that she gave Resident #1 Tylenol 500 mg and called the x-ray company at 10:11 AM and they stated they would be there soon. LVN B stated she must have forgotten to document she gave the Tylenol to Resident #1 in the Medication Administration Record (MAR) because there was a lot going on and Resident #1 ended up going back to sleep but was restless. LVN B stated that she did her best to make Resident #1 as comfortable as possible while waiting for x-ray to arrive and repositioned resident with legs in straight alignment using pillows to keep the legs straight based on her nursing experience that if a resident has a broken hip then you want to keep the legs straight. LVN B stated that around 12:24 PM the x-ray arrived and resident was observed to be moaning and crying during the x-ray and she repositioned the resident with straight legs and gave her another Tylenol 500 mg. LVN B stated Resident #1 was restless and with any little movement, expressed pain verbally, said she was hurting, had facial grimacing, and was pointing and holding at both sides of her hip but mostly the left side. LVN B stated that around 4:00 PM on 02/24/2024 the POA arrived and was concerned about the resident. LVN B stated Resident #1 had facial grimacing, grabbed at both of her hips, cried with any movement and said she was in pain. She stated at the POA's request she contacted Physician C and received an order to transfer resident to the emergency room around 5:00 PM. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/19/24 at 2:36 PM with CNA G revealed she worked the day shift on 02/24/24 when Resident #1 was grunting. She stated she overheard LVN A tell LVN B about Resident #1 having a fall on the night shift. She stated at breakfast Resident #1 did not want to get up and eat breakfast. She recalled during her shift Resident #1 was crying constantly and looked to be in pain by holding and gesturing to left side. She stated LVN B gave Resident #1 pain medication not sure what time sometime after breakfast. CNA G stated she used gait belt to transfer Resident #1 into wheelchair and put her back in bed with gait belt. She stated Resident #1 was showing signs of pain of moaning and crying along with holding and guarding her left side. She stated LVN B did not give her any instruction about transferring or positioning resident. She stated Resident #1 stayed in the bed for the rest of the shift after noticing Resident #1 was in pain with transfer. She stated sometime after lunch before supper Resident #1's family came and were upset the x-ray results were not in yet for Resident #1 asking for her to be sent to hospital due to her being in pain. She stated LVN B sent Resident #1 to the hospital. Interview on 07/16/2024 at 12:58 PM with the DON revealed if a resident falls they are assessed by a nurse for pain and injury and if a resident could not speak, the PAINAD (pain assessmnt scale) should be used. The DON stated she expected mobile STAT x-ray can take anywhere up to 4-6 hours to be completed. The DON stated that she expected staff to document any medication given in the MAR. She was not able to find documentation of pain medication given in the February 2024 MAR for Resident #1. Interview on 07/16/2024 at 1:26 PM with the Corporate Nurse, revealed her expectations for staff documentation of medication administration were the same as the DON mentioned and expected it to be documented in the MAR to show pain medication administered. Interview on 07/17/2024 at 10:56 AM with LVN F revealed she was familiar with Resident #1 and was not working on the day of her fall on 02/24/2024. LVN F stated Resident #1 did not typically display pain indicators before her fall on 02/24/2024 and she was able to point to or tell you where the pain was and cried if in pain. She stated she could not recall an in-service on pain management she received. Interview on 07/17/24 at 11:01 AM with LVN I revealed she had not received an in-service or training on x-ray services or pain management within the last year that she could recall. Interview on 07/17/24 at 11:12 AM with CNA H revealed Resident #1 yelled out when in pain after she sustained hip fracture but she did not work on 02/24/24. She stated Resident #1 grumbling or mumbling during movements was not normal it would tell me she was hurting and in pain. She states she would tell the nurse of any indicators of pain for residents immediately. Review of Email received from X-ray Company N dated 07/16/24 at 4:38 PM sent to ADON revealed the X-ray Company N notes indicated received phone call from [LVN A] at 4:01 AM who took the order. It was originally placed as routine. [LVN B] called at 10:21 AM and the order was changed to a STAT. [X-ray tech] called facility at 10:40 am and spoke to [LVN A] with ETA. [X-ray tech] arrived at 12:15 PM . Interviews on 07/16/24 at 5:32 and 5:56 PM with ADON revealed Resident #1 was sent out via 911 by LVN B after LVN B notified Physician C and physician ordered Resident #1 to be sent out to hospital for further evaluation. She stated she expected stat x-ray results to be completed within 4 to 6 hours. She was not sure what time stat x-ray results had come to the facility and Resident #1 was sent to the hospital prior to receiving stat x-ray results. She stated she was not working on 02/24/24 and did not read her email to indicate Resident #1 had critical finding for her x-ray. She stated she was aware of Resident #1 being sent to the hospital and having a fracture on 02/25/24 when she was at work. Interview on 07/17/24 at 9:05 AM with DON revealed she expected charge nurse to document what time she contacted x-ray company to order stat x-ray and when she notified Physician C. She stated the stat x-ray order should have been put in the electronic record as a telephone order after getting the order from Physician C. She stated she was unable to find documentation of telephone physician order by LVN A. She stated LVN B should have documented the administration of the prn Tylenol order on 02/24/24 but stated at least it was in the progress notes when Resident #1 received Tylenol. She stated Resident #1 was sent out to the hospital on [DATE] at 5:09 PM and facility had not received the stat x-ray results. The DON stated Resident #1 should have been sent out to the hospital prior to 5 pm if Resident #1 was exhibiting increasing signs of pain as indicated by the progress notes. She stated LVN A should have reached out to the physician for a pain medication order and to give a report of Resident #1's pain to the physician. The DON stated a delay in pain management placed Resident #1 at risk for increased pain and suffering. She stated she did not review Resident #1's stat x-ray results until 02/25/24 and she did receive an email in the evening about a critical x-ray result but she did not review it until the next morning. She stated Resident #1's stat x-ray results were not received until after Resident #1 was sent to the hospital. She stated the facility had not in-serviced on pain management or x-ray services since 02/24/24. Interview on 07/19/2024 at 3:20 PM with ADON revealed Resident #1 did not usually have pain and when she did she would be able to say she is in pain by gesturing to area she was hurting. She stated Resident #1 would display pain indicators with facial grimaces, crying, or sweating. The ADON stated that if a resident is nonverbal then they would display signs of pain such as grimacing, breathing changes, guarding of the site, crying; and for residents with dementia the PAINAD scale should be used to assess pain. She stated based on reviewing Resident #1's progress notes on 02/24/24 by LVN A and LVN B there were indicators of pain displayed by Resident #1 including grumbling during transfer, grimacing, crying, moaning and holding onto her hip. Review of facility's in-service dated 10/21/23 to Nurses and CNA reflected Acute Condition Changes - Clinical Protocol policy was reviewed which included Nurse shall assess and document/report the following baseline information .c. Current level of pain, and any recent changes in pain level . It reflected LVN B attended in-service but LVN A did not attend in-service. Review of facility's policy titled Pain Assessment and Management, dated 2001 and revised March 2015, reflected to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under 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. Pain management is a multidisciplinary care process that includes the following: a. assessing the potential for pain; b. effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. addressing the underlying causes of the pain; e. developing and implementing approaches to pain management; f. identifying and using specific strategies for different levels and sources of pain; g. monitoring for effectiveness of interventions; and h. modifying approaches as necessary . 5. Conduct a comprehensive pain assessment .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain . Under Recognizing Pain, it reflected .2. Possible Behavioral signs of pain a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing .d. Behavior such as .decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body . Under Assessing pain it reflected During the comprehensive pain assessment gather the following as indicated from the resident .Characteristics of pain (1) Intensity of Pain, (2) Descriptors of pain (3) Pattern of pain (4) Location and radiation of pain and (5) Frequency, timing and duration of pain . An Immediate Jeopardy was identified on 07/17/24. The Administrator and the DON were notified on 07/17/24 at 12:15 PM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 07/18/24 at 3:49 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Problem: Pain (F697) The facility failed to treat residents' pain in a timely manner. Plan: 1. [Physician C] Medical Director has been notified of the Immediate Jeopardy by the Administrator on 07/17/2024. QAPI was conducted with the medical director. 2. Administrator/Designee initiated in-service on abuse and neglect on 07/17/24. 3. Regional Nurse to educate DON regarding assessing residents for pain after an incident and of sending the resident to the ER for evaluation if inhouse Xray cannot be obtained timely. DON educated on assessing pain in the moderate to severely cognitively impaired. Completion: 07/18/24 4. DON/designee will initiate assessing residents who have fallen from July 1, 2024, to current for indicators of pain i.e., verbal/non-verbal on 07/17/24. Completion date: 07/17/24. 5. DON/designee initiated in-service on 07/17/24 with charge nurses/agency nurses on the following: o Pain Management verbal and non-verbal indicators following a fall. o Pain Assessment observation form completion following a fall. o Notification to physician when pain medication is ineffective. o Assessing pain using a consistent approach and a standardized pain assessment (PAINAD) instrument appropriate to the resident's cognitive level (moderate to severe cognitive impairment). Completion: 07/18/24 and ongoing 6. DON/designee initiated in-service with nurse aides, medication aides and managers on duty/agency staff on reporting indicators of pain i.e., verbal or non-verbal to the charge nurse. Completion: 7/18/24 and ongoing 7. Charge nurses, agency nurses, aides, certified staff not working during the in-services on Pain, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period. Agency nurses will be in-service prior to beginning their shift. 8. Licensed and certified nursing staff/agency staff will be given a competency-based quiz on pain. Completion: 7/18/24 9. Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall pain management. 10. Weekend supervisor was in-serviced on monitoring the Facility Activity Report and follow-up on orders i.e., X-ray, and residents with pain. Completed: 07/18/24 The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 07/17/24 reflected CNAs, nursing and nursing administration (ADON, Weekend RN Supervisor and DON) were in-serviced on pain management, nursing documentation about pain assessment, notification to physician when exhibit change of condition of pain onset, physician orders for pain medication and x-ray orders, and laboratory, diagnostic and radiology services On 07/19/24 between 10:55 AM and 6:51 PM revealed four (4) licensed vocational nurses were interviewed, from different shifts, on training and new system to ensure compliance for pain management. All nursing staff were able to verbalize understanding of how to assess for pain for residents with nonverbal indicators to use painad scale and give examples of pain indicators for nonverbal residents. Nursing was in-serviced on training regarding stat x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of physician's orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. Nursing was knowledgeable on inputting physician orders for x-rays and to notify physician if there is a delay in stat x-ray services. Nursing stated if resident showed increasing signs of pain since unwitnessed fall and/or pain during movements they would send resident out to hospital for further evaluation. They would contact ADON, DON or weekend RN supervisor if having issues with x-ray services. Nursing aware of time for completion of stat x-rays to be with 4 to 6 hours and to follow up if results of stat x-ray have not been received. On 07/19/24 between 2:36 PM to 6:15 PM revealed four (4) CNAs were interviewed, from different shifts on training and notifying nurses of indicators of resident pain. All CNAs could give examples of verbal and nonverbal indicators of pain and would immediately notify charge nurse of any concerns with resident pain. If CNAs felt like nurse was not following up with resident about pain,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for one (Resident #1) of six residents reviewed for radiology services. 1. The facility failed to ensure that a stat x-ray was completed in a timely manner for Resident #1 on 02/24/24. 2. The facility failed to follow up to get Resident #1's stat x-ray results in a timely manner on 02/24/24. Resident #1 had an unwitnessed fall on 02/24/24 at 12:17 AM and sustained an injury. LVN A failed to ensure x-ray physician order was placed stat and not routine 12 hours after the unwitnessed fall, X-ray tech was at facility to complete stat x-ray for Resident #1. 17 hours after unwitnessed incident, Resident was sent to hospital for increasing pain and x-ray results had not been received. As a result, Resident #1 was admitted to the hospital (19 hour delay) since pain onset and unwitnessed fall for a left displaced hip fracture and had surgery to repair the fracture. An Immediate Jeopardy (IJ) was identified on 07/17/24. The IJ Template was provided to the facility on [DATE] at 12:15 PM. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained on x-ray services. These failures could place resident at risk of results in delayed diagnosis, medical treatment, and hospitalization. Findings include: Review of Resident #1's face sheet dated 07/16/24 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had diagnoses of traumatic brain injury (form of acquired brain injury occurs when a sudden trauma causes damage to the brain), hypertension (high blood pressure), unsteadiness on feet, cognitive communication deficit, anxiety disorder (persistent feelings of worry or fear) and depression disorder (episodes of persistently sad moods) and a BIMS score of 00 (severely impaired cognition). Review of Resident #1's comprehensive care plan last revised on 06/11/24 revealed resident had experienced multiple falls included a fall on 02/24/2024 but did not indicate injury of hip fracture. Interventions included floor mats next to bed when resident was in bed, ensure her nonskid socks are on, and check frequently to make sure resident was not self-transferring, and to monitor pain during task. Review of Event Report for Resident #1 by LVN A with an event date of 02/24/2024 at 12:17 AM, dated recorded 02/24/2024 at 06:18 AM and closed date of 02/26/2024 at 1:38 PM by the DON reflected an unwitnessed fall in resident room. Resident seen lying on her right side on the floor in her room. Resident confused, pacing around in hallway & room. Resident re-directed & repositioned back to bed several times but prove abortive. CNA called [Charge Nurse] that resident is on the floor, resident seen lying on her right side on the floor close to the door. When asked, resident unable to explain, Resident mumbling & grumbling during transfer. Vital signs Blood pressure: 129/73, Pulse :68, Respiratoins:18, 02:96% [room air], T:97.4. No skin tear noted. Stat xray to bilateral hip ordered. Resident's POA, Supervisor & MD notified. Neuro checks initiated. Resident's pain was noted to be a 1 out of 10 (mild) and had painful and/or limited range of motion in her lower extremities. She was responsive to her name and to pain and was able to perceive her environment clearly and responded appropriately to stimuli. Review of Post Fall Observation report with an observation date of 02/24/2024 at 12:21 AM and completed dated of 02/24/2024 at 6:24 AM by LVN A reflected Resident #1 was previously in her bed and had an unwitnessed fall and was seen lying on her left side in her room. LVN A documented that Resident #1 had an agitated and confused mental status prior to the fall, and a pain level of 3 of 10 at 06:26 AM. Review of Resident #1's nurse's progress note dated 02/24/2024 at 1:48 AM by LVN A revealed resident had an unwitnessed fall and the Physician, supervisor, and resident's representative were notified and a STAT x-ray to both hips were ordered. Review of Resident #1's nurse's progress note dated 02/24/2024 at 10:11 AM by LVN B reflected 9am Resident has facial grimacing and has been holding her left hip. [Physician C] notified ordered [Tylenol] 500mg tablet one q 4hrs prn pain.[Tylenol] 500mg tab one given for pain inital [sp] dose given for pain for pain level of 5. Repositioned in bed with both legs in straight alignment using pillows to keep legs straight align ment.10am good results from pain med.(1) 1011am Phone call made to [X-ray Company N] and they said he will be here shortly. Review of Resident #1's nurse's progress note dated 02/24/2024 at 12:27 PM by LVN B revealed at 12:24 PM [x-ray company N] had arrived to x-ray resident's hips and resident was observed moaning and holding her left hip and was given a Tylenol 500 mg for a pain level noted as a 4 and was turned and repositioned with pillows. Review of Resident #1's nurse's progress note date 02/24/2024 at 7:21 PM by LVN B revealed Resident #1's family had visited and were told the x-ray results were not in yet and staff had called x-ray services and they stated it would be awhile until results were ready. LVN B documented that the POA wanted Physician C called to ask for an order to transfer Resident #1 to the hospital via ambulance to be evaluated by the emergency room doctor. LVN B documented that Physician C gave orders to send Resident #1 to the hospital and Resident #1 was being transported via ambulance at 5:00 PM and DON notified at 5:09 PM. Review of Resident #1's Physician Orders for February 2024 reflected a physician order with a start date of 02/24/2024 and end date of 02/28/2024 for APAP [Tylenol] 500 MG one tablet, every 4 hours for pain. Review of Hospital EMS record dated 02/24/24 reflected EMS received a phone call on 02/24/24 at 5:02 PM from facility. Resident #1 was transported from facility to local hospital for a possible hip fracture. Patient was having right hip pain secondary to a fall she sustained at 0100 this morning. Nursing staff stated they called for transport due to the patient not getting better. Patient was transported supine and immobilized the right hip area. Patient also has a history of [traumatic brain injury] due to a fall and hitting her head on a marble coffee table as stated by family in the room .Patient complains of pain on the left side during any movement .Lower extremities-patient had pain on left side with shortening of the left leg The EMS record reflected Resident #1 had chief complaint of hip hurting for 16 hour duration. Review of Hospital paperwork for Physician documentation dated 02/24/24 from Emergency Doctor reflected Resident #1 diagnosis of fracture of unspecified part of neck of left femur. Resident #1 presented to ER with complaints of hip injury .coming into the emergency room with left hip pain after she had a fall at the nursing home patient denies any other injuries, she does have deformity on the left hip X-ray shows a femoral neck fracture on the left side. Review of Hospital paperwork of Admitting History and Physical dated 02/24/24 reflected Resident #1 was a [AGE] year-old female nursing home resident with history of dementia, coronary artery disease, hypertension, type 2 diabetes and seizure disorder .She continued to have pain in left hip area after the fall at nursing home .Evaluation revealed left femoral neck (hip) fracture .It is relieved with oral hydrocodone .Pain with any movement of left hip .Plan.1. Left femoral neck fracture: Patient will be admitted to the hospital. IV morphine will be given as needed for pain control .orthopedic surgery was consulted. Plan to have surgical open reduction internal fixation tomorrow . Review of Hospital X-rays CR for pelvis and left hip with pain with traumas/injury dated 02/24/24 reflected Resident #1 had an acute left displaced subcapital femoral neck fracture (hip). Review of Resident #1's X-ray by X-ray Company N of bilateral hips with pelvis dated 02/24/24 signed at 7:55 PM reflected an acute transverse fracture of the left of the neck femur (hip). Review of Email dated 02/24/24 at 7:59 PM reflected DON and ADON were emailed to indicate a critical finding (findings/results require immediate or urgent communication with the provider) was flagged for patient [Resident #1], service date 02/24/24. Observation on 07/16/2024 at 9:40 AM of Resident #1 revealed she was asleep in bed on low position and with floor mats and interview with resident revealed she was confused, pleasant, and did not remember falling. Interview on 07/16/24 at 2:09 PM with resident's POA revealed on 02/24/2024 she was notified by the night nurse (LVN A) in the middle night that Resident #1 had a fall and was found on the floor with her blankets tangled around her legs and x-ray was ordered for Resident #1. She had another call later in the morning by LVN B about Resident #1 had been in bed all day and had a little discomfort and crying and was given Tylenol for pain and were awaiting x-ray to come. The POA and another family member visited Resident #1 on 02/24/24 in the late afternoon and resident was in bed with a pillow propped under her knee. POA seemed like the resident could not get comfortable because when she would make any movement with left leg she would cry and grab it. She stated Resident #1 did not typically have pain and she was concerned that the fall had occurred in the middle of the night but there were still no x-ray results and resident was crying with any little movement and said it hurt. The POA stated she told the nurse (LVN B) that she was going to call 911 and have resident transported to ER and nurse said they needed to call the doctor to get an order and that the nurse would call. The POA checked a few minutes later and the nurse was helping a different resident and the POA and family member stated they would call 911 and nurse said no, she would do it immediately. The POA stated that she was frustrated that it seemed to take another 45 minutes before they had the call from Physician C to send resident to hospital via ambulance. The POA stated that the resident ended up having a fracture and had hip surgery. The POA stated she called the Administrator the following day and expressed her frustration about the delay in getting the resident to the hospital and x-ray results. The POA stated that the Administrator stated she knew and understood and had turned it in [to HHSC]. Interview on 07/16/2024 at 2:42 PM via phone with Physician C revealed he was notified in the middle of the night on 02/24/2024 that Resident #1 had a fall with some pain with movement and he ordered a STAT x-ray. He stated he thought he was called again later in the morning about the resident having some pain and he ordered Tylenol 500 mg every 4 hours as needed and asked about the status of the x-ray and was told they were waiting for x-ray to arrive. He stated he did not know Resident #1 was experiencing increasing pain until later into the evening when he was contacted by facility and informed that the family requested Resident #1 be sent to the emergency room (ER) due to her pain levels. He instructed that Resident #1 be sent to the hospital for an evaluation due to the level of pain resident had and the results of the x-ray were still pending. Physician C stated he reviewed the nurse's progress notes and did not know why Resident #1 received Tylenol 500 mg on 02/24/2024 at 9 am and then at 12:24 pm because it was too soon for another dose that if contacted he would have ordered a Tylenol #3 which is slightly stronger to manage the pain. Physician C stated that his expectation was if a resident's pain was not controlled then he would be called and he would either order stronger pain medication or send the resident to the hospital. Physician C stated that he expected the nurses to use their judgement and if a resident fell, and there was a suspicion of injury or the resident had uncontrolled pain, then they can send her to the ER themselves. He stated Resident #1 had injury of hip fracture. Interview on 07/16/2024 at 3:12 PM via phone with LVN A revealed on 02/24/24 resident was up and pacing the halls that evening which was typical for her and she was put back to bed a number of times. LVN A stated the CNA alerted LVN that Resident #1 had fallen and she observed the resident lying on right side on the floor in her room next to her bed. LVN A stated that she assessed Resident #1 and she didn't seem to be in much pain but only mumbled and grumbled during transfer back into bed. She states she notified the doctor and the POA and an x-ray was ordered STAT by physician due to resident having some pain. LVN A stated she did not remember giving any pain medication to Resident #1 on her shift. LVN A stated she noticed later into her shift that Resident #1 was having more pain and discomfort when moving her lower extremities. She stated she contacted x-ray company about the STAT x-ray by phone but could not recall when she called the STAT x-ray in. LVN A stated she notified LVN B at shift change of Resident #1 had a fall and x-ray ordered for Resident #1. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/17/2024 at 5:09 PM via phone with LVN B revealed she was familiar with Resident #1 and that she had falls in the past but never had a serious injury until February 2024. She stated Resident #1 typically walked up and down the halls and it was common for her to cry, ask for family members, to lash out and throw things, hit or kick. LVN B stated that Resident #1 was able to indicate that she had pain verbally and would point to the area or say hurt. LVN B stated that on 02/24/2024 during the night to day shift change, LVN A informed her that Resident #1 had experienced a fall around the middle of the night- the POA and physician had been contacted, and an order for a STAT X-ray had been ordered. LVN B stated that during her shift Resident #1 did not display her typical behavior, she was in bed, displayed signs of pain such as facial grimacing and holding her left leg which appeared slightly turned out and was painful to touch. LVN B stated she thought Resident #1 had broken her hip. LVN B stated that she called Physician C around 9:00 AM to ask for pain medication because the resident did not have any orders pain medication and he prescribed Tylenol 500 mg as needed every 4 hours for pain and asked if the x-ray results were in yet. LVN A stated she told him they were not in yet and she would call about the x-ray status. LVN B stated that she gave Resident #1 Tylenol 500 mg and called the x-ray company at 10:11 AM and they stated they would be there soon. LVN B stated she must have forgotten to document she gave the Tylenol to Resident #1 in the Medication Administration Record (MAR) because there was a lot going on and Resident #1 ended up going back to sleep but was restless. LVN B stated that she did her best to make Resident #1 as comfortable as possible while waiting for x-ray to arrive and repositioned resident with legs in straight alignment using pillows to keep the legs straight based on her nursing experience that if a resident has a broken hip then you want to keep the legs straight. LVN B stated that around 12:24 PM the x-ray arrived and resident was observed to be moaning and crying during the x-ray and she repositioned the resident with straight legs and gave her another Tylenol 500 mg. LVN B stated Resident #1 was restless and with any little movement, expressed pain verbally, said she was hurting, had facial grimacing, and was pointing and holding at both sides of her hip but mostly the left side. LVN B stated that around 4:00 PM on 02/24/2024 the POA arrived and was concerned about the resident. LVN B stated Resident #1 had facial grimacing, grabbed at both of her hips, cried with any movement and said she was in pain. She stated at the POA's request she contacted Physician C and received an order to transfer resident to the emergency room around 5:00 PM. She stated she was not in-serviced on pain management or x-ray services since incident. Interview on 07/19/24 at 2:36 PM with CNA G revealed she worked the day shift on 02/24/24 when Resident #1 was grunting. She stated she overheard LVN A tell LVN B about Resident #1 having a fall on the night shift. She stated at breakfast Resident #1 did not want to get up and eat breakfast. She recalled during her shift Resident #1 was crying constantly and looked to be in pain by holding and gesturing to left side. She stated LVN B gave Resident #1 pain medication not sure what time sometime after breakfast. CNA G stated she used gait belt to transfer Resident #1 into wheelchair and put her back in bed with gait belt. She stated Resident #1 was showing signs of pain of moaning and crying along with holding and guarding her left side. She stated LVN B did not give her any instruction about transferring or positioning resident. She stated Resident #1 stayed in the bed for the rest of the shift after noticing Resident #1 was in pain with transfer. She stated sometime after lunch before supper Resident #1's family came and were upset the x-ray results were not in yet for Resident #1 asking for her to be sent to hospital due to her being in pain. She stated LVN B sent Resident #1 to the hospital. Interview on 07/16/2024 at 12:58 PM with the DON revealed if a resident falls they are assessed by a nurse for pain and injury and if a resident could not speak, the PAINAD should be used. The DON stated she expected mobile STAT x-ray can take anywhere up to 4-6 hours to be completed. The DON stated charge nurse was responsible for calling X-ray company N by phone after obtaining a physician order for x-ray orders including stat x-ray orders. Interview on 07/17/2024 at 10:56 AM with LVN F revealed she could not recall an in-service on pain management she received and was unaware of any in-service for X-ray services Interview on 07/17/24 at 11:01 AM with LVN I revealed she had not received an in-service or training on x-ray services or pain management within the last year that she could recall. Review of Email received from X-ray Company N dated 07/16/24 at 4:38 PM sent to ADON revealed the X-ray Company N notes indicated received phone call from [LVN A] at 4:01 AM who took the order. It was originally placed as routine. [LVN B] called at 10:21 AM and the order was changed to a STAT. [X-ray tech] called facility at 10:40 am and spoke to [LVN A] with ETA. [X-ray tech] arrived at 12:15 PM . Interviews on 07/16/24 at 5:32 and 5:56 PM with ADON revealed Resident #1 was sent out via 911 by LVN B after LVN B notified Physician C and physician ordered Resident #1 to be sent out to hospital for further evaluation. She stated she expected stat x-ray results to be completed within 4 to 6 hours. She stated X-ray company N reported according to their records Resident #1's x-ray was called in as routine at 4:01 by LVN A on 02/24/24 but was changed to stat by LVN B when she reached out to them. She was not sure what time stat x-ray results had come to the facility and Resident #1 was sent to the hospital prior to receiving x-ray results. She stated she was not working on 02/24/24 and did not read her email to indicate Resident #1 had critical finding for her x-ray. She stated she was aware of Resident #1 being sent to the hospital and having a fracture on 02/25/24 when she was at work. Interview on 07/17/24 at 9:05 AM with DON revealed she expected charge nurse to document what time she contacted x-ray company to order stat x-ray and when she notified Physician C. She stated the stat x-ray order should have been put in the electronic record as a telephone order after getting the order from Physician C. She stated she was unable to find documentation of telephone physician order by LVN A. She stated LVN A should have documented and inputted x-ray order into the electronic record as a physician telephone order. She stated Resident #1 was sent out to the hospital on [DATE] at 5:09 PM and facility had not received the stat x-ray results. The DON stated Resident #1 should have been sent out to the hospital prior to 5 pm if Resident #1 was exhibiting increasing signs of pain and x-ray results had not been received as indicated by the progress notes. The DON stated a delay in receiving stat x-ray results could place Resident #1 at risk for increased pain and suffering. She stated she did not review Resident #1's stat x-ray results until 02/25/24 and she did receive an email in the evening about a critical x-ray result but she did not review it until the next morning. She stated Resident #1's stat x-ray results were not received until after Resident #1 was sent to the hospital. She stated the facility had not in-serviced on pain management or x-ray services since 02/24/24. Facility was unable to provide any in-service on X-ray services per DON on 07/16/24. Review of X-ray Company N's Contract with Facility effective 12/01/19 reflected C. Provider shall perform the service required hereunder in accordance with: I. All applicable federal, state, and local laws, rules and regulations. II. All applicable standards of all relevant accrediting organizations, and III. All applicable policies, rules and regulations. The facility did not have a policy for X-ray services per DON on 07/16/24. An Immediate Jeopardy was identified on 07/17/24. The Administrator and the DON were notified on 07/17/24 at 12:15 PM of the Immediate Jeopardy. IJ template provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 07/18/24 at 3:49 PM. The accepted plan of removal for the Immediate Jeopardy included the following: Problem: Radiology (F776) The facility failed to ensure an x-ray was completed in a timely manner for a resident who sustained an injury/pain from a fall. The facility failed to follow up to get the results for a stat x-ray for a resident who sustained injury/pain from a fall in a timely manner. The facility failed to follow their policy for x-rays with residents who sustain an injury/pain with a fall. Plan: 11. [Physician C], Medical Director has been notified of the Immediate Jeopardy by the Administrator on 07/17/2024. QAPI was conducted with the medical director. 12. Administrator/Designee initiated in-service on abuse and neglect on 07/17/24. 13. Regional Nurse to educate DON regarding assessing residents for pain after an incident, ordering STAT X-ray, completion, and follow-up of X-ray. Education includes obtaining order for X-ray, entering order in EHR/Matrix, sending the resident to the ER for evaluation if in-house X-ray cannot be obtained timely. Completion: 7/17/2024 14. DON/Designee initiated in-services on 07/17/24 with charge nurses/agency nurses on how to order a STAT X-ray, timely follow-up on X-rays related to X-ray completion and results which should be obtained within four hours when related to injury/pain, if longer than four hours resident(s) need to be transported to emergency room per physician's order. 15. In-service charge nurses/agency nurses on notification to the DON/designee after hours and on weekends related to resident falls and results of pending X-rays initiated on 07/17/24. Completion: 07/17/24 16. Audit was completed on X-rays ordered in the last 30 days. Completion: 07/17/2024 17. Charge nurses, agency nurse/aides, and certified staff not working during the in-services on X-rays, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period. 18. The weekend supervisor was in-service monitoring the Facility Activity Report and follow-up on orders i.e, X-ray, and residents with pain. Completed: 07/17/24 19. Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by the weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall with major injury for timely completion of X-ray and results. 20. Facility charge nurses and agency nurses will be given a competency-based quiz on following physician orders. Completion: 7/18/24 The facility's implementation of the IJ Plan of Removal was verified through the following: Review of facility's in-service initiated for 07/17/24 reflected CNAs, nursing and nursing administration (ADON, Weekend RN Supervisor and DON) were in-serviced on pain management, nursing documentation about pain assessment, notification to physician when exhibit change of condition of pain onset, following physician orders for pain medication and x-ray orders, and laboratory, diagnostic and radiology services timeliness. On 07/19/24 between 10:55 AM and 6:51 PM revealed four (4) licensed vocational nurses were interviewed, from different shifts, on training and new system to ensure compliance for pain management. All nursing staff were able to verbalize understanding of how to assess for pain for residents with nonverbal indicators to use painad scale and give examples of pain indicators for nonverbal residents. Nursing was in-serviced on training regarding stat x-rays to be completed in timely manner and to follow up to get results in a timely manner. They were knowledgeable of expectation of physician's orders for x-rays that they needed to obtain x-ray orders and contact x-ray company to follow the physician x-ray orders. Nursing were knowledgeable on inputting physician orders for x-rays and to notify physician if there is a delay in stat x-ray services. Nursing stated if resident showed increasing signs of pain since unwitnessed fall and/or pain during movements they would send resident out to hospital for further evaluation. They would contact ADON, DON or weekend RN supervisor if having issues with x-ray services. Nursing aware of time for completion of stat x-rays to be with 4 to 6 hours and to follow up if results of stat x-ray have not been received. Interview on 07/19/24 with ADON at 4:45 PM revealed LVN B is currently on leave and she will be in-serviced 1:1 about pain management and x-ray services timeliness. She stated she was responsible to ensure new nurses were in-serviced going forward prior to working the floor on pain management and x-ray services. She stated her and the DON have incorporate a tool of auditing residents sent to hospital and x-ray services to ensure timeliness of stat x-rays ordered. She stated they have not in-serviced LVN A yet and will be doing a 1:1 inservice with her about pain management, documentation and x-ray services timeliness. She stated all current staff have been in-serviced and she will be working this weekend to ensure all nursing are in-serviced. She stated at morning meeting they will discuss any residents sent to the hospital, any concerns with pain management and x-ray services. She stated RN weekend supervisor will be overseeing on the weekends to ensure pain management and x-ray services are addressed. She stated the DON is out today due to personal leave. She stated her and the DON will be notified of any critical x-ray lab results and will look at them immediately then they will contact the charge nurse to follow up to ensure nursing is addressing resident needs. On 07/19/24 at 7:03 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of pattern that is not immediate jeopardy and severity level of potential for more than minimal harm. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems for diagnostic services.