**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #14) residents reviewed for intravenous fluids. The facility failed to ensure LVN A removed bubbles from the IV tubing, removed air from the syringe and flushed the PICC line before IV medication administration for Resident# 14. An IJ was identified on 09/26/24. The IJ template was provided to the facility on [DATE] at 5:59 p.m. While the IJ was removed on 09/27/24 at 9:40 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system. This deficient practice could place residents at risk for serious harm, injury, or death by introducing air into an PICC line which could cause an air embolism (bubbles trapped in a blood vessel that can block blood flow). Findings include: Record review of Resident #14's face sheet dated 09/12/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included: diabetes mellitus (the body cannot control the amount of sugar in the blood), hypertension (pressure in the blood vessels is always higher than normal), and heart failure (when heart is unable to pump enough oxygenated blood to meet the body's needs). Record review of Resident #14's admission MDS assessment dated [DATE] revealed a BIMS score of 13 of 15 which indicated intact cognition. Further review revealed the resident needed moderate to extensive assistance with ADLs which required at least one staff assistance. Further review did not reflect Resident #14 was on IV medication. Record review of Resident #14's care plan initiated on 07/28/24 revealed resident had an ADL self-care deficit related to inability to perform activities of daily living independently. Intervention: Requires assistance of staff. Further review reflected the resident was on IV antibiotic therapy related to infection osteomyelitis of the right toe. Intervention: administer medication as ordered. Record review of Resident #14's clinical physician orders read in part . PICC/CENTRAL LINE (Peripherally Inserted Central Catheter): flush with 10 CC NS each shift before medication administration .order date 07/25/24 . meropenem intravenous solution reconstituted 500mg every 12 hours for osteomyelitis(bone infection ) for 2 weeks start date 09/04/24 . During an observation on 09/11/24 at 6:52 a.m., LVN A administered IV meropenem 500 mg intravenously to Resident #14, who was lying in bed on his back. LVN A went into the medication room, brought the medication and the tubing, and placed the medication at the nursing station. LVN A broke the medication seal, spiked the medication bag with the tubing, hung it on the IV pole, and cleaned Resident #14's port. After LVN A cleaned Resident #14's port, he opened the clamp, and the medication flowed into the tubing. There were numerous bubbles in the tubing a few inches below the chamber and at intervals throughout the tubing. LVN A was about to connect the tubing to the port on Resident #14's arm when the surveyor intervened. LVN A said he was moving too fast and should have primed the medication and removed all the bubbles. LVN A primed the tubing and removed the bubbles. LVNA was about to connect the tubing to Resident #14's port without flushing the port, and the surveyor intervened. LVN A opened the flush and was about to flush Resident #14's port, but he did not remove the air in the flush. LVN A was about to insert the flush syringe into Resident #14's port when the surveyor intervened, and he primed the flush and administered the medication. During an interview on 09/11/24 at 3:54 p.m., LVN A said he did not realize the IV line had bubbles, and if he had administered the IV medication with bubbles, he could have caused Resident #14 to have an air embolism (bubbles trapped in a blood vessel that can block blood flow) . LVN A said he did not take out the air in the flush, and it was unsafe for Resident #14 because that would be air going through Resident #14's vein. LVN A said he had training in IV medication administration, and the DON and clinical manager monitored the nurses during rounding. During an interview on 09/12/24 at 11:55 a.m., The DON said LVN A should have ensured all the air was out of the tubing before he hooked up to Resident #14's port. The DON said LVN A should have primed the IV line to prevent air embolism and pain. The DON said LVN A should have flushed the port before administering the medication. The DON said the line should be flushed to make sure the line was patent (open and unobstructed free passage) and there was no clot or infiltration. During an interview on 09/26/24 at 2:55 p.m., LVN A said the facility provided in-services in the last month, and he did skills check-off, but the facility did not provide a certificate. LVN A said he never did a training that issued an IV administration certificate. During an interview on 09/26/24 at 3:27 p.m., the DON said their contract pharmacy had done the nurse's IV Training. Still, the pharmacy representative told her he could not locate any training for facility nurses from 2021 to the present. The DON said RNs and LVNs should have an IV Administration Certificate before administering their first IV and be monitored during their first IV administration. The DON said she did not know if the IV Certificate was a requirement with the facility, State, or Board of Nursing, but she would look into it. During an interview on 09/26/24 at 3:53 p.m., the NP said she did not get a call from the facility about LVN A's attempt to administer IV medication with bubbles in the line and not flushing the line before administering the medication. The NP said LVN A should have primed the tubing and made sure there were no bubbles in the line, if the bubble was big(3mm), then the bubble could cause respiratory distress, air embolism. The NP said LVN A should have pushed out the air from the flush syringe before he attempted to flush Resident #14's port, which was done to make sure the line was patent. The NP said 3mm of air could be bad for Resident #14. During an interview on 09/26/24 at 3:58 p.m., the Educator said IV certification was not required, but nurses are checked off on IV medication skills. The Educator said IV monitoring and staff rounding should be done randomly and periodically by the CM and the DON. The Educator said if issues are observed, the facility will go back and look at where the nurse had a hard time with skills, and the nurse would be retrained. During an interview on 09/27/24 at 10:59 a.m., the DON said the system breakdown happened when LVN A did not follow the correct procedure of IV medication administration because he did not lock the IV tubing before he spiked the IV medication bag. The DON said it caused the medication to flow fast, and bubbles formed in the tubing. The DON said LVN A should have primed the tube until he expelled the bubbles from the tube before he attempted to administer the medication to Resident #14. During an interview on 09/27/24 at 9:30 p.m., the Administrator and DON, the Administrator said there was a break when LVN A did not follow the proper procedure for IV medication. The Administrator stated LVN A was nervous, and LVN A goofed, which caused the error in the IV medication administration procedure. Record review of the facility intravenous medication administration skills - check off dated 11/01/23 revealed LVN A was trained on IV medication administration. Record review of the facility medication and treatment order dated 12/15/24 read in part purpose . to ensure accurate, safe, and effective administration of prescribed medications . policy statement #21 . intravenous Orders: Will specify the type of solution, rate of flow, and volume to be infused . Record review of the facility IV medication administration policy dated 09/27/24 read in part . procedure #4 . prime new administration set, including add - on devices and tubing . #4b . remove cap from the tubing, open roller clamp to prime tubing, then hold the distal end of the tubing over sink, or trash can (keep the tip sterile) and allow all of the air bubbles to leave the tubing . #4c . ensure that no air bubble remain in tubing . Record review of the Texas board of nursing practice read . It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an IV Validation Course or for LVN IV certification. The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards . This was determined to be an Immediate jeopardy (IJ) on 09/26/24 at 5:59 p.m. The Administrator, Senior [NAME] President, DON and [NAME] Present for Post - Acute Care, was notified. The Administrator was provided with the IJ template on 09/26/24 at 5:59p.m. The following Plan of Removal was accepted on 09/27/24 at 12:26p.m. a.m. PLAN OF REMOVAL Facility Name Immediate Jeopardy Plan of Removal Annual Survey Completed: 09/11/2024 Survey Reopened: 09/26/2024 Notice of IJ: 09/26/2024 F-694 Parenteral Fluids / IV Fluids The facility has implemented the following Plan confirming systems are in place to ensure that the nursing staff have and demonstrate competency skill sets necessary to safely administer parenteral/intravenous (IV) medications including, but not limited to, checking for contraindications to ordered IV medication; confirming that the correct medication is selected with the appropriate concentration and dosage; practicing strict sterile technique when preparing and administering the IV medications; verifying correct IV equipment is used; completing hand hygiene; priming the IV tubing and ensuring there are no air bubbles in the line; inspecting the IV insertion site for signs of infection and infiltration; disinfecting the IV insertion site; flushing the IV site prior to connecting the tubing with the IV medication; administering medications at the prescribed rate to avoid complications; documenting correct information; and reporting. For further details, see No. 4 below. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, providing training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need to be coordinated what day the service or goods are available to the facility). 1. The facility initially undertook corrective action with regards to Resident #14. The facility confirmed that Resident #14 was discharged from the facility on September 24, 2024. At the time of the survey, and after prompting by the Surveyor, the involved LVN administering Resident 14's IV medications correctly primed the IV tubing, flushed the IV, and correctly administered the ordered IV medication. 2. After being alerted by the surveyor to what happened, the Director of Nursing immediately performed just-in-time education on the appropriate procedure for administering IV medications with the involved LVN, who successfully demonstrated the correct procedure to administer IV medications. 3. The facility reviewed and revised its clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include more detail about the administration of IV medications. The facility also developed an IV Administration Checklist to include the step-by-step process for administration of IV medications. This updated process includes: Process: 1. Equipment and Supplies Steps 1. Non-sterile gloves; 2. Infusion administration sets (tubing and add-on devices); 3. Add-on devices: o Catheter end cap, injection port; o Filters (if necessary); o Stopcock; and o Extension tubing. 4. Infusate solution; and 5. Alcohol pads. 2. Assessment: Inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. Observe equipment for sterility or problems. 3. Steps in the Procedure: Perform Hand Hygiene Prepare equipment: a. Attach add-on devices to administration set; b. Clamp new administration tubing; c. Spike access site of infusate container with new administration set; and d. Hang infusate from IV pole. Prime new administration set, including add-on devices and tubing: a. Squeeze drip chamber to fill according to manufacturer's instructions (1/3 to 1/2 full); b. Remove cap from tubing, open roller clamp to prime tubing, then hold distal end of tubing over sink or trash can (keep tip sterile) and allow all of the air bubbles to leave tubing; c. Ensure that no air bubbles remain in tubing; and d. When primed, clamp tubing and replace cap. Don clean non-sterile gloves. Connecting new tubing: a. Disinfect catheter hub with antiseptic solution (usually alcohol); b. Remove cap from distal end of new tubing; c. Attach primed tubing to catheter access cap; and d. Secure connection by screwing tubing into catheter access cap. Tape connections if needed for extra security. Resume Infusion: a. Unclamp catheter; b. Open roller clamp; c. Check pump program or flow regulator device for proper rate/volume; and d. Observe flow rate for 1-2 minutes to ensure accuracy. Discard used supplies. Remove gloves and perform hand antisepsis. Label administration set and tubing with date, time and initials. 4. Documentation: 1.The date and time of the administration set change. 2. The type of flow-control device. 3.The type of solution or medication infusing. 4.The amount of solution or medication to be infused. 5.The rate of infusion. 6.The condition of the IV site. 7. Notification of the physician of any intravenous complications. 8.Resident's response to treatment. 9. The signature and title of the person recording the data. 5. Reporting 1.Notify physician, supervisor and oncoming shift of Resident refusal of procedure or any complications. 2. Report other information in accordance with facility policy and professional standards of practice. 1. The facility is using the IV Administration Checklist to evaluate staff competency on IV medication administration. 2. The Director of Nursing/Designee re-educated all nursing staff on the revised clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include the step-by-step process for the administration of IV medications. 3. Utilizing the newly developed IV Administration Checklist, the Director of Nursing/Designee re-educated nursing staff on the process for administering IV medications as outlined in No. 3 above. No staff will be allowed to schedule shifts without first completing this re-education with demonstrated competency. 4. All newly employed nursing staff will be educated on IV medication administration utilizing the Guideline and the newly developed IV Administration Checklist. 5. Annually all nursing staff will undergo competency validation for IV medication administration. ***The effectiveness of the re-education and the competency of the nursing staff will be measured by reviewing fallouts from the audits performed by the Director of Nursing/Designee and providing just-in-time re-education of the staff member responsible for the fallout. Also, for identified areas of non-compliance, staff members will be re-educated in mandatory staff meetings held monthly. Attendance at these meetings will be tracked. ***All staff members will be educated on the process for IV medication administration described above before being allowed to work a shift. Completion Date: September 27, 2024 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 1. The Director of Nursing immediately performed just-in-time education on the appropriate procedure for administering IV medications with the involved LVN, who demonstrated competency in the procedure. 2. The facility reviewed and revised its clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include more detail on the administration of IV medications. 3. The facility developed a new IV Administration Checklist to evaluate staff competency on IV medication administration. 4. The Director of Nursing/Designee re-educated all nursing staff on the revised clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include the step-by-step process for the administration of IV medications. 5. Utilizing the newly developed IV Administration Checklist, the Director of Nursing/Designee re-educated nursing staff on the process for administering IV medications as outlined in No. 3 above. No staff will be allowed to schedule shifts without first completing this re-education with demonstrated competency. What program will be put into place to monitor the continued effectiveness of the system changes? 1. There will be daily observation by the Clinical Educational Specialist/Nursing Manager/Designee of 100% of IV medication administrations for 30 days with 100% compliance. 2. For days thirty-one (31) to ninety (90), the Clinical Educational Specialist/Nursing Manager/Designee will perform random observations of IV medication administration weekly to confirm sustained compliance. 3. During monthly QAPI Committee meetings, the IDT team will review the results of the observations/audits performed by the Clinical Educational Specialist/Nursing Manager/Designee and follow-up monthly to ensure adherence to policies/procedures. PIPs will be developed to address any areas of concern. Completion Date: September 27, 2024 Responsible Person: Director of Nursing/Designee Surveyor monitored the plan of removal for effectiveness as follows: Record review of the facility just in time training revealed the DON did one on training for LVN A on 09/11/24 on IV medication administration and he returned demonstration. Record review of the facility policy on clinical guideline for central venous access peripherally inserted central catheter, implanted access port, and peripheral venous access reflected the facility included a step by step administration of IV medication. Record review of the facility training for nurses dated 09/26/24 and 09/27/24 revealed the nurses were trained with new skills check off which revealed process and steps from equipment and supplies gathering, maintaining infection control, assessment, steps in the procedure for IV medication administration, documentation and reporting. During interviews on 09/27/24 between 12:10 p.m. and 12:16 P.m., the MC and IP said the educator retrained them on IV medication administration from gathering supplies and equipment, medication verification, verification of resident, and maintaining infection control during medication administration. The MC and IP said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and the clamp and flow dial on the IV tubing should be closed before spiking the IV medication bag. The MC and IP said that after spiking the medication bag, you would open the flow dial, clamp, prime the tubing, make sure there was no bubble, and hang the tubing on the pole. The MC and IP said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. The MC and IP said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 between 12:33 p.m. and 1:16 p.m., four nurses (2 RN and 2LVN) from day and night shifts were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 between 2:33 p.m. and 4:38 p.m., four nurses (2 RN and 2 LVN) from day and night shifts were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 at 3:02 p.m., the DON said she reviewed the facility policy on IV medication administration and created a new skills check-off list, which she used to train the nurses. The DON said the new skills check-off has processes and steps from equipment and supplies, assessment, steps in the procedure for IV medication administration, documentation, and reporting. The DON said she retrained the nurses. The DON said the facility had not placed the IV medication administration procedure error in QAPI, but the facility would discuss it when they have a QAPI meeting in 2 weeks, which is between October 8 and 9, 2024. During an observation on 09/27/24 at 7:50 p.m., LVN O administered IV medication to Resident #400 (Ceftriaxone 1 gm (50ML) infuse over 30 minutes at 100 ml/hour. LVN O gathered supplies from the medication room. LVN O cleaned the medication cart, placed a barrier, placed her medication and tubing, and syringes flush. LVN O sanitized her hands, donned her PPE, knocked on Resident #400's door, entered Resident #400's, introduced herself, and verified Resident #400 and medication. LVN O notified Resident #400 that she would administer his ABT for UTI. LVN O placed the pole beside Resident #400, seated in his wheelchair. The medication came mixed, and LVN O opened the IV tubing, closed off the flow dial and clamp, and spiked the medication bag. LVN O opened the flow dial and the clamp and primed the medication to flow through the tubing, three drops of medication were expelled from the tubing, and there was no bubble in the tubing. LVN O placed the tubing on the pole and primed the flush syringe. LVN O cleaned the port for 15 minutes and let the port air dry. LVN O flushed the port, administered the IV medication, and labeled the tubing. LVN O returned at 8:55 p.m. to Resident #40's room and checked the IV medication. There was still medication left in the tubing, about half of the tubing, and LVN O told Resident #400 that she would be back in a few minutes. LVN O returned to Resident #40's room and disconnected the IV tubing at 9:13 p.m. LVN O primed another flush syringe, flushed Resident #400's port, and capped it. LVN O assessed the IV site, and Resident #400 said he was fine. During an interview on 09/27/24 between 6:56 p.m. and 9:14 p.m., four nurses (2 RN and 2 LVN) from the night shift were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. On 09/27/24 at 9:40 p.m., the Administrator, the DON, the vice president were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1of 1 residents (Resident #14) provided care by 1 of 1 staff (LVN A) reviewed for proficiency of license nurses. The facility failed to have a system in place to ensure the competency of nurses in Intravenous (IV) therapy techniques and failed to ensure LVN A demonstrated competency when he did not remove bubbles from the IV tubing, remove air from the syringe and flush the PICC line port before IV medication administration for Resident# 14. An IJ was identified on 09/26/24. The IJ template was provided to the facility on [DATE] at 5:59 p.m. While the IJ was removed on 09/27/24 at 9:40 p.m., with the Administrator, Senior [NAME] President, DON and [NAME] Present for Post - Acute Care. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system. These failures could place Residents requiring Intravenous therapy at risk for serious harm, injury, and adverse effect from improper Intravenous (IV) therapy techniques. Findings include: Record review of Resident #14's face sheet dated 09/12/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included: diabetes mellitus (the body cannot control the amount of sugar in the blood), hypertension (pressure in the blood vessels is always higher than normal), and heart failure (when heart is unable to pump enough oxygenated blood to meet the body's needs). Record review of Resident #14's admission MDS assessment dated [DATE] revealed a BIMS score of 13 of 15 which indicated intact cognition. Further review revealed the resident needed moderate to extensive assistance with ADLs which required at least one staff assistance. Further review did not reflect Resident #14 was on IV medication. Record review of Resident #14's care plan initiated on 07/28/24 revealed resident had an ADL self-care deficit related to inability to perform activities of daily living independently. Intervention: Requires assistance of staff. Further review reflected the resident was on IV antibiotic therapy related to infection osteomyelitis of the right toe. Intervention: administer medication as ordered. inability to perform activities of daily living independently. Intervention: Requires assistance of staff. Record review of Resident #14's clinical physician orders read in part . PICC/CENTRAL LINE (Peripherally Inserted Central Catheter): flush with 10 CC NS each shift before medication administration .order date 07/25/24 . meropenem intravenous solution reconstituted 500mg every 12 hours for osteomyelitis(bone infection ) for 2 weeks start date 09/04/24 . During an observation on 09/11/24 at 6:52 a.m., LVN A administered IV meropenem 500 mg intravenously to Resident #14, who was lying in bed on his back. LVN A went into the medication room, brought the medication and the tubing, and placed the medication at the nursing station. LVN A broke the medication seal, spiked the medication bag with the tubing, hung it on the IV pole, and cleaned Resident #14's port. After LVN A cleaned Resident #14's port, he opened the clamp, and the medication flowed into the tubing. There were bubbles in the tubing from a few inches below the chamber and at intervals throughout the tubing, and LVN A was about to connect the tubing to the port on Resident #14's arm when the surveyor intervened. LVN A said he was moving too fast and should have primed the medication and removed all the bubbles. Then LVN A primed the tubing and removed the bubbles. LVNA was about to connect the tubing to Resident #14's port without flushing the port, and the surveyor intervened. Then LVN A opened the flush and was about to flush Resident #14's port, but he did not remove the air in the flush. LVN A was about to insert the flush syringe into Resident #14 port when the surveyor intervened, and he primed the flush and administered the medication. During an interview on 09/11/24 at 3:54 p.m., LVN A said he did not realize the IV line had bubbles, and if he had administered the IV medication with bubbles, he could have caused Resident #14 to have an air embolism (bubbles trapped in a blood vessel that can block blood flow) . LVN A said he did not take out the air in the flush, and it was unsafe for Resident #14 because that would be air going through Resident #14's vein. LVN A said he had training in IV medication administration, and the DON and clinical manager monitored the nurses during rounding. During an interview on 09/12/24 at 11:55 a.m., The DON said LVN A should have ensured all the air was out of the tubing before he hooked up to Resident #14's port. The DON said LVN A should have primed the IV line to prevent air embolism and pain. The DON said LVN A should have flushed the port before administering the medication. The DON said the line should be flushed to make sure the line was patent (open and unobstructed free passage) and there was no clot or infiltration. During an interview on 09/26/24 at 2:55 p.m., LVN A said the facility provided in-services in the last month, and he did skills check-off, but the facility did not provide a certificate. LVN A said he never did a training that issued an IV administration certificate. During an interview on 09/26/24 at 3:27 p.m., the DON said that their contract pharmacy had done the nurse's IV Training. Still, the pharmacy representative told her he could not locate any training for facility nurses from 2021 to the present. The DON said RNs and LVNs should have an IV Administration Certificate before administering their first IV and be monitored during their first IV administration. The DON said she did not know if the IV Certificate was a requirement with the facility, State, or Board of Nursing, but she would look into it. During an interview on 09/26/24 at 3:53 p.m., NP said she did not get a call from the facility about LVN A attempted to administer IV medication with bubbles in the line or not flushing the line before administering the medication. NP said LVN A should have primed the tubing and made sure there were no bubbles in the line, but if the bubble was small, it might not cause any harm to Resident #14, but if the bubble was big(3mm), then the bubble could cause respiratory distress, air embolism. NP said LVN A should have pushed out the air from the flush syringe before he attempted to flush Resident #14's port, which was done to make sure the line was patent. The NP said 3mm of air could be bad for Resident #14. During an interview on 09/26/24 at 3:58 p.m., the Educator said IV certification was not required, but nurses are checked off on IV medication skills. The Educator said IV monitoring and staff rounding should be random and periodically by the CM and the DON. The Educator said if issues are observed, the facility will go back and look at where the nurse is having a hard time with skills, and the nurse would be retrained. During an interview on 09/26/24 at 4:59 p.m., the DON said the Educator and CM should randomly check the nurses for IV medication administration. The DON said since LVN A did not perform the IV medication administration as trained, the training was ineffective, and the Educator would re-educate LVN A. During an interview on 09/26/24 at 5:16 p.m., the Educator said the train was ineffective because LVN A did not demonstrate the competency needed for IV medication administration when he administered IV medication to Resident #14. During an interview on 09/27/24 at 10:59 a.m., the DON said the system breakdown happened when LVN A did not follow the correct procedure of IV medication administration because he did not lock the IV tubing before he spiked the IV medication bag. The DON said it caused the medication to flow fast, and bubbles formed in the tubing. The DON said LVN A should have primed the tube until he expelled the bubbles from the tube before he attempted to administer the medication to Resident #14. During an interview on 09/27/24 at 9:30 p.m., the Administrator and DON, the Administrator said there was a break when LVN A did not follow the proper procedure for IV medication. The Administrator stated LVN A was nervous, and LVN A goofed, which caused the error in the IV medication administration procedure. Record review of the facility medication and treatment order dated 12/15/24 read in part purpose . to ensure accurate, safe, and effective administration of prescribed medications . policy statement #21 . intravenous Orders: Will specify the type of solution, rate of flow, and volume to be infused . Record review of the facility IV medication administration policy dated 09/27/24 read in part . procedure #4 . prime new administration set, including add - on devices and tubing . #4b . remove cap from the tubing, open roller clamp to prime tubing, then hold the distal end of the tubing over sink, or trash can (keep the tip sterile) and allow all of the air bubbles to leave the tubing . #4c . ensure that no air bubble remain in tubing . Record review of the Texas board of nursing practice read . It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an IV Validation Course or for LVN IV certification. The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards . This was determined to be an Immediate jeopardy (IJ) on 09/26/24 at 5:59 p.m. The Administrator, Senior [NAME] President, DON and [NAME] Present for Post - Acute Care, was notified. The Administrator was provided with the IJ template on 09/26/24 at 5:59p.m. The following Plan of Removal submitted by the facility was accepted on 09/27/24 at 12:26p.m. a.m. PLAN OF REMOVAL [Facility} Medicare [number] Immediate Jeopardy Plan of Removal Annual Survey Completed: 09/11/2024 Survey Reopened: 09/26/2024 Notice of IJ: 09/26/2024 F-726 Competent Nursing Staff Facility has implemented the following Plan confirming systems are in place to ensure that the nursing staff have and demonstrate competency skill sets necessary to safely administer intravenous (IV) medications including, but not limited to, checking for contraindications to ordered IV medication; confirming that the correct medication is selected with the appropriate concentration and dosage; practicing strict sterile technique when preparing and administering the IV medications; verifying correct IV equipment is used; completing hand hygiene; priming the IV tubing and ensuring there are no air bubbles in the line; inspecting the IV insertion site for signs of infection and infiltration; disinfecting the IV insertion site; flushing the IV site prior to connecting the tubing with the IV medication; administering medications at the prescribed rate to avoid complications; documenting correct information; and reporting. For further details, see No. 4 below. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, providing training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need to be coordinated what day the service or goods are available to the facility). 6. The facility initially undertook corrective action with regards to Resident #14. The facility confirmed that Resident #14 was discharged from the facility on September 24, 2024. At the time of the survey and after prompting by the surveyor, the involved LVN administering Resident 14's IV medications correctly primed the IV tubing, flushed the IV, and correctly administered the ordered IV medication. 7. After being alerted by the surveyor to what happened, the Director of Nursing immediately performed just-in-time education on the appropriate procedure for administering IV medications with the involved LVN, who then successfully demonstrated the correct procedure to administer IV medications. 8. The facility reviewed and revised its clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include more detail about the administration of IV medications. The facility also developed an IV Administration Checklist to include the step-by-step process for administration of IV medications. This updated process includes: Process: 1. Equipment and Supplies Steps 1. Non-sterile gloves; 2. Infusion administration sets (tubing and add-on devices); 3. Add-on devices: o Catheter end cap, injection port; o Filters (if necessary); o Stopcock; and o Extension tubing. 4. Infusate solution; and 5. Alcohol pads. 2. Assessment: Inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. Observe equipment for sterility or problems. 3. Steps in the Procedure: Perform Hand Hygiene Prepare equipment: a. Attach add-on devices to administration set; b. Clamp new administration tubing; c. Spike access site of infusate container with new administration set; and d. Hang infusate from IV pole. Prime new administration set, including add-on devices and tubing: a. Squeeze drip chamber to fill according to manufacturer's instructions (1/3 to 1/2 full); b. Remove cap from tubing, open roller clamp to prime tubing, then hold distal end of tubing over sink or trash can (keep tip sterile) and allow all of the air bubbles to leave tubing; c. Ensure that no air bubbles remain in tubing; and d. When primed, clamp tubing and replace cap. Don clean non-sterile gloves. Connecting new tubing: a. Disinfect catheter hub with antiseptic solution (usually alcohol); b. Remove cap from distal end of new tubing; c. Attach primed tubing to catheter access cap; and d. Secure connection by screwing tubing into catheter access cap. Tape connections if needed for extra security. Resume Infusion: a. Unclamp catheter; b. Open roller clamp; c. Check pump program or flow regulator device for proper rate/volume; and d. Observe flow rate for 1-2 minutes to ensure accuracy. Discard used supplies. Remove gloves and perform hand antisepsis. Label administration set and tubing with date, time and initials. 4. Documentation: 1.The date and time of the administration set change. 2. The type of flow-control device. 3.The type of solution or medication infusing. 4.The amount of solution or medication to be infused. 5.The rate of infusion. 6.The condition of the IV site. 7. Notification of the physician of any intravenous complications. 8.Resident's response to treatment. 9. The signature and title of the person recording the data. 5. Reporting 1.Notify physician, supervisor and oncoming shift of Resident refusal of procedure or any complications. 2. Report other information in accordance with facility policy and professional standards of practice. 9. The facility is using the IV Administration Checklist to evaluate staff competency on IV medication administration. 10. The Director of Nursing/Designee re-educated all nursing staff on the revised clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include the step-by-step process for the administration of IV medications. 11. Utilizing the newly developed IV Administration Checklist, the Director of Nursing/Designee re-educated nursing staff on the process for administering IV medications as outlined in No. 3 above. No staff will be allowed to schedule shifts without first completing this re-education with demonstrated competency. 12. All newly employed nursing staff will be educated on IV medication administration utilizing the Guideline and the newly developed IV Administration Checklist. 13. Annually all nursing staff will undergo competency validation for IV medication administration. ***The effectiveness of the re-education and the competency of the nursing staff will be measured by reviewing fallouts from the audits performed by the Director of Nursing/Designee and providing just-in-time re-education of the staff member responsible for the fallout. Also, for identified areas of non-compliance, staff members will be re-educated in mandatory staff meetings held monthly. Attendance at these meetings will be tracked. ***All staff members will be educated on the process for IV medication administration described above before being allowed to work a shift. Completion Date: September 27, 2024 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 6. The Director of Nursing immediately performed just-in-time education on the appropriate procedure for administering IV medications with the involved LVN, who demonstrated competency in the procedure. 7. The facility reviewed and revised its clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include more detail on the administration of IV medications. 8. The facility developed a new IV Administration Checklist to evaluate staff competency on IV medication administration. 9. The Director of Nursing/Designee re-educated all nursing staff on the revised clinical guideline entitled Central Venous Access, Peripherally Inserted Central Catheters, Implanted Access Ports, and Peripheral Venous Access - Nursing Center to include the step-by-step process for the administration of IV medications. 10. Utilizing the newly developed IV Administration Checklist, the Director of Nursing/Designee re-educated nursing staff on the process for administering IV medications as outlined in No. 3 above. No staff will be allowed to schedule shifts without first completing this re-education with demonstrated competency. What program will be put into place to monitor the continued effectiveness of the system changes? 4. There will be daily observation by the Clinical Educational Specialist/Nursing Manager/Designee of 100% of IV medication administrations for 30 days with 100% compliance. 5. For days thirty-one (31) to ninety (90), the Clinical Educational Specialist/Nursing Manager/Designee will perform at random observations of IV medication administration weekly to confirm sustained compliance. 6. During monthly QAPI Committee meetings, the IDT team will review the results of the observations/audits performed by the Clinical Educational Specialist/Nursing Manager/Designee and follow-up monthly to ensure adherence to policies/procedures. PIPs will be developed to address any areas of concern. Completion Date: September 27, 2024 Responsible Person: Director of Nursing/Designee Surveyor monitored the plan of removal for effectiveness as follows: Record review of the facility just in time training revealed the DON did one on training for LVN A on 09/11/24 on IV medication administration and he returned demonstration. Record review of the facility policy on clinical guideline for central venous access peripherally inserted central catheter, implanted access port, and peripheral venous access reflected the facility included a step by step administration of IV medication. Record review of the facility training for nurses dated 09/26/24 and 09/27/24 revealed the nurses were trained with new skills check off which revealed process and steps from equipment and supplies gathering, maintaining infection control, assessment, steps in the procedure for IV medication administration, documentation and reporting. During interviews on 09/27/24 between 12:10 p.m. and 12:16 P.m., the MC and IP said the educator retrained them on IV medication administration from gathering supplies and equipment, medication verification, verification of resident, and maintaining infection control during medication administration. The MC and IP said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and the clamp and flow dial on the IV tubing should be closed before spiking the IV medication bag. The MC and IP said that after spiking the medication bag, you would open the flow dial, clamp, prime the tubing, make sure there was no bubble, and hang the tubing on the pole. The MC and IP said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. The MC and IP said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 between 12:33 p.m. and 1:16 p.m., four nurses (2 RN and 2LVN) from day and night shifts were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 between 2:33 p.m. and 4:38 p.m., four nurses (2 RN and 2 LVN) from day and night shifts were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. During an interview on 09/27/24 at 3:02 p.m., the DON said she reviewed the facility policy on IV medication administration and created a new skills check-off list, which she used to train the nurses. The DON said the new skills check-off has processes and steps from equipment and supplies, assessment, steps in the procedure for IV medication administration, documentation, and reporting. The DON said she retrained the nurses. The DON said the facility had not placed the IV medication administration procedure error in QAPI, but the facility would discuss it when they have a QAPI meeting in 2 weeks, which is between October 8 and 9, 2024. During an observation on 09/27/24 at 7:50 p.m., LVN O administered IV medication to Resident #400 (Ceftriaxone 1 gm (50ML) infuse over 30 minutes at 100 ml/hour. LVN O gathered supplies from the medication room. LVN O cleaned the medication cart, placed a barrier, placed her medication and tubing, and syringes flush. LVN O sanitized her hands, donned her PPE, knocked on Resident #400's door, entered Resident #400's, introduced herself, and verified Resident #400 and medication. LVN O notified Resident #400 that she would administer his ABT for UTI. LVN O placed the pole beside Resident #400, seated in his wheelchair. The medication came mixed, and LVN O opened the IV tubing, closed off the flow dial and clamp, and spiked the medication bag. LVN O opened the flow dial and the clamp and primed the medication to flow through the tubing, three drops of medication were expelled from the tubing, and there was no bubble in the tubing. LVN O placed the tubing on the pole and primed the flush syringe. LVN O cleaned the port for 15 minutes and let the port air dry. LVN O flushed the port, administered the IV medication, and labeled the tubing. LVN O returned at 8:55 p.m. to Resident #40's room and checked the IV medication. There was still medication left in the tubing, about half of the tubing, and LVN O told Resident #400 that she would be back in a few minutes. LVN O returned to Resident #40's room and disconnected the IV tubing at 9:13 p.m. LVN O primed another flush syringe, flushed Resident #400's port, and capped it. LVN O assessed the IV site, and Resident #400 said he was fine. During an interview on 09/27/24 between 6:56 p.m. and 9:14 p.m., four nurses (2 RN and 2 LVN) from the night shift were interviewed said the nurse should prep IV medication in the resident room on a clean field, then hang the medication bag on the pole, and close the clamp and flow dial on the IV tubing before spiking the IV medication bag. All nurses said that after spiking the medication bag, you would open the flow dial, the clamp, prime the tubing, make sure there was no bubble in the tubing. All of nurses said the nurse should prime the flush syringe before use; clean the port, flush the port; administered medication; and monitor the resident during medication administration. All nurses said after the nurse had administered the medication, the nurse would flush the resident's port with a primed flush syringe, and the resident would be monitored and documented. Record review of the facility policy dated 09/26/24 read in part . procedure purpose . establish a facility - wide approach for assessing and maintaining staff competency in the provision of care and services . definitions .competency means the employee demonstrates the skills/procedure safely, correctly, effectively, legally, and has the capacity to complete the skill/procedure independently . On 09/27/24 at 9:40 p.m., the Administrator, the DON, the vice president were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition for 1 of 5 residents (Resident #238) reviewed for change of condition. - RN C failed to read Resident #238's x-ray results and failed to notify/consult the provider about the resident's femur fracture and change of condition using the facility's approved notification methods leaving Resident #238 in an undiagnosed/untreated fracture and in pain for 6 days (07/28/23 to 08/03/23). - The facility failed to immediately notify Resident #238's family of a fall on 07/23/23 and a second fall on 07/28/23 that resulted in an injury. On 08/07/23 at 05:02 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 03:48 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failure could place residents who required radiology services at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, suffering and death. Findings included: Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's Accident/Incident Report dated 07/23/23 signed by LVN A revealed, the resident was found on the floor of the restroom besides the toilet. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. Record review of Resident #238's Care Plan Conference Summary dated 07/25/23 revealed Family Member #1 and Family Member #2 attended the meeting and there was not documented evidence Resident #238's fall that occurred on 07/23/23 was discussed in the care plan meeting. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. The nurse attempted to notify the resident's family about the fall but she did not receive an answer. There was no documentation of a message being left. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. The resident was assessed for new injuries and none were discovered. The resident reported pain at 9 out of 10 and NP A gave an order for Acetaminophen 500 mg to be administered for pain. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident #238 was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w and as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documented notification of the fall to Resident #238's family. Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not cooperative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continued to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider places an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad but she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and legs. She said earlier in the morning of 07/28/23 an x-ray tech came to the resident's room to perform an x-ray of Resident #238's hips but the resident wasn't cooperative so a CNA had to assist the x-ray tech. RN C said since the resident was non-complaint during the previous x-ray the resident had to be taken to the hospital on the evening of 07/28/23. She said when the results came back, she took pictures of the x-ray results and sent it to NP A who reviewed the results and said everything was ok. RN C said she never read the x-ray results and only relied on the assessment given by NP A. RN C said the facility policy was that all nurses were expected to read the results and then notify the provider of the findings. She said she was not supposed to send pictures of the results to NP A but she was busy so she just sent pictures of the results without reading them. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at 09:03 AM , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the resident was symptomatic. NP A said RN C probably didn't call her with Resident #238's fracture results and the fracture was missed by all. She said the results she received did not have an alert stamp and the results were on the bottom and not the top of the report, so she missed the result. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility staff are trying their best. She said failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. She said the facility policy requires nurses to read the results, then verbally notify the provider of the results, nurses do not text results. In an interview on 08/15/23 at 03:09 PM, Family Member #2 said Resident #238 supposedly had 2 falls in the facility on 07/23/23 and 07/28/23. He said he even attended the care plan meeting on 07/25/23 and the 07/23/23 fall was not discussed. Family Member #2 said he was not notified of the second fall until 07/29/23 when he came to visit his mother and she was in unbearable pain and could not walk. Family Member #2 said after seeing his mother's change of condition he asked the staff what happened and that was when it was reported that she had fallen the day before. He said his expectation was that the facility would inform him of any accidents involving his mother as well as any change of conditions and he was not even notified of the 07/23/23 fall until 08/11/23 when the facility Administrator called him. Family Member #2 said he could not trust the facility since they failed to report his mother's falls and that made him wonder when exactly the injury happened. In an interview on 08/16/23 at 11:15 AM, the Administrator said following an accident/incident the facility must notify the resident's emergency contact of the incident, any change of conditions and then document the notification in the EMR. The Administrator said she spoke with Family Member #2 on Friday 08/11/23 to discuss his mother's fall and unidentified fracture. She said after talking to the resident she came to the realization that the resident was never informed about the 07/23/23 fall even though there was a care plan meeting on 07/25/23. The Administrator said the conversation she had with Family Member #2 gave her the impression that the resident's family was not immediately informed about the resident's fall on 07/28/23. She said failure to report accidents/incidents to resident emergency contacts is a violation of the resident or their advocates right and leaves them unaware of the resident's true state. Record review of the facility policy titled Test Results revised on 04/2007 revealed, 1- results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2- should the tests be provided to the facility, the attending physician shall be promptly notified of the results. 3- the DON or the charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. This was determined to be an Immediate Jeopardy (IJ) on 08/07/23 at 05:02 PM. The Administrator and was notified and provided the IJ template on 08/07/23 at 05:44 PM; a Plan of Removal (POR) was requested at that time. The following plan of removal was approved on 08/10/23 at 02:22 PM and the immediacy was removed on 08/12/23 at 03:48 PM. F-777 Radiology/Diagnostic Services Ordered/Notify Result [Facility name] has implemented the following Plan confirming systems are in place to ensure that radiology/diagnostic tests for residents are appropriately ordered, the results of the tests obtained and placed in the residents' medical records, and that the ordering physician is aware of the test results and took appropriate action. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, provide training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need coordinated what day the service of goods available to the facility). 1. The facility undertook corrective action with regards to Resident #238 to confirm that all radiology/diagnostic tests were appropriately ordered, the results obtained and placed in her medical records, and the ordering physician made aware of the results. Resident #238 was discharged from the facility on August 3, 2023. 2. The Interim Director of Nursing/Designee will audit all residents (as of August 1, 2023) to confirm that all ordered radiology/diagnostic tests were performed, results placed in the paper and electronic medical records, the physician notified of the results, and the physician reviewed the tests and took appropriate action, as necessary. See the details of the plan for continued auditing/monitoring outlined on page 5. 3. The facility identified that it had a process in place for ordering, obtaining the results, reviewing the results, and notification of the physician for radiology/diagnostic tests. The process includes: o Confirming that there is a physician order for the diagnostic/radiology test; o Confirming that the diagnostic/radiology test is completed as ordered by the physician; o Accessing the Care4 electronic medical record to obtain the diagnostic/radiology report; o Identifying and reviewing the diagnostic/radiology report; o Printing the diagnostic/radiology report; o Entering the diagnostic/radiology report into the Point Click Care electronic medical record; o Notifying the physician of the diagnostic/radiology result; o Ordering physician reviewing the diagnostic/radiology result and taking appropriate action; and o Nursing staff will document the notification of the physician and any orders given in Point Click Care. The Interim Director of Nursing/Designee has reinforced and re-educated all nursing staff on the process for ordering, obtaining the results, reviewing the results, and notification of the physician for radiology/diagnostic tests. For the details on the measures implemented, see the section below entitled Facility's Plan to Ensure Compliance Quickly. (Completed: August 10, 2023) 4. The Medical Director has issued a written communication to physicians reeducating them on the expectations with respect to the ordering and reviewing of results of radiology/diagnostic tests for residents. 5. The Interim Director of Nursing/Designee will audit all incident/accident reports of falls for the past thirty (30) days to ensure that proper nursing assessments were completed following the fall. 6. The Interim Director of Nursing/Designee has re-educated staff members on recognizing the risk factors for falls, fall precautions, resident assessment, appropriate documentation, and how to properly escalate following falls. 7. The Interim Director of Nursing/Designee has re-educated staff members (nurses and therapists) on the assessment and documentation of changes in resident's condition and escalation to physician, as necessary. In addition, the Interim Director of Nursing/Designee has re-educated nursing staff on the timely performance and documentation of pain assessments (within thirty minutes for IV medications and one (1) hour for oral medications), as well as the administration of pain medications in accordance with physician orders. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. Completion Date: August 10, 2023 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 1. The Interim Director of Nursing/Designee will audit all current residents (as of August 1, 2023) to confirm that all ordered radiology/diagnostic tests were performed, results placed in the electronic medical record, the physician notified of the results, and the physician reviewed the tests and took appropriate action, as necessary. See the details of the plan for continued auditing/monitoring outlined on page 5. 2. The Interim Director of Nursing/Designee and the Director of Operations are reviewing relevant facility policies and procedures to determine whether revisions are necessary to be consistent with the outlined measures in this Plan. 3. The facility Medical Director will re-educate all physicians via written communication about the process for ordering and reviewing the results of radiology/diagnostic tests. 4. By August 8, 2023, the Interim Director of Nursing/Designee is re-educating of all nursing staff members on the following topics: a) The end-to-end process for the ordering and completion of all radiology/diagnostic tests: o Confirming that there is a physician order for the diagnostic/radiology test; o Confirming that the diagnostic/radiology test is completed as ordered by the physician; o Accessing the Care4 electronic medical record to obtain the diagnostic/radiology report; o Identifying and reviewing the diagnostic/radiology report; o Printing the diagnostic/radiology report; o Entering the diagnostic/radiology report into the Point Click Care electronic medical record; o Notifying the physician of the diagnostic/radiology result; o Ordering physician reviewing the diagnostic/radiology result and taking appropriate action; and o Nursing staff will document the notification of the physician and any orders given in Point Click Care. b) Effective hand-off communication between shifts. This communication will include whether there are any pending orders for radiology/diagnostic tests; whether any radiology/diagnostic tests were performed; whether the results of any radiology/diagnostic tests are available; whether the final radiology/diagnostic test results have been printed and entered into the Point Click Care electronic medical records; whether the physician has been notified of the results of the radiology/diagnostic tests; and whether the physician gave any follow-up orders based on the radiology/diagnostic tests. c) The timely performance and documentation of pain assessments (within thirty minutes for IV medications and one (1) hour for oral medications), as well as the administration of pain medications in accordance with physician orders. d) The assessment and documentation of changes in a resident's condition and escalation to the physician, as necessary. e) The process for notifying the resident's physician if there are issues with pain control. f) The facility's existing policy on fall prevention. g) The facility's incident and accident reporting policy. h) The re-assessment of residents including, but not limited to, neurovascular checks up to 72 hours following a fall. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. Completion Date: August 10, 2023 Monitoring: In an interview on 08/11/23 at 02:48 PM, CNA A said she had received training on 08/09/23 about the accident/incident reporting process as well as the fall procedure. CNA A understood the trainings and she was able to explain the actions to be taken. In an interview on 08/12/23 at 09:05 AM, RN D said she received one-on-one training with the IP on radiology and laboratory reports/shifts to shift communications, facility fall policy, accident/incident reporting expectations, pain assessment, pain management and physician escalation. RN D understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 08:03 AM, RN E said she did not receive one-on-one training on the facility fall policy, radiology and laboratory reports/shift to shift communications. accident/incident reporting expectations, abuse and neglect, documentation and physician escalation, . She said she was informed by RN D that training needed to be completed and she reviewed the papers left at the nursing station. RN E understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:02 PM, RN G said she received one on one in servicing falls, MD escalation, accident/incident reporting, pain assessments, change of conditions, radiology/laboratory reports, physician escalations and shift to shift communications. RN G understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:16 PM, RN D said she received one on one in servicing, falls, MD escalation, accident/incident reporting, radiology/laboratory reports, physician escalations, pain management. documentation and changes of condition. RN D understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:24 PM, RN I said she received one on one in servicing on , falls, MD escalation, radiology/laboratory reports, accident/incident reporting, change of conditions and documentation. RN I understood the trainings and she was able to explain the actions to be taken. In an interview on 08/14/23 at 11:40 AM, the DON said she had not completed a full audit of the accident/incidents specifically falls. She said she just confirmed that she had taken action on the fall, she had not thoroughly reviewed each fall to ensure that the proper nursing assessments were completed following the fall as stated in the approved POR. In an interview on 08/15/23 at 09:49 AM, the DON said she completed a full audit on all falls in the last 30 days the previous evening (08/14/23) to ensure appropriate action/nursing assessments were completed following falls. She said her audit identified consistent deficiencies in completion of neuros/assessments, documentation and follow up after these incidents. Record review of facility Order Listing Report, dated 08/08/23, revealed all pending radiology/diagnostic orders and results were reviewed and appropriate action taken by the DON. Record review of facility in-services records revealed facility staff were trained on the following: 08/07/23 TO 08/08/23 Accidents and Incidents, attendees included- RN E, LVN E, LVN A, LVN B, RN A, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Change in condition Assessment and Reporting, attendees included- RN A, LVN B, RN C, LVN E, LVNA, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Escalation/Chain of Command Procedure, attendees included- RN C, RN A, LVN B, LVN E, RN F, LVN F, LVN G, RN G, RN E, LVN A - 08/08/23 Following MD orders for Medication Administration Parameters, attendees included- LVN A, LVN B, LVN D, LVN E, LVN F, LVN G, RN A, RN E, RN F, RN G - 08/08/23 Falls Program and Incident Report, attendees included- LN E, LVN B, RN A, RN F, LVN F, LVN G, RN G - 08/09/23 Pain Assessment and Reassessment, attendees included- RN A, RN C, LVN A, - 08/09/23 Falls Program, attendees included- LVN B, RN C, RN E, RN C, RN B,, LVN A - 08/09/23 Reviewing, Printing out & filing diagnostic reports, attendees included- RN A, RN C, RN E, LVN A, LVN F, RN D, LVN B - 08/11/23 Fall Procedure, attendees included- RN C, RN D, LVN E, RN A - 08/11/23 Documentation (Admission; Fall Risk Assessment; Pain Tool, Transfer Form, SBAR, Change of Condition), attendees included- RN C, RN D, LVN E, RN A Record review of facility email titled Immediate Attention to Radiology/Diagnostic Services Results dated 08/08/23 at 05:15 PM and signed by the Medical Director revealed, the Medical Director notified the facility affiliated physicians the following: 1- for newly admitted patients, radiology/diagnostic services orders must address the patient's immediate needs. 2- results for routine radiology/diagnostic service must be reviewed within 24 hours of being notified that results are available 3- for stat orders, results must be reviewed within 2 hours of being notified that results are available. 4- acknowledgement of receipt and review of results must be documented in the patients EMR and a note of the plan of care must be included. Record review of a facility email titled Policies Reviewed UP dated 08/11/23 at 10:44 PM revealed the following policies were reviewed for needed changes by facility management: Pain assessment/reassessment and management, admission process, medication administration, incidents/accidents, medication reconciliation, escalation/chain of command, acute condition changes, ANE, administrating pain medications, standard medication administration times and critical results reporting policy. Record review of the facility Accident/Incident Audit revealed, the facility had identified failures in assessments following incidents, documentation or follow up on 10 out of 11 falls in the last 30 days. The Administrator was informed the IJ was removed on 08/15/23 at 03:48 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 6 of 12 residents (Resident #26, Resident #235, Resident #236, Resident #237, Resident #238 and Resident #270) reviewed for neglect. - The facility failed to ensure nursing staff properly assessed Resident #238 following a fall, identify a femur fracture, and properly notified the provider of a fracture for 6 days following a fall leaving the resident in pain up to 09 out of 10. - The facility failed to acquire and administer pain medication to Resident #235; the facility failed to assess Resident #235's pain following medication administration and failed to notify the resident's provider of ineffective pain control. - The facility failed to acquire and administer pain medication to Resident #237; the facility failed to assess Resident #237's pain following medication administration and failed to notify the resident's provider of ineffective pain control. - Nursing staff failed to enter accurately and timely acquire/administer medications to Resident #26, Resident #236 and Resident #270. On 08/03/23 09:20 AM an Immediate Jeopardy (IJ) was identified. The IJ was revised on 08/09/23 at 12:15 PM. While the IJ was removed on 08/15/23 at 03:48 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk of continued neglect, major injury and a decreased quality of life. Findings included: Resident #238 Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's Accident/Incident Report dated 07/23/23 signed by LVN A revealed, the resident was found on the floor of the restroom besides the toilet. The patient said she fell while trying to wash her hands, she hit her butt pretty hard and her back really hurts, hell everything hurts. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. The resident was assessed for new injuries and none were discovered. The resident reported pain at 9 out of 10 and NP A gave an order for Acetaminophen 500 mg to be administered for pain. There was no documentation of the resident's ROM or initiation of Neurochecks. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documentation of neuro checks being initiated, specific of a head-to-toe assessment or assessment of Resident #238's ROM. Record review of Resident 238's paper and electronic chart revealed, LVN A did not perform any neuro checks on the resident following her falls on 07/23/23 or 07/28/23. There was no follow-up documented following Resident #238's fall on 07/23/23. LVN A did not complete a fall risk assessment for Resident #238's fall on 07/28/23. There was no follow-up documented following Resident #238's fall on 07/28/23 Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not cooperative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continued to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A were responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider placed an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad and she experienced falls on 07/23/23 and 07/28/23. He said there was no change in the resident after her fall on 07/23/23 but when she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said the facility's policy requires a head to toe assessment including the resident's ROM prior to moving the resident as well as neuro checks. LVN A said she did not initiate neuro checks on Resident #238 after the fall because she forgot and the fall occurred almost at the time of her shift. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. LVN A said in retrospect the resident should not have been moved from the floor since she was in severe pain and her ROM could not be assessed. She said failure to assess residents properly following a fall could place residents at risk for fracture, infection, discomfort, neurological issues if the resident hit their heat and development of a blood clot at the site of the fracture. LVN A said she could not remember the specifics of Resident #238's fall on 07/23/23. In an interview on 08/09/23 at 08:40 AM, the Interim DON said following a fall nursing staff must immediately assess residents for injury including ROM assessments prior to moving the resident, any bleeding and initiation of neurological checks. She said the resident must be followed for 72 hours to ensure no injuries occurred. She said she noticed that some nurses are not performing neuro checks following falls and LVN A did not initiate neuro checks on Resident #238 following her falls on 07/23/23 and 07/28/23. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and leg. She said earlier in the morning of 07/28/23 an X-ray tech came to the resident's room to perform an xray of Resident #238's hip but the resident wasn't cooperating so a CNA had to assist the xray tech. RN C said since the resident was non-complaint during the previous xray the resident had to be taken to the hospital on the evening of 07/28/23. She said when the results came back she took pictures of the xray results and sent it to the NP A who reviewed the results and said everything was ok. RN C said she never read the xray results and only relied on the assessment given by NP A. RN C said the facility policy was that all nurses were expected to read the results and then notify the provider of the findings. She said that she was not supposed to send pictures of the results to NP A but she was busy so she just sent pictures of the results without reading them. In an interview on 08/09/23 at 09:10 AM, the interim DON said neglect can result from failure to take care or provide services to residents even if done unconsciously. She said when Resident #238's fracture was identified on 08/03/23 she did not consider it neglect but now she would consider it neglect since the facility failed to identify and take action on a resident's acute left femur fracture. In an interview on 08/09/23 at 10:24 AM, the Administrator said Neglect did not have to been done consciously. When asked by the surveyor if Resident #238's unidentified fracture that left the resident in pain for 6 days after the incident (07/28/23 to 08/03/23) was neglect, the Administrator said no she did not consider it neglect because the injury stemmed from the fall on 07/28/23. In an interview on 08/09/23 at 11:04 PM, the PT director said Resident #238 experienced a decline in therapy due to her pain so when she was discussed in the morning meeting on 08/02/23 he requested another xray be performed. He said he talked to NP A who said she would enter in an order for an xray but she did not so he followed up with MD A. He said MD A said she would enter in an order for an xray on 08/02/23, so on the morning of 08/03/23 he logged on to the radiology portal in anticipation of the results and that is when he saw the report dated 07/28/23 that identified Resident #238's left femur fracture. The Therapy Director said he immediately printed out the results and turn it over to the IP and Administrator. In an interview on 08/09/23 at 11:40 AM, the IP said the Therapy Director brought it to her attention on 08/03/23 that Resident #238 had an unidentified femur fracture from an xray performed on 07/28/23. Once notified she took it to the nurse responsible who then notified the doctor right away. The IP said she had no lab or radiology review responsibility but instead did what any prudent nurse would do. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at 09:03 AM , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said the Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the patient was symptomatic. NP A said RN C probably didn't call her with Resident #238's fracture results and the fracture was missed by all. She said the results she received did not have an alert stamp and the results were on the bottom and not the top of the report so she missed the result. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility its best but failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. She said the facility policy required nurses to read the results, then verbally notify the provider of the results; nurses do not text results. Resident #235 Record review of Resident #235's face sheet dated 06/28/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, UTI and unspecified fall. The resident discharged on 07/18/23. Record review of Resident #235's secondary Face Sheet dated 06/28/23 at 10:28 AM revealed, Resident #235 admitted to the facility on [DATE] at 09:01 PM. Record review of Resident #235's Baseline Care Plan dated 06/27/23 revealed, the resident was alert & oriented and experiencing generalized aching pain Record review of Resident #235's Hospital Discharge Record dated 06/27/23 at 03:45 PM revealed, Resident #235's next scheduled dose of pain medications as follows: - Morphine 15 mg ER (an opioid pain medication)- 1 tablet be mouth every six hours with next dose due on 06/27/23 at 09:00 PM. - Oxycodone 10 mg (an opioid pain medication)- 1 Tablet by mouth every 6 hours with next dose due on 06/27/23 at 06:00 PM. Record review of Resident #235's Order Summary Report dated 06/28/23 revealed, - Morphine Sulfate 15 mg- give 1 tablet by mouth every 12 hours for pain ordered on 06/27/23 with a start date of 06/28/23. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours for pain ordered on 06/27/23 with a start date of 06/28/23 Record review of Resident #235's Progress Note dated 06/28/23 revealed - 01:16 AM- resident came in after 9 pm, [automated medication dispensing machine] does not have name. - 04:19 AM - complaint of pain to legs - 05:25 AM- no medication on hand - 05:56 AM- Resident #235 was informed that the MD was notified for prescriptions to be sent to the pharmacy. Resident #235 informed the facility that she had her Morphine and Oxycodone at home and she asked if her son brought them to the facility could the facility staff administer it. Record review of Resident #235's June MAR printed 06/28/23 at 12:50 PM revealed, her medications were not started until 06/28/23 and the following medications were not administered: - Famotidine 20 mg (used to treat acid reflux)- give 1 tablet by mouth for acid reflux scheduled for 06/28/23 at 08:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours due at 06/28/23 at 12:00 AM. The start date was not entered until 06/28/23 at 06:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours scheduled for 06/28/23 at 06:00 AM. Reason not administered- medication not available. - Morphine Sulfate 15 mg ER- give 1 tablet by mouth every 12 hours for pain due at 06/27/23 at 09:00 PM. The Order was entered incorrectly as Morphine Sulfate 15 mg (IR) with a start date of 06/28/23 at 08:00 AM Record review of Resident #235's Pharmacy Records dated 06/28/23 revealed, MD A did not submit electronic prescriptions for Resident #235's Oxycodone 10 mg and Morphine ER 15 mg until 06/28/23 at 05:31 PM, over 20 hours after the resident's admission. Record review of Resident #235's June MAR dated 06/28/23 at 12:50 PM revealed the following pain scores: - 05 out of 10 on 06/28/23 at 04:19 PM - 10 out of 10 when Resident was administered her Morphine 15 mg scheduled for 08:00 AM. - 08 out of 10 when Resident was administered her Oxycodone 10 mg scheduled for 12:00 PM. Record review of Resident #235's Physician's Notes from 06/27/23 to 07/18/23 revealed, no documentation of reported ineffective pain management, uncontrolled pain, or pain scores that remained the same after medication administration by nursing staff. Record review of Resident #235's June Progress Notes revealed, no documentation of unchanged or increased pain scores which indicated ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER June MAR revealed, - increased pain recorded on 06/28/23 between 06:00 AM and 12:00 PM doses from a 3 to an 8 out of 10. - unchanged pain recorded on 06/28/23 between 12:00 PM and 08:00 PM doses at an 8 out of 10. - unchanged pain recorded on 06/29/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. - increased pain recorded on 06/29/23 between 06:00 AM and 12:00 PM doses from a 5 to a 7 out of 10. - increased pain recorded on 06/29/23 between 12:00 AM and 06:00 PM doses from a 7 to an 8 out of 10. - unchanged pain recorded on 06/30/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. Record review of Resident #235' July Progress Notes revealed, no documentation of unchanged or increased pain scores which indicate ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER July MAR revealed, - increased pain from a 0 to a 4 out of 10 on 07/03/23 between 06:00 PM to 07/0/423 at 12:00 AM doses. - increased pain from a 0 to a 5 out of 10 on 07/04/23 between 12:00 Pm to 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/06/23 between 12:00 PM to 06:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/07/23 between 12:00 PM to 06:00 PM doses. - unchanged pain at 5 out of 10 recorded on 07/08/23 between 12:00 AM and 06:00 AM doses. - unchanged pain at 5 out of 10 recorded on 07/09/23 between 12:00 AM and 06:00 AM doses. - increased pain from a 5 to 6 out of 10 on 07/09/23 between 06:00 AM to 12:00 PM doses. - unchanged pain at 6 out of 10 recorded on 07/09/23 between 12:00 PM and 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/11/23 between 06:00 AM to 12:00 PM doses. - increased pain from a 2 to a 9 out of 10 on 07/12/23 between 06:00 AM to 12:00 PM doses. Record review of Resident #235's Medication Administration Audit from 06/27/23 to 07/18/23 dated 08/03/23 revealed, the resident received her Oxycodone and Morphine outside of scheduled administration times on 23 different occasions during her stay: 1- Morphine ER 15 mg scheduled for 06/28/23 at 08:00 AM, administered at 09:15 PM 2- Morphine ER 15 mg scheduled for 06/30/23 at 08:00 PM, administered at 9:33 PM 3- Morphine ER 15 mg scheduled for 07/01/23 at 08:00 AM, administered at 09:05 PM 4- Oxycodone 10 mg scheduled for 07/02/23 at 06:00 PM, administered at 7:11 PM 5- Morphine ER 15 mg scheduled for 07/02/23 at 08:00 PM, administered at 11:32 PM 6- Morphine ER 15 mg scheduled for 07/03/23 at 08:00 PM, administered at 09:58 PM 7- Oxycodone 10 mg scheduled for 07/04/23 at 06:00 AM, administered at 7:05 AM 8- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 AM, administered at 09:15 AM 9- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 PM, administered at 10:44 PM 10- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 AM, administered at 09:19 AM 11- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 PM, administered at 09:20 PM 12- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 AM, administered at 11:53AM 13- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 PM, administered at 09:03 PM 14- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 AM, administered at 11:03AM 15- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 PM, administered at 10:07 PM 16- Morphine ER 15 mg scheduled for 07/09/23 at 08:00 AM, administered at 09:30AM 17- Morphine ER 15 mg scheduled for 07/10/23 at 08:00 PM, administered at 09:05 PM 18- Oxycodone 10 mg scheduled on 07/12/23 at 12:00 AM, administered at 3:16 AM 19- Oxycodone 10 mg scheduled for 07/14/23 at 12:00 PM, administered at 02:17 PM 20- Morphine ER 15 mg scheduled for 07/16/23 at 08:00 AM, administered at 10:05 AM 21- Oxycodone 10 mg scheduled for 07/17/23 at 06:00 PM, administered at 07:30 PM 22- Morphine ER 15 mg scheduled for 07/17/23 at 08:00 PM, administered at 09:12 PM 23- Morphine ER 15 mg scheduled for 07/18/23 at 08:00 AM, administered at 09:03 AM An observation on 06/28/23 at 08:45 AM revealed, Resident #235's family member approaching RN B while she prepared for medication administration to Resident #235. He said that he was very upset with the facility because prior to admission he was assured that Resident #235's medication would be available upon her admission but it was not. He said Resident #235 called him multiple times overnight to inform him that she had not received any of her medication since she arrived at the facility and she was in severe pain. Resident #235's family member then handed RN B 2 bottles of medication (Morphine ER 15 mg and Oxycodone 10 mg) and said he brought only a 2 days' supply to cover Resident #235 until the medication arrived at the facility. After Resident #235's family member entered the resident's room, RN B alerted the Interim DON to the arrival of the mediation at which point they both counted the medications and logged them into individual control sheets. In an interview on 06/28/23 at 10:10 AM, RN B said Resident #235 admitted to the facility on the night shift of 06/27/23. She said the patient's medications had not yet arrived from the pharmacy and the night shift nurse said Resident #235's family member would be bringing her pain medication so she was waiting for its arrival. When asked if RN B could have pulled the rest of Resident #235's unavailable medication from the facility EKit (floor stock of prescription medications available for emergency use), she said she administered the OTC medications as well as the pain medication brought in by the family member but she would have to check the facility EKit for the rest of Resident #235's medications. RN B said she immediately administered Morphine ER 15 mg to Resident #235 once it was delivered by the resident's family member but the Oxycodone was not due yet. She could not say when Resident #235 received her last dose of Oxycodone. RN B said failure to administer medications as ordered could place residents at risk for uncontrolled disease states such as uncontrolled pain. In an interview on 06/28/23 at 10:35 AM, the Interim DON said when a resident arrived at the facility the admitting nurse is expected to review the hospital paperwork to verify the last dose of medications received as well as when the next dose is due. She said the nurse then enters the order into the system and verifies it with the physician. The Interim DON said Resident #235 admitted to the facility on [DATE] at around 08:30 PM so her medications were not yet delivered by the pharmacy. She said that the expectation was for residents to receive their medications as ordered and that the nurse should have taken into consideration Resident #235's last doses to determine when the next dose was due and to at least get an order for a one-time dose to ensure that the resident received her medications. The interim DON said if a CII medication ( scheduled 2 controlled substances that require additional care because of the potential to intentionally or unintentionally abuse the drug) was unavailable nursing staff are expected to request an appropriate alternative treat the patients pain and most other medications could be found in the e-kit until the medication arrived. The Interim DON said that failure to administer medication to residents as ordered could place residents at risk for uncontrolled disease states and pain. In an interview on 06/28/23 at 11:11 AM, Resident #235 said she discharged from the hospital on [DATE] at 04:00 PM but she did not get picked up by the transport company until after 08:00 PM so by the time she arrived at the facility her medications were already due. She said when she arrived at the facility she explained to the staff that since she was discharged from the hospital at 4:00 PM the hospital was unable to administer any of her medications due after 4:00 PM. Resident #235 said she asked for her medications especially her pain medication but she was told the medication was not available at the facility. She said she specifically asked for her pain medications Morphine and Oxycodone because her pain was a 10 out of 10 but it was unavailable so her son had to bring in her pain medication in the morning (06/28/23). Resident #235 said she was in severe pain rendering her unable to do anything and writhing in pain prior to receiving her Morphine morning. She said after receiving her Morphine her pain was at 08 out of 10 but she had still not received her Oxycodone. In an interview on 08/02/23 at 01:56 PM, LVN B said resident pain can be assessed based on verbalization of pain on a scale of 0-10. She said the pain level is documented prior to administration of the pain medication but there is no trigger to document a post administration assessment in the EMR for scheduled medication. LVN B said nursing staff are expected to assess the patients pain level 30 minutes - 1 hr. after administration of the medication and document it in the progress notes. She said if a resident was assessed to have increase or unchanged pain levels then the medication was not effective and the provider must be notified. LVN B said Resident #235 was generally pleasant and she had been taking Oxycodone for a long time. She said she could not recall any issues with Resident #235's pain management but she did remember that the residents facial expressions did not match the level of pain she reported. In an interview on 08/13/23 at 08:03 AM, RN E said she was the admitting nurse for Resident #235 on 06/28/23. She said when the resident admitted to the facility she entered reconciled the medications with the provider, including the Resident #235's pain medications Oxycodone and Morphine. She said when she notified the provider, the provider stated that late admissions always resulted in problems with CII medication acquisition because they were unable to electronically prescribe the medications. She said she asked for an alternative and the provider gave an order for Tylenol and nothing else. RN E said Acetaminophen was not sufficient pain control for patients on opioid medications but that was the medication ordered for the resident upon admission. RN E said she thought the provider would send the prescription for Oxycodone and Morphine Immediately so she was not concerned of the need for alternative pain coverage. Resident #237 Record review of Resident #237's Nurse report dated 07/26/23 revealed, Resident #237 arrived at the facility at 7 PM. Record review of Resident #237's Face Sheet dated 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses of: atrial fibrillation (irregular heartbeat), acute kidney failure, opioid dependence, anemia, hypertension (high blood pressure) and type 2 diabetes. The resident discharged from the facility on 08/05/23. Record review of Resident #237's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel. Yes- resident received scheduled and PRN pain medication in the last 5 days[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate for 1 of 5 Residents (Resident #238) reviewed for neglect. -The facility failed to thoroughly investigate Resident #238's injury of unknown origin which resulted in a delay in identification and consultation of the resident's provider of a left hip fractured confirmed from a radiology report on 07/28/23 causing the resident severe pain until the resident was transferred to the hospital on [DATE]. - The facility failed to submit the investigation results of Resident #238's injury to the State Survey Agency within 5 working days of reporting the incident. On 08/09/23 12:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 02:10 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could affect residents at risk for delayed identification of health conditions/treatment, severe injury, delated treatment and death. Findings Included Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w and as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documentation of neuro checks being initiated, specific of a head to toe assessment or assessment of Resident #238's ROM. Record review of Resident 238's paper and electronic chart revealed, LVN A did not perform any neuro checks on the resident following her falls on 07/23/23 or 07/28/23. There was no follow-up documented following Resident #238's fall on 07/23/23. LVN A did not complete a fall risk assessment for Resident #238's fall on 07/28/23. There was no follow-up documented following Resident #238's fall on 07/28/23 Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not corporative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continues to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. Record review of Facility Self-Report dated 08/07/23 revealed, the facility submitted an incident report to the SA regarding Resident #238's Fall with fracture. The report did not specifically detail the facilities failure to identify the fracture for 6 days. Record review of the Provider Investigation Report dated 08/15/23 for Resident #238's 07/28/23 fall and presented on 08/15/23 revealed, the PIR was due on 08/14/23. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility could not manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours In an interview on 08/07/23 at 4:58 PM, the Administrator said Resident #238's fall was not reported to the SA on 08/03/23 because she only had to report injury of unknown origin and the resident's fracture was from a fall. In an interview on 08/07/23 at 05:23 PM, the Administrator said the DON was responsible for completing retrospective reviews of lab/radiology reports to ensure that the results are read, fractures identified, notifications are completed, and action was taking immediately on any acute negative radiological findings. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 x-ray results but there was no order entered for the 2nd x-ray so she couldn't track it. She said all x-ray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify x-ray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain She said she failed to thoroughly investigate the incident once the fracture was identified on 08/03/23. In an interview on 08/09/23 at 08:40 AM, the Interim DON said following a fall nursing staff must immediately assess residents for injury including ROM assessments prior to moving the resident, any bleeding and initiation of neurological checks. She said the resident must be followed for 72 hours to ensure no injuries occurred. She said the DON is responsible for immediately reviewing the resident's chart to make sure all the information regarding the accident/incident is correct and appropriate action/follow up was performed. The Interim DON said she reviewed Resident #238's unwitnessed fall the next day (07/29/23) but she did not go into detail(she did not review the resident's chart) so she did not identify LVN A did not initiate neuro checks on Resident #238 following her falls on 07/23/23 and 07/28/23 and assessments were not completed as required by the fall protocol. The Interim DON said she was still working on the investigation into Resident #238's fall with injury so she did not know who was responsible for the failure to identify the fracture but the incomplete assessments and missed fracture should have been caught. She said she did not perform a retrospective review of pending labs or accident/incidents and Resident #238's unidentified fracture seemed to have resulted from a multi system failure. In an interview on 08/09/23 at 09:40 AM, the Interim DON she was responsible for investigating any accident/incidents like falls to determine the cause or if neglect factored into the incident. She said she was notified of Resident #238's fall and complaint of pain 07/28/23 and she before she left in the evening she was aware that the resident had a pending x-ray result. She said she did not properly investigate Resident #238's fall and she did not go back to check on the pending x-ray results. The Interim DON said she did not review the resident's paper and electronic chart to determine if all necessary notifications and assessments were completed but instead interviewed the staff days following the fall about the incident. The DON said she did not go through the facility fall protocol when reviewing Resident #238's fall on 07/28/23. The Interim DON said on 08/03/23 she was notified by the IP that Resident #237 's x-ray from 07/28/23 resulted in a left femur fracture so she started looking into the investigation. The DON said she did not go back to her initial investigation on 07/28/23 and had sufficient evidence to determine the cause of the fall or any staff failures regarding the facility fall procedures. She said she didn't think she was properly trained to perform her DON roll because she was unaware of her obligation to perform retrospective reviews on nursing services. In an interview on 08/09/23 at 10:24 AM, the Administrator said she was notified of Resident #238's fall on 07/28/23 and the DON was responsible for investigating all reported incidents to ensure the appropriate action and follow up is performed. The Administrator said she was the abuse coordinator and responsible for reporting any allegations of abuse but she relies on the DON to provide the preliminary information used to determine if an incident was potentially neglect. The Administrator said all accidents/incidents must be reviewed by nursing within 24 hours and on the weekend there is a manager on duty and a nurse on call, and on 07/28/23 the Interim DON was the nurse on call thus making her responsible for investigating the incident. She said she was made aware of the unidentified fracture on 08/03/23 by the Therapy Director and after reviewing the chart the accident/incident and falls policy was not followed, the incident was not investigated, the resident was followed up immediately following the falland for 72 hours following the incident. The Administrator said failures should have been caught on day 1 and it is clear that these things did not occur when referring to proper investigation on accident/incidents. She said neglect does not have to be done intentionally and when asked if failure to promptly identify Resident #238's fracture leaving the resident in pain for 6 days was a form of neglect, she said it was not because the injury resulted from a fall and was not an injury of unknown origin. When asked what action should have been taken on 08/03/23 when she was notified of the fall, the Administrator said the facility took appropriate action by sending the resident to the hospital. The Administrator said the quality department was made aware of the 6 day late unidentified fracture on 08/03/23 and they made the decision on how to handle the incident. In an interview on 08/15/23 at 03:00 PM, the Administrator said she was aware the PIR was due on 08/14/23 but she was awaiting facility management to approve her submission. Record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022 revealed, Investigating allegations- 1- all allegations are thoroughly investigated, the Administrator initiates investigation. Follow-Up Report-1- within five business days of the incident, the administrator will provide a follow up investigation report. On 08/09/23 at 12:15 PM an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 08/09/23 at 12:53 PM; and a POR was requested at that time. The following plan of removal was approved on 08/11/23 at 09:30 AM and the immediacy was removed on 08/15/23 at 02:10 PM F-835 Administration [The facility] has implemented the following Plan to confirm that systems are in place to ensure that all resident falls are thoroughly investigated and that the required State report is submitted as required by law. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, provide training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need coordinated what day the service of goods available to the facility). 1. The facility undertook corrective action with regards to Resident #238 to confirm that a thorough investigation of the fall was completed and a report of an allegation of neglect was filed with HHSC on August 7, 2023. Resident #238 was discharged from the facility on August 3, 2023. 2. The Interim Director of Nursing/Designee audited all incident/accident reports of falls for the past thirty (30) days to confirm whether the following was done: o Proper nursing assessments were completed following the fall; o Physician was notified of the fall; o Family was notified of the fall; o All ordered interventions were performed and accurately documented; o The incident/accident report of the fall was accurately and completely filled out; and o The information about the fall was documented in the skilled nursing notes that are used to prepare the 24 Hour Report. 3. The facility confirmed that it has an existing process in place to investigate patient falls and to make appropriate reports of the falls to HHSC. The process includes: o The treating nurse documents the fall on the incident/accident report in [electronic medical records system]; o The treating nurse prepares the skilled nursing note documenting the fall, the patient assessment following the fall, and any ordered interventions; o The treating nurse collects witness statements, if any, and documents them on the incident/accident report; o The Interim Director of Nursing/Designee reviews the incident/accident report to confirm its completion and accuracy; o As part of the investigation of the fall, the Interim Director of Nursing/Designee interviews the resident and staff members. The findings of the interviews are documented on the incident/accident report; o The Interim Director of Nursing/Designee assesses the completion of the incident/accident report and the investigation to confirm that all of the details of the fall are included; that the physician and family have been notified; and that all ordered interventions have been completed; o The Interim Director of Nursing/Designee signs off on the incident/accident report as complete; o Fall events and the status of the residents' condition and investigation are discussed during daily Stand Up and Stand Down meetings; o Fall events and the status of the residents' condition and investigation are discussed during Grand Rounds; and o Based on the findings of the completed investigation and a determination that the resident's fall caused bodily injury that was suspicious for abuse or neglect, the Facility Administrator timely reports the fall event to HHSC as follows: i. Within two (2) hours of forming the suspicion if (a) there is a suspicion of abuse or (b) the fall resulted in serious bodily injury, or ii. Within twenty-four (24) hours if there is not a suspicion of abuse and the bodily injury was not serious. 4. The Quality Department has re-educated the Interim Director of Nursing/Designee and the Facility Administrator on the process to investigate patient falls and to make appropriate reports of the falls to HHSC as outlined in No. 3 above. 5. The Interim Director of Nursing/Designee has re-educated nursing staff members on recognizing the risk factors for falls, fall precautions, resident assessment, appropriate documentation, and how to properly escalate following falls. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. ***The effectiveness of the re-education and the competency of the nursing staff will be measured by reviewing fallouts from the audits performed by the Director of Nursing/Designee and providing just-in-time re-education of the staff member responsible for the fallout. Also, for identified areas of non-compliance, staff members will be re-educated in mandatory staff meetings held monthly. Attendance at these meetings will be tracked. Finally, the facility, in collaboration with the Quality and Education Departments, is developing an annual competency tool, which will cover the topics in this Plan, along with other nursing skills/competencies. Completion Date: August 10, 2023 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 1. The Interim Director of Nursing/Designee and the Director of Operations are reviewing relevant facility policies and procedures to determine whether revisions are necessary to be consistent with the outlined measures in this Plan. 2. By August 10, 2023, the Quality Department is re-educating the Interim Director of Nursing and the Facility Administrator of the process to investigate patient falls and to make appropriate reports of the falls to HHSC. The process includes: o The treating nurse documents the fall on the incident/accident report in [electronic medical records system]; o The treating nurse prepares the skilled nursing note documenting the fall, the patient assessment following the fall, and any ordered interventions; o The treating nurse collects witness statements, if any, and documents them on the incident/accident report; o The Interim Director of Nursing/Designee reviews the incident/accident report to confirm its completion and accuracy; o As part of the investigation of the fall, the Interim Director of Nursing/Designee interviews the resident and staff members. The findings of the interviews are documented on the incident/accident report; o The Interim Director of Nursing/Designee assesses the completion of the incident/accident report and the investigation to confirm that all of the details of the fall are included; that the physician and family have been notified; and that all ordered interventions have been completed; o The Interim Director of Nursing/Designee signs off on the incident/accident report as complete; o Fall events and the status of the residents' condition and investigation are discussed during daily Stand Up and Stand Down meetings; o Fall events and the status of the residents' condition and investigation are discussed during Grand Rounds; and o Based on the findings of the completed investigation and a determination that the resident's fall caused bodily injury that was suspicious for abuse or neglect, the Facility Administrator timely reports the fall event to HHSC as follows: i. Within two (2) hours of forming the suspicion if (a) there is a suspicion of abuse or (b) the fall resulted in serious bodily injury, or ii. Within twenty-four (24) hours if there is not a suspicion of abuse and the bodily injury was not serious. 3. By August 10, 2023, the Interim Director of Nursing/Designee is re-educating all nursing staff members on the following topics: o Recognizing the risk factors for falls, fall precautions, resident assessment, appropriate documentation, and how to properly escalate following falls. o The assessment and documentation of changes in a resident's condition and escalation to the physician, as necessary. o The process for notifying the resident's physician if there are issues with pain control. o The facility's existing policy on fall prevention. o The facility's incident and accident reporting policy. This re-education covers the staff members accurately and completely preparing the report of the fall. o The re-assessment of residents including, but not limited to, neurovascular checks done up to 72 hours following a fall. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. ***The effectiveness of the re-education and the competency of the nursing staff will be measured by reviewing fallouts from the audits performed by the Director of Nursing/Designee and providing just-in-time re-education of the staff member responsible for the fallout. Also, for identified areas of non-compliance, staff members will be re-educated in mandatory staff meetings held monthly. Attendance at these meetings will be tracked. Finally, the facility, in collaboration with the Quality and Education Departments, is developing an annual competency tool, which will cover the topics in this Plan, along with other nursing skills/competencies. Completion Date: August 10, 2023 Monitoring: In an interview on 08/11/23 at 02:48 PM, CNA A said she received training on 08/09/23 about the accident/incident reporting process as well as the fall procedure. CNA A understood the trainings and she was able to explain the actions to be taken. In an interview on 08/12/23 at 09:05 AM, RN D said she received one-on-one training with the IP facility fall policy, abuse and neglect, accident/incident reporting expectations, documentation, and physician escalation. RN D understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 08:03 AM, RN E said she did not receive one-on-one training on the facility fall policy, accident/incident reporting expectations, abuse and neglect, documentation and physician escalation. She said she was informed by RN D that training needed to be completed and she reviewed the papers left at the nursing station. RN E understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:02 PM, RN G said she received one on one in servicing falls, MD escalation, accident/incident reporting, pain assessments, change of conditions and documentation. RN G understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:16 PM, RN D said she received one on one in servicing, falls, MD escalation, accident/incident reporting, pain documentation and changes of condition. RN D understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:24 PM, RN I said she received one on one in servicng on , falls, MD escalation, accident/incident reporting, change of conditions and documentation. RN I understood the trainings and she was able to explain the actions to be taken. In an interview on 08/14/23 at 11:40 AM, the DON said she had not completed a full audit of the accident/incidents specifically falls. She said she just confirmed that she had taken action on the fall, she had not thoroughly reviewed each fall to ensure that the proper nursing assessments were completed following the fall as stated in the approved POR. In an interview on 08/15/23 at 09:30 AM, the VP of operations said she in-serviced the Interim DON and administrator on: the fall protocol, accident/incidents, documentation, assessments, completion of full investigations and reporting. She said the facility audits identified overall challenges with completion of Neurochecks, assessment of ROM, and insufficient/inappropriate documentation of resident follow up across multiple multiple incidents, In an interview on 08/15.23 at 09:49 AM, the DON said she completed a full audit on all falls in the last 30 days the previous evening (08/14/23) to ensure appropriate action/nursing assessments were completed following falls. She said her audit identified consistent failures in completion of assessments and neuro checks. The DON said she is expected to complete a thorough investigation following an incident ensuring the appropriate/ immediate assessments are completed, Neurochecks performed, MD/family notification and resident follow up. She said all allegations of neglect should be reported immediately and failure to investigate and report accidents/incidents could place residents at risk of increased neglect, pain, decrease in health or cause a sentinel event like serious harm or death. Record review of facility email titled Policies Reviewed UP dated 08/11/23 at 10:44 PM revealed the following policies were reviewed for needed changes by facility management: Pain assessment/reassessment and management, admission process, medication administration, incidents/accidents, medication reconciliation, escalation/chain of command, acute condition changes, ANE, administrating pain medications, standard medication administration times and critical results reporting policy. Record review of facility in-service records revealed the following training listed in the POR was completed with nursing staff; 08/07/23 TO 08/08/23 Accidents and Incidents, attendees included- RN E, LVN E, LVN A, LVN B, RN A, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Change in condition Assessment and Reporting, attendees included- RN A, LVN B, RN C, LVN E, LVNA, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Escalation/Chain of Command Procedure, attendees included- RN C, RN A, LVN B, LVN E, RN F, LVN F, LVN G, RN G, RN E, LVN A - 08/08/23 Following MD orders for Medication Administration Parameters, attendees included- LVN A, LVN B, LVN D, LVN E, LVN F, LVN G, RN A, RN E, RN F, RN G - 08/08/23 Falls Program and Incident Report, attendees included- LN E, LVN B, RN A, RN F, LVN F, LVN G, RN G - 08/09/23 Pain Assessment and Reassessment, attendees included- RN A, RN C, LVN A, - 08/09/23 Falls Program, attendees included- LVN B, RN C, RN E, RN C, RN B,, LVN A - 08/09/23 Reviewing, Printing out & filing diagnostic reports, attendees included- RN A, RN C, RN E, LVN A, LVN F, RN D, LVN B - 08/11/23 Fall Procedure, attendees included- RN C, RN D, LVN E, RN A - 08/11/23 Documentation (Admission; Fall Risk Assessment; Pain Tool, Transfer Form, SBAR, Change of Condition), attendees included- RN C, RN D, LVN E, RN A Record review of Facility Administration in-service records revealed: - 08/03/23 the DON received training on Medication Reconciliation - 08/07/23 the DON received training on Falls - 08/07/23 the DON received training on Accidents and Incidents - 08/10/23 the Administrator and DON received training on Incident and Fall investigation and reporting. Record review performed on 08/14/23 of the facility Accident/Incident Audit signed 08/10/23 revealed, the DON had not audited all reported accidents/incidents over the last 30 days. There was no result to the audit. In a side by side record review performed with the DON on 08/15/23 of the facility Accident/Incident Audit revealed, the facility had identified failures in assessments following incidents, documentation or follow up on 10 out of 11 falls in the last 30 days. The surveyor identified a fall experienced by Resident #248 that the facility failed to identify during its audit. The Administrator was informed the IJ was removed on 08/15/23 at 02:10 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices 1 of 8 residents (Resident #238) reviewed for quality of care. - The facility failed to properly assess Resident #238 following a fall, identify a femur fracture and properly notify the provider of a fracture for 6 days following a fall leaving the resident in pain up to 09 out of 10. On 08/09/23 12:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 02:10 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for a delay of care or treatment, pain, suffering and death. Findings included: Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to the hospital on [DATE] for acute care Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Hospital Discharge Record dated 07/21/23 revealed, the resident was treated for a wedge compression fracture of the chest and spine following a fall that required spinal surgery. Record review of Resident #238's Accident/Incident Report dated 07/23/23 signed by LVN A revealed, the resident was found on the floor of the restroom besides the toilet. The patient said she fell while trying to wash her hands, she hit her butt pretty hard and her back really hurts, hell everything hurts. Record review of Resident #238's Assessments dated 07/23/23 revealed, resident had a recent fall and was identified as having a high risk of falls per her fall risk assessment. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. The resident was assessed for new injuries and none were discovered. The resident reported pain at 9 out of 10 and NP A gave an order for Acetaminophen 500 mg to be administered for pain. There was no documentation of the resident's ROM or initiation of Neurochecks. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documentation of neuro checks being initiated, specific of a head-to-toe assessment or assessment of Resident #238's ROM. Record review of Resident 238's paper and electronic chart revealed, LVN A did not perform any neuro checks on the resident following her falls on 07/23/23 or 07/28/23. There was no follow-up documented following Resident #238's fall on 07/23/23. LVN A did not complete a fall risk assessment for Resident #238's fall on 07/28/23. There was no follow-up documented following Resident #238's fall on 07/28/23 Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not corporative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. No documentation of notification of Resident #238's pain to the physician Record review of Resident #238's progress notes from 07/29/23 to 08/02/23 revealed, 07/30/23 at 06:42 AM signed by RN H- general pain at 6/10 07/30/23 at 05:03 PM signed by RN J- at 05:00 PM resident complained of pain in her left leg. 07/30/23 at 10:00 PM signed by RNG- general pain at 6/10 07/31/23 at 04:09 AM signed by RN G- general pain at 5/10 08/01/23- no nursing notes about the resident's pain 08/02/23- no nursing notes about the resident's pain Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's Provider Progress Note effective date 08/01/23 signed by NP A at 12:03 AM revealed, Therapy staff at bedside, resident sitting in wheelchair, leaning over to her knees and refusing to straighten her. Therapy attempted to straighten her but refusing to sit upright, reporting pain to left leg, had a fall earlier. But after further attempt, resident was able to sit up in wheelchair. Reporting pain and staff reporting increased anxiety, night nurse reported that she gave an extra dose of BuSpar. Record review of Resident #238's Provider Progress Note dated 08/02/23 signed by NP A at 12:02 AM revealed, resident Allowed me to examine lower extremity, edema (swelling) to left lower extremity noticed also resident reporting pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Attempted to explain to the resident but consistently declining x-ray. At 1 point, resident also was attempting to raise her leg to show that she can move her leg warranting noted on x-ray. Discussed with the nursing staff, continue monitoring and if resident continues to report pain, advised to repeat x-ray continue tramadol. Resident continues to report pain to the left leg but per phone call, previous x-ray was negative. Will repeat x-ray stat. The note was signed by the NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Provider Progress Note dated 08/03/23 signed by NP A at 12:04 AM revealed, Resident examined today. Lying down in bed. X-ray reviewed showed left intertrochanteric fracture although the pelvic x-ray was unremarkable. Resident continues to have pain, has been difficulty putting weight onto the left leg. Currently on tramadol and ibuprofen scheduled alternatingly, with no benefits. Transportation has been called and as per staff for resident to be sent out to the hospital although staff mentioned that she has been refusing to go to the hospital. The note was signed by NPA on 08/06/23 at 03:07 PM. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continues to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider places an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad and she experienced falls on 07/23/23 and 07/28/23. He said there was no change in the resident after her fall on 07/23/23 but when she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. In an interview on 08/08/23 at 08:40 AM, the Interim DON said immediately when a resident falls nursing staff are expected to assess the resident's range of motion, identify any injuries and check vitals. She said all unidentified falls also requires the initiation and completion of Neurochecks to identify any potential brain injuries. The interim DON said residents should be monitored for 72 hours following a fall to ensure there are no residual injuries like unretractable pain or altered mental status. She said that after reviewing the resident's file, the nurse did not complete proper post fall assessments and failure to assess residents appropriately following a fall could place residents at risk of delayed identification and treatment of injuries, uncontrolled pain and even death. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said the facility policy requires a head to toe assessment including the resident's ROM prior to moving the resident as well as neuro checks. LVN A said she did not initiate neuro checks on Resident #238 after the fall because she forgot and the fall occurred almost at the time of her shift. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. LVN A said in retrospect the resident should not have been moved from the floor since she was in severe pain and her ROM could not be assessed and the resident should have been sent out to the hospital. LVN A could not answer why she didn't send Resident #238 out. She said failure to assess residents properly following a fall could place residents at risk for fracture, infection, discomfort, neurological issues if the resident hit their head and development of a blood clot at the site of the fracture. In an interview on 08/09/23 at 08:40 AM, the Interim DON said following a fall nursing staff must immediately assess residents for injury including ROM assessments prior to moving the resident, any bleeding and initiation of neurological checks. She said the resident must be followed for 72 hours to ensure no injuries occurred. She said she has noticed that some nurses are not performing neuro checks following falls and LVN A did not initiate neuro checks on Resident #238 following her falls on 07/23/23 and 07/28/23. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and leg. She said earlier in the morning of 07/28/23 an X-ray tech came to the resident's room to perform an xray of Resident #238's hip but the resident wasn't corporation so a CNA had to assist the xray tech RN C said since the resident was non-complaint during the previous xray the resident had to be taken to the hospital on the evening of 07/28/23. She said when the results came back she took pictures of the xray results and sent it to the NP A who reviewed the results and said everything was ok. RN C said she never read the xray results and only relied on the assessment given by NP A. RN C said the facility policy was that all nurses were expected to read the results and then notify the provider of the findings. She said that she was not supposed to send pictures of the results to NP A but she was busy so she just sent pictures of the results without reading them. In an interview on 08/09/23 at 11:04 PM, the PT director said Resident #238 experienced a decline in therapy due to her pain so when she was discussed in the morning meeting on 08/02/23 he requested another xray be performed. He said he talked to NP A who said she would enter in an order for an xray but she did not so he followed up with MD A. He said MD A said she would enter in an order for an xray on 08/02/23, so on the morning of 08/03/23 he logged on to the radiology portal in anticipation of the results and that is when he saw the report dated 07/28/23 that identified Resident #238's left femur fracture. The Therapy Director said he immediately printed out the results and turn it over to the IP and Administrator. In an interview on 08/09/23 at 11:40 AM, the IP said the Therapy Director brought it to her attention on 08/03/23 that Resident #238 had an unidentified femur fracture from an t performed on 07/28/23. Once notified she took it to the nurse responsible who then notified the doctor right away. The IP said she had no lab or radiology review responsibility but instead did what any prudent nurse would do. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at 09:03 AM , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said the Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the patient was symptomatic. NP A said RN C probably didn't call her with Resident #238's fracture results and the fracture was missed by all. She said the results she received did not have an alert stamp and the results were on the bottom and not the top of the report so she missed the result. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility its best but failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. She said the facility policy required nurses to read the results, then verbally notify the provider of the results; nurses do not text results. In an interview on 08/16/23 at 10:32 AM, the Interim DON said there are pharmacological and non-pharmacological methods to manage residents' pain. She said proper pain management involves the acquisition of medications, timely administration of the medications, proper post administration assessments, as well as notification and documentation of ineffective pain control. The interim DON said that the facility identified discrepancies in medication administration times, acquisitions of medications, timely reassessment, provider escalation and documentation in their pain management program. She said failure to manage residents pain thoroughly and the above deficient practices could place residents at risk of uncontrolled/unretractable pain, worsening/decline of health, decreased quality of life, and slowed recovery due to the inability to complete therapy. The Interim DON said that upon a resident's admission nurses are expected to receive the order, reconcile the medications determining the first dose, identify any discrepancies and escalate and clarify all issues. She said over the survey the facility had identified discrepancies in the first doses of medications administered either through incorrect data entry or unavailable medications. The Interim DON said failure to enter and receive admissions orders could place residents at risk for worsening of condition, uncontrolled pain as well as a decreased therapeutic effect of prescribed medications. The Interim said that neglect was a failure to provide services such as: failure to properly assess residents following a fall and timely identifying negative radiology/laboratory findings. She said during the survey process the facility had identified discrepancies in the fall program and radiology reporting system and these failures could place residents at risk for delay in diagnosis of problems, delay in treatment, uncontrolled pain and death. Record review of the facility policy titled Test Results revised on 04/2007 revealed, 1- results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2- should the tests be provided to the facility, the attending physician shall be promptly notified of the results. 3- the DON or the charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. Record review of the facility policy titled Charting and Documentation revised 07/2017 revealed, 2- the following information is to be documented in the residents medical record: a- objective observations; b- medication administered; c- treatments or services performed; d- changes in the resident's condition; e- events, incidents or accidents involving the resident. 7-documentation of procedures and treatments will include care-specific details, including: c- the assessment data and/or any unusual findings obtained during the procedure/treatment. Record review of the facility policy titled Falls- Clinical Protocol revised 03/2018 revealed, 5- the staff will valuate and document falls that occur while the individual is in the facility. Monitoring and Follow-up: 1- the staff, with the physician's guidance will follow up on any fall associated with injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Record review of the facility policy titled Assessing Falls and Their Causes revised 03/2018 revealed, After a fall: 1- if a resident has just fallen, or is found on the floor without a witness to the event evaluate for possible injuries to the head, neck, spine, and extremities; 2- obtain and record vital signs as soon as it is safe to do so. 3- if there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4- if an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position and then document relevant details. 6- observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record. Document ant observed signs and symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. Documentation- when a resident falls, the following information should be recorded in the resident's medical record: 1-the condition in which the resident was found; 2- assessment data including vital signs and any obvious injuries; 3- interventions, first-aid, or treatment administered; 4- notifications to the family and physician as indicated; 5- completion of a fall risk assessment On 08/09/23 at 12:15 PM an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 08/09/23 at 12:53 PM; and a POR was requested at that time. The following plan of removal was approved on 08/11/23 at 09:30 AM and the immediacy was removed on 08/15/23 at 02:10 PM F-835 Administration [The facility] has implemented the following Plan to confirm that systems are in place to ensure that all resident falls are thoroughly investigated and that the required State report is submitted as required by law. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, provide training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need coordinated what day the service of goods available to the facility). 1. The facility undertook corrective action with regards to Resident #238 to confirm that a thorough investigation of the fall was completed and a report of an allegation of neglect was filed with HHSC on August 7, 2023. Resident #238 was discharged from the facility on August 3, 2023. 2. The Interim Director of Nursing/Designee audited all incident/accident reports of falls for the past thirty (30) days to confirm whether the following was done: o Proper nursing assessments were completed following the fall; o Physician was notified of the fall; o Family was notified of the fall; o All ordered interventions were performed and accurately documented; o The incident/accident report of the fall was accurately and completely filled out; and o The information about the fall was documented in the skilled nursing notes that are used to prepare the 24 Hour Report. 3. The facility confirmed that it has an existing process in place to investigate patient falls and to make appropriate reports of the falls to HHSC. The process includes: o The treating nurse documents the fall on the incident/accident report in [electronic medical records system]; o The treating nurse prepares the skilled nursing note documenting the fall, the patient assessment following the fall, and any ordered interventions; o The treating nurse collects witness statements, if any, and documents them on the incident/accident report; o The Interim Director of Nursing/Designee reviews the incident/accident report to confirm its completion and accuracy; o As part of the investigation of the fall, the Interim Director of Nursing/Designee interviews the resident and staff members. The findings of the interviews are documented on the incident/accident report; o The Interim Director of Nursing/Designee assesses the completion of the incident/accident report and the investigation to confirm that all of the details of the fall are included; that the physician and family have been notified; and that all ordered interventions have been completed; o The Interim Director of Nursing/Designee signs off on the incident/accident report as complete; o Fall events and the status of the residents' condition and investigation are discussed during daily Stand Up and Stand Down meetings; o Fall events and the status of the residents' condition and investigation are discussed during Grand Rounds; and o Based on the findings of the completed investigation and a determination that the resident's fall caused bodily injury that was suspicious for abuse or neglect, the Facility Administrator timely reports the fall event to HHSC as follows: i. Within two (2) hours of forming the suspicion if (a) there is a suspicion of abuse or (b) the fall resulted in serious bodily injury, or ii. Within twenty-four (24) hours if there is not a suspicion of abuse and the bodily injury was not serious. 4. The Quality Department has re-educated the Interim Director of Nursing/Designee and the Facility Administrator on the process to investigate patient falls and to make appropriate reports of the falls to HHSC as outlined in No. 3 above. 5. The Interim Director of Nursing/Designee has re-educated nursing staff members on recognizing the risk factors for falls, fall precautions, resident assessment, appropriate documentation, and how to properly escalate following falls. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. ***The effectiveness of the re-education and the competency of the nursing staff will be measured by reviewing fallouts from the audits performed by the Director of Nursing/Designee and providing just-in-time re-education of the staff member responsible for the fallout. Also, for identified areas of non-compliance, staff members will be re-educated in mandatory staff meetings held monthly. Attendance at these meetings will be tracked. Finally, the facility, in collaboration with the Quality and Education Departments, is developing an annual competency tool, which will cover the topics in this Plan, along with other nursing skills/competencies. Completion Date: August 10, 2023 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 1. The Interim Director of Nursing/Designee and the Director of Operations are reviewing relevant facility policies and procedures to determine whether revisions are necessary to be consistent with the outlined measures in this Plan. 2. By August 10, 2023, the Quality Department is re-educating the Interim Director of Nursing and the Facility Administrator of the process to investigate patient falls and to make appropriate reports of the falls to HHSC. The process includes: o The treating nurse documents the fall on the incident/accident report in [electronic medical records system]; o The treating nurse prepares the skilled nursing note documenting the fall, the patient assessment following the fall, and any ordered interventions; o The treating nurse collects [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 6 residents (Resident #238, Resident #235 and Resident #237) reviewed for pain management. - The facility failed to reassess and manage Resident #238's pain regimen resulting in a decline in therapy due to her pain described as unbearable and worse than having a baby. - The facility failed to send prescriptions to the pharmacy timely upon admission and administer pain medication to Resident #235; the facility failed to assess Resident #235's pain following medication administration and failed to notify the resident's provider of ineffective pain control. Resident #235 suffered from pain up to 10 out of 10. - The facility failed to send prescriptions to the pharmacy timely upon admission and administer pain medication to Resident #237; the facility failed to assess Resident #237's pain following medication administration and failed to notify the resident's provider of ineffective pain control. Resident #237 reported pain up to 07 out of 10. On 08/03/23 09:20 AM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/09/23 at 12:53 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk for uncontrolled, irretractable pain, and decreased quality of life. Findings included: Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to the hospital on [DATE] for acute care Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Hospital Discharge Record dated 07/21/23 revealed, the resident was treated for a wedge compression fracture of the chest and spine following a fall that required spinal surgery. Record review of Resident #238's Assessments dated 07/23/23 revealed, resident had a recent fall and was identified as having a high risk of falls per her fall risk assessment. Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of Resident #238's progress notes from 07/29/23 to 08/02/23 revealed, 07/30/23 at 06:42 AM signed by RN H- general pain at 6/10, there was no documentation of notification to the provider. 07/30/23 at 05:03 PM signed by RN J- at 05:00 PM resident complained of pain in her left leg. there was no documentation of notification to the provider. 07/30/23 at 10:00 PM signed by RNG- general pain at 6/10 there was no documentation of notification to the provider. 07/31/23 at 04:09 AM signed by RN G- general pain at 5/10; there was no documentation of notification to the provider. 08/01/23- no nursing notes about the resident's pain 08/02/23- no nursing notes about the resident's pain Record review of Resident #238's Physicians Orders revealed, on 07/28/23 the resident was prescribed Tramadol 50 mg every 6 hours for pain and the order was changed to every 8 hours for pain on 07/31/23. on 07/31/23 the resident was prescribed Ibuprofen 400 mg three times a day. There were no new orders for scheduled pain medicines entered after 07/31/23. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. The Physician ordered Tramadol 50 mg 1 tablet every 6 hours for pain. Record review of Resident #238's Provider Progress Note effective date 08/01/23 signed by NP A at 12:03 AM revealed, Therapy staff at bedside, resident sitting in wheelchair, leaning over to her knees and refusing to straighten her. Therapy attempted to straighten her but refusing to sit upright, reporting pain to left leg, had a fall earlier. But after further attempt, resident was able to sit up in wheelchair. Reporting pain and staff reporting increased anxiety, night nurse reported that she gave an extra dose of BuSpar. Resident #238 was taking tramadol 50 mg tablet - Take 1 tablet by mouth every six hours as needed ordered. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Provider Progress Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. Continue tramadol as needed, ibuprofen 3 times a day until 8/10/2023. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Provider Progress Note dated 08/03/23 signed by NP A at 12:04 AM revealed, Resident continues to have pain, has been difficulty putting weight onto the left leg. Currently on tramadol and ibuprofen scheduled alternatingly, with no benefits. The resident was sent out to the hospital. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A NP A said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. In an interview on 08/07/23 at 02:06 PM, the Rehab Director said upon admission Resident #238 was not bad and she experienced falls on 07/23/23 and 07/28/23. He said there was no change in the resident after her fall on 07/23/23 but when she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. The Rehab Director said after the fall on 07/28/23 the resident drastically was not able to meet her therapy goal. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said the facility policy requires a head to toe assessment including the resident's ROM prior to moving the resident as well as neuro checks. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. LVN A said in retrospect the resident should not have been moved from the floor since she was in severe pain and her ROM could not be assessed and the resident should have been sent out to the hospital. LVN A could not answer why she didn't send Resident #238 out. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and leg. In an interview on 08/09/23 at 11:04 PM, the Rehab director said Resident #238 experienced a decline in therapy due to her continuous pain after the fall on 07/28/23 so he discussed the resident with the prescriber the morning meeting on 08/02/23 he requested another xray be performed. He said he talked to NP A who said she would enter in an order for an xray but she did not so he followed up with MD A. He said MD A said she would enter in an order for an xray on 08/02/23, so on the morning of 08/03/23 he logged on to the radiology portal in anticipation of the results and that is when he saw the report dated 07/28/23 that identified Resident #238's left femur fracture. The Rehab Director said he immediately printed out the results and turn it over to the IP and Administrator. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at 09:03 AM , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said the Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the patient was symptomatic. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility its best but failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. In an interview on 08/16/23 at 10:32 AM, the Interim DON said there are pharmacological and non-pharmacological methods to manage residents' pain. She said proper pain management involves the acquisition of medications, timely administration of the medications, proper post administration assessments, as well as notification and documentation of ineffective pain control. The interim DON said that the facility identified discrepancies in medication administration times, acquisitions of medications, timely reassessment, provider escalation and documentation in their pain management program. She said failure to manage residents pain thoroughly and the above deficient practices could place residents at risk of uncontrolled/unretractable pain, worsening/decline of health, decreased quality of life, and slowed recovery due to the inability to complete therapy. The Interim DON said that upon a resident's admission nurses are expected to receive the order, reconcile the medications determining the first dose, identify any discrepancies and escalate and clarify all issues. She said over the survey the facility had identified discrepancies in the first doses of medications administered either through incorrect data entry or unavailable medications. The Interim DON said failure to enter and receive admissions orders could place residents at risk for worsening of condition, uncontrolled pain as well as a decreased therapeutic effect of prescribed medications. The Interim said that neglect was a failure to provide services such as: failure to properly assess residents following a fall and timely identifying negative radiology/laboratory findings. She said during the survey process the facility had identified discrepancies in the fall program and radiology reporting system and these failures could place residents at risk for delay in diagnosis of problems, delay in treatment, uncontrolled pain and death. Resident #235 Record review of Resident #235's face sheet dated 06/28/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, UTI and unspecified fall. The resident discharged on 07/18/23. Record review of Resident #235's secondary Face Sheet dated 06/28/23 at 10:28 AM revealed, Resident #235 admitted to the facility on [DATE] at 09:01 PM. Record review of Resident #235's Baseline Care Plan dated 06/27/23 revealed, the resident was alert & oriented and experiencing generalized aching pain Record review of Resident #235's Hospital H & P dated 06/27/23 revealed, Resident #235 had an accidental fall, abdominal pain, small hernia and chronic pain disorder. Record review of Resident #235's Hospital Discharge Record dated 06/27/23 at 03:45 PM revealed, Resident #235's next scheduled dose of pain medications as follows: - Morphine 15 mg ER (an opioid pain medication)- 1 tablet be mouth every six hours with next dose due on 06/27/23 at 09:00 PM. - Oxycodone 10 mg (an opioid pain medication)- 1 Tablet by mouth every 6 hours with next dose due on 06/27/23 at 06:00 PM. Record review of Resident #235's Order Summary Report dated 06/28/23 revealed, - Morphine Sulfate 15 mg- give 1 tablet by mouth every 12 hours for pain ordered on 06/27/23 with a start date of 06/28/23. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours for pain ordered on 06/27/23 with a start date of 06/28/23 - Acetaminophen 650- 1 tablet by mouth every 8 hours as needed for pain starting 06/27/23 at 10:45 PM. Record review of Resident #235's Progress Note dated 06/28/23 revealed - 01:16 AM- resident came in after 9 pm, [automated medication dispensing machine] does not have name. - 04:19 AM - complaint of pain to legs - 05:25 AM- no medication on hand - 05:56 AM- Resident #235 was informed that the MD was notified for prescriptions to be sent to the pharmacy. Resident #235 informed the facility that she had her Morphine and Oxycodone at home and she asked if her son brought them to the facility could the facility staff administer it. Record review of Resident #235's June MAR printed 06/28/23 at 12:50 PM revealed, her medications were not started until 06/28/23 and the following medications were not administered: - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours due at 06/28/23 at 12:00 AM. The start date was not entered until 06/28/23 at 06:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours scheduled for 06/28/23 at 06:00 AM. Reason not administered- medication not available. - Morphine Sulfate 15 mg ER- give 1 tablet by mouth every 12 hours for pain due at 06/27/23 at 09:00 PM. The Order was entered incorrectly as Morphine Sulfate 15 mg (IR) with a start date of 06/28/23 at 08:00 AM Record review of Resident #235's Pharmacy Records dated 06/28/23 revealed, MD A did not submit electronic prescriptions for Resident #235's Oxycodone 10 mg and Morphine ER 15 mg until 06/28/23 at 05:31 PM, over 20 hours after the resident's admission. Record review of Resident #235's June MAR dated 06/28/23 at 12:50 PM revealed the following pain scores: - 05 out of 10 when Resident was administered her only dose of Acetaminophen 650 mg on 06/28/23 at 04:19 AM - 10 out of 10 when Resident was administered her Morphine 15 mg scheduled for 08:00 AM. - 08 out of 10 when Resident was administered her first dose of Oxycodone 10 mg scheduled for 12:00 PM. Record review of Resident #235's Physician's Notes from 06/27/23 to 07/18/23 revealed, no documentation of reported ineffective pain management, uncontrolled pain or pain scores that remained the same after medication administration by nursing staff. Record review of Resident #235's June Progress Notes revealed, no documentation of unchanged or increased pain scores which indicated ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER June MAR revealed, - increased pain recorded on 06/28/23 between 06:00 AM and 12:00 PM doses from an 3 to an 8 out of 10. - unchanged pain recorded on 06/28/23 between 12:00 PM and 08:00 PM doses at an 8 out of 10. - unchanged pain recorded on 06/29/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. - increased pain recorded on 06/29/23 between 06:00 AM and 12:00 PM doses from an 5 to a 7 out of 10. - increased pain recorded on 06/29/23 between 12:00 AM and 06:00 PM doses from an 7 to an 8 out of 10. - unchanged pain recorded on 06/30/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. Record review of Resident #235' July Progress Notes revealed, no documentation of unchanged or increased pain scores which indicate ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER July MAR revealed, - increased pain from a 0 to a 4 out of 10 on 07/03/23 between 06:00 PM to 07/0/423 at 12:00 AM doses. - increased pain from a 0 to a 5 out of 10 on 07/04/23 between 12:00 Pm to 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/06/23 between 12:00 PM to 06:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/07/23 between 12:00 PM to 06:00 PM doses. - unchanged pain at 5 out of 10 recorded on 07/08/23 between 12:00 AM and 06:00 AM doses. - unchanged pain at 5 out of 10 recorded on 07/09/23 between 12:00 AM and 06:00 AM doses. - increased pain from a 5 to an 6 out of 10 on 07/09/23 between 06:00 AM to 12:00 PM doses. - unchanged pain at 6 out of 10 recorded on 07/09/23 between 12:00 PM and 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/11/23 between 06:00 AM to 12:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/12/23 between 06:00 AM to 12:00 PM doses. Record review of Resident #235's Medication Administration Audit from 06/27/23 to 07/18/23 dated 08/03/23 revealed, the resident received her Oxycodone and Morphine outside of scheduled administration times on 23 different occasions during her stay and there were no documented reasons for the late doses: 1- Morphine ER 15 mg scheduled for 06/28/23 at 08:00 AM, administered at 09:15 PM; The medication was not available 2- Morphine ER 15 mg scheduled for 06/30/23 at 08:00 PM, administered at 9:33 PM; There was no documented reason for the late administration. 3- Morphine ER 15 mg scheduled for 07/01/23 at 08:00 AM, administered at 09:05 PM; There was no documented reason for the late administration. 4- Oxycodone 10 mg scheduled for 07/02/23 at 06:00 PM, administered at 7:11 PM; There was no documented reason for the late administration. 5- Morphine ER 15 mg scheduled for 07/02/23 at 08:00 PM, administered at 11:32 PM; There was no documented reason for the late administration. 6- Morphine ER 15 mg scheduled for 07/03/23 at 08:00 PM, administered at 09:58 PM: There was no documented reason for the late administration. 7- Oxycodone 10 mg scheduled for 07/04/23 at 06:00 AM, administered at 7:05 AM; There was no documented reason for the late administration. 8- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 AM, administered at 09:15 AM; There was no documented reason for the late administration. 9- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 PM, administered at 10:44 PM: There was no documented reason for the late administration. 10- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 AM, administered at 09:19 AM; There was no documented reason for the late administration. 11- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 PM, administered at 09:20 PM; There was no documented reason for the late administration. 12- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 AM, administered at 11:53AM; There was no documented reason for the late administration. 13- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 PM, administered at 09:03 PM; There was no documented reason for the late administration. 14- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 AM, administered at 11:03AM; There was no documented reason for the late administration. 15- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 PM, administered at 10:07 PM; There was no documented reason for the late administration. 16- Morphine ER 15 mg scheduled for 07/09/23 at 08:00 AM, administered at 09:30AM; There was no documented reason for the late administration. 17- Morphine ER 15 mg scheduled for 07/10/23 at 08:00 PM, administered at 09:05 PM; There was no documented reason for the late administration. 18- Oxycodone 10 mg scheduled on 07/12/23 at 12:00 AM, administered at 3:16 AM; There was no documented reason for the late administration. 19- Oxycodone 10 mg scheduled for 07/14/23 at 12:00 PM, administered at 02:17 PM; The medication ran out of refills. 20- Morphine ER 15 mg scheduled for 07/16/23 at 08:00 AM, administered at 10:05 AM 21- Oxycodone 10 mg scheduled for 07/17/23 at 06:00 PM, administered at 07:30 PM; There was no documented reason for the late administration. 22- Morphine ER 15 mg scheduled for 07/17/23 at 08:00 PM, administered at 09:12 PM; There was no documented reason for the late administration. 23- Morphine ER 15 mg scheduled for 07/18/23 at 08:00 AM, administered at 09:03 AM; There was no documented reason for the late administration. Record review of Resident #235's Progress Notes dated 07/18/23 revealed resident discharged home with home health care. An observation on 06/28/23 at 08:45 AM revealed, Resident #235's family member approaching RN B while she prepared for medication administration to Resident #235. He said that he was very upset with the facility because prior to admission he was assured that Resident #235's medication would be available upon her admission but it was not. He said Resident #235 called him multiple times overnight to inform him that she had not received any of her medication since she arrived at the facility and she was in severe pain. Resident #235's family member then handed RN B 2 bottles of medication (Morphine ER 15 mg and Oxycodone 10 mg) and said he brought only a 2 days' supply to cover Resident #235 until the medication arrived at the facility. After Resident #235's family member entered the resident's room, RN B alerted the Interim DON to the arrival of the mediation at which point they both counted the medications and logged them into individual control sheets. In an interview on 06/28/23 at 10:10 AM, RN B said Resident #235 admitted to the facility on the night shift of 06/27/23. She said the patient's medications had not yet arrived from the pharmacy and the night shift nurse said Resident #235's family member would be bringing her pain medication so she was waiting for its arrival. When asked if RN B could have pulled the rest of Resident #235's unavailable medication from the facility EKit (floor stock of prescription medications available for emergency use), she said she administered the OTC medications as well as the pain medication brought in by the family member but she would have to check the facility EKit for the rest of Resident #235's medications. RN B said she immediately administered Morphine ER 15 mg to Resident #235 once it was delivered by the resident's family member but the Oxycodone was not due yet. She could not say when Resident #235 received her last dose of Oxycodone, but she could not administer it due to the scheduled time in the MAR. RN B said failure to administer medications as ordered could place residents at risk for uncontrolled disease states such as uncontrolled pain. In an interview on 06/28/23 at 10:35 AM, the Interim DON said when a resident arrived at the facility the admitting nurse is expected to review the hospital paperwork to verify the last dose of medications received as well as when the next dose is due. She said the nurse then enters the order into the system and verifies it with the physician. The Interim DON said Resident #235 admitted to the facility on [DATE] at around 08:30 PM so her medications were not yet delivered by the pharmacy. She said that the expectation was for residents to receive their medications as ordered and that the nurse should have taken into consideration Resident #235's last doses to determine when the next dose was due and to at least get an order for a one-time dose to ensure that the resident received her medications. The interim DON said if a CII medication ( scheduled 2 controlled substances that require additional care because of the potential to intentionally or unintentionally abuse the drug) was unavailable nursing staff are expected to request an appropriate alternative treat the patients pain and most other medications could be found in the e-kit until the medication arrived. The Interim DON said that failure to administer medication to residents as ordered could place residents at risk for uncontrolled disease states and pain. In an observation and interview on 06/28/23 at 11:11 AM, Resident #235 said she discharged from the hospital on [DATE] at 04:00 PM but she did not get picked up by the transport company until after 08:00 PM so by the time she arrived at the facility her medications were already due. She said when she arrived at the facility she explained to the staff that since she was discharged from the hospital at 4:00 PM the hospital was unable to administer any of her medications due after 4:00 PM. Resident #235 said she asked for her medications especially her pain medication but she was told the medication was not available at the facility. She said she specifically asked for her pain medications Morphine and Oxycodone because her pain was a 10 out of 10 but it was unavailable so her son had to bring in her pain medication in the morning (06/28/23). Resident #235 said she was in severe pain rendering her unable to do anything and writhing in pain prior to receiving her Morphine morning. She said after receiving her Morphine her pain was at 08 out of 10 but she had still not received her Oxycodone. The observation of Resident #238's facial expressions showed no sign of grimacing or discomfort. In an interview on 08/02/23 at 01:56 PM, LVN B said resident pain can be assessed based on verbalization of pain on a scale of 0-10. She said the pain level is documented prior to administration of the pain medication but there is no trigger to document a post administration assessment in the EMR for scheduled medication. LVN B said nursing staff are expected to assess the patients pain level 30 minutes - 1 hr. after administration of the medication and document it in the progress notes. She said if a resident was assessed to have increase or unchanged pain levels then the medication was not effective and the provider must be notified. LVN B said Resident #235 was generally pleasant and she had been taking Oxycodone for a long time. She said she could not recall any issues with Resident #235's pain management but she did remember that the residents facial expressions did not match the level of pain she reported. In an interview on 08/13/23 at 08:03 AM, RN E said she was the admitting nurse for Resident #235 on 06/28/23. She said when the resident admitted to the facility she entered reconciled the medications with the provider, including the Resident #235's pain medications Oxycodone and Morphine. She said when she notified the provider, the provider stated that late admissions always resulted in problems with CII medication acquisition because they were unable to electronically prescribe the medications. She said she asked for an alternative and the provider gave an order for Tylenol and nothing else. RN E said Acetaminophen was not sufficient pain control for patients on opioid medications but that was the medication ordered for the resident upon admission. Resident #237 Record review of Resident #237's Nurse report dated 07/26/23 revealed, Resident #237 arrived at the facility at 7 pm. Record review of Resident #237's Face Sheet dated 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses of: atrial fibrillation (irregular heartbeat), acute kidney failure, opioid dependence, anemia, hypertension (high blood pressure) and type 2 diabetes. The resident discharged from the facility on 08/05/23. Record review of Resident #237's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel. Yes- resident received scheduled and PRN pain medication in the last 5 days as well as received non-medication intervention for pain. Resident #237 reported frequent pain and the worst pain reported was a 5 out of 10. Record review of Resident #237's Baseline Care Plan dated 07/26/23 and signed by RN F revealed, admission goals to return to the family home, one person assist with most ADLs, wheelchair use, always continent of both bladder and bowel. Physician orders for opioids was not selected, presence of pain was documented as no. Record review of Resident #237's Hospital D[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 6 of 15 staff ( LVN A, LVN B, LVN C, RN B, RN C and RN F) and 6 of 13 residents ( Resident #26, Resident #235, Resident #236, Resident #237, Resident #238 and Resident #270) reviewed for nursing competency. - The facility failed to ensure nursing staff failed to properly assess Resident #238 following a fall, identify a femur fracture, and properly notify the provider of a fracture for 6 days following a fall; leaving the resident in pain up to 09 out of 10. - The facility failed to ensure nursing staff entered admission orders accurately, timely, acquired medications, accurately assessed pain and notified the MD of ineffective pain control following pain medication administration for Resident #235 and Resident #237; leaving the residents in pain from 07 to 10 out of 10. - The facility failed to ensure nursing staff failed to enter accurately and timely acquire/administer medications to Resident #236. - The facility failed to ensure nursing staff failed to accurately enter the start time of Resident #26's medication at re-admission from the hospital. - The facility failed to ensure nursing staff failed to accurately enter the start time of Resident #270's medication at admission. On 08/09/23 12:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 03:48 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could affect residents at risk for uncontrolled pain, severe injury, delated treatment and death. Findings included: Record review of the facility's Nurse New/Annual Competency Skills Assessment revealed, nursing competencies were not assessed annually and the staff completed self-assessments regarding reporting/documentation, medications, physical assessment, documentation, and computer skills for network, EMR, and radiology/laboratory lab results portal. Staff were not assessed by any member of nursing administration. - RN D last self assessed her competency skills on 11/05/21 as I have performed many times in the last 5 years. No further review necessary. - LVN B last self assessed her competency skills on 11/20/20 as I have performed many times in the last 5 years. No further review necessary. - RN C last self assessed her competency skills on an undocumented date as I have performed many times in the last 5 years. No further review necessary. - RN F last self assessed her competency skills on 03/09/22 as I have performed many times in the last 5 years. No further review necessary. -- LVN A last self assessed her competency skills on 01/26/22 as I have seen and/or read but have not had an opportunity to perform regarding documentation, abuse and neglect training, resident respect and rights training, Neurovascular assessments, documentation ( transcription/confirmation of MD orders in EMR, admission assessments, incident reports, SNF/LTC protocols skin assessments, functional assessments and mini mental assessments. I have performed three (3) times or less- general/admission assessments and neurological assessments. I have performed many times but not in the last (5) years for oral, subcutaneous (under the skin) and intramuscular medications. - RN A last self assessed her competency skills on 11/02/21 as I have performed many times in the last 5 years. No further review necessary. - RN E last self assessed her competency skills on 12/06/18 as I have performed many times in the last 5 years. No further review necessary> In an interview on 08/15/23 at 04:00 PM, the Corporate Quality Manager said that during the survey the facility identified that annual competency checks were not completed by nurse management. She said nurses were allowed to self-assess their skills but they were assigned training in an online learning management system as applicable. The Corporate Quality Manager said that the online trainings had tests at the end of each course but there was no actual check off/sign off of nursing competencies completed by facility administration prior to nursing staff working on the floor. She said going forward, nursing competencies would be validated. Resident #238 Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's Accident/Incident Report dated 07/23/23 signed by LVN A revealed, the resident was found on the floor of th restroom besides the toilet. The patient said she fell while trying to wash her hands, she hit her butt pretty hard and her back really hurts, hell everything hurts. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. The resident was assessed for new injuries and none were discovered. The resident reported pain at 9 out of 10 and NP A gave an order for Acetaminophen 500 mg to be administered for pain,. There was no documentation of the resident's ROM or initiation of Neurochecks. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w and as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documentation of neuro checks being initiated, specific of a head to toe assessment or assessment of Resident #238's ROM. Record review of Resident 238's paper and electronic chart revealed, LVN A did not perform any neuro checks on the resident following her falls on 07/23/23 or 07/28/23. There was no follow-up documented following Resident #238's fall on 07/23/23. LVN A did not complete a fall risk assessment for Resident #238's fall on 07/28/23. There was no follow-up documented following Resident #238's fall on 07/28/23 Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not corporative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continues to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider places an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad and she experienced falls on 07/23/23 and 07/28/23. He said there was no change in the resident after her fall on 07/23/23 but when she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said the facility policy requires a head to toe assessment including the resident's ROM prior to moving the resident as well as neuro checks. LVN A said she did not initiate neuro checks on Resident #238 after the fall because she forgot and the fall occurred almost at the time of her shift. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. LVN A said in retrospect the resident should not have been moved from the floor since she was in severe pain and her ROM could not be assessed. She said failure to assess residents properly following a fall could place residents at risk for fracture, infection, discomfort, neurological issues if the resident hit their heat and development of a blood clot at the site of the fracture. LVN A said she could not remember the specifics of Resident #238's fall on 07/23/23. In an interview on 08/09/23 at 08:40 AM, the Interim DON said following a fall nursing staff must immediately assess residents for injury including ROM assessments prior to moving the resident, any bleeding and initiation of neurological checks. She said the resident must be followed for 72 hours to ensure no injuries occurred. She said she has noticed that some nurses are not performing neuro checks following falls and LVN A did not initiate neuro checks on Resident #238 following her falls on 07/23/23 and 07/28/23. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and leg. She said earlier in the morning of 07/28/23 an X-ray tech came to the resident's room to perform an xray of Resident #238's hip but the resident wasn't corporation so a CNA had to assist the xray tech RN C said since the resident was non-complaint during the previous xray the resident had to be taken to the hospital on the evening of 07/28/23. She said when the results came back she took pictures of the xray results and sent it to the NP A who reviewed the results and said everything was ok. RN C said she never read the xray results and only relied on the assessment given by NP A. RN C said the facility policy was that all nurses were expected to read the results and then notify the provider of the findings. She said that she was not supposed to send pictures of the results to NP A but she was busy so she just sent pictures of the results without reading them. In an interview on 08/09/23 at 11:04 PM, the PT director said Resident #238 experienced a decline in therapy due to her pain so when she was discussed in the morning meeting on 08/02/23 he requested another xray be performed. He said he talked to NP A who said she would enter in an order for an xray but she did not so he followed up with MD A. He said MD A said she would enter in an order for an xray on 08/02/23, so on the morning of 08/03/23 he logged on to the radiology portal in anticipation of the results and that is when he saw the report dated 07/28/23 that identified Resident #238's left femur fracture. The Therapy Director said he immediately printed out the results and turn it over to the IP and Administrator. In an interview on 08/09/23 at 11:40 AM, the IP said the Therapy Director brought it to her attention on 08/03/23 that Resident #238 had an unidentified femur fracture from an t performed on 07/28/23. Once notified she took it to the nurse responsible who then notified the doctor right away. The IP said she had no lab or radiology review responsibility but instead did what any prudent nurse would do. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said the Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the patient was symptomatic. NP A said RN C probably didn't call her with Resident #238's fracture results and the fracture was missed by all. She said the results she received did not have an alert stamp and the results were on the bottom and not the top of the report so she missed the result. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility its best but failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. She said the facility policy requires nurses to read the results, then verbally notify the provider of the results, nurses do not text results. Resident #235 Record review of Resident #235's face sheet dated 06/28/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, UTI and unspecified fall. The resident discharged on 07/18/23. Record review of Resident #235's secondary Face Sheet dated 06/28/23 at 10:28 AM revealed, Resident #235 admitted to the facility on [DATE] at 09:01 PM. Record review of Resident #235's Baseline Care Plan dated 06/27/23 revealed, the resident was alert & oriented and experiencing generalized aching pain Record review of Resident #235's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #235's admission Nursing Screening dated 06/27/23 and signed by RN E revealed, the resident's cognition was intact and the resident was assessed visually for pain and it was documented as hurts a little bit. Record review of Resident #235's Hospital Discharge Record dated 06/27/23 at 03:45 PM revealed, Resident #235's next scheduled dose of medications as follows: - Famotidine 20 mg (used to treat acid reflux)- 1 Tablet by mouth daily with the next dose due on 06/28/23 at 09:00 AM. - Morphine ( an opioid pain medication) 15 mg ER- 1 Tablet be mouth every six hours with next dose due on 06/27/23 at 09:00 PM. - Oxycodone 10 mg (an opioid pain medication)- 1 Tablet by mouth every 6 hours with next dose due on 06/27/23 at 06:00 PM. - Metronidazole 500 mg (an antibiotic)- 1 tablet by mouth every 8 hours with next dose scheduled on 06/27/23 at 08:00 PM. - Simvastatin 20 mg (used to treat high cholesterol)- 1 tablet by mouth at bed time with next dose scheduled on 06/27/23 at bedtime. - Hydralazine 50 mg ( used to treat high blood pressure)- 1 tablet by mouth 4 times daily with next dose scheduled on 06/27/23 at 09:00 PM. Record review of Resident #235's Order Summary Report dated 06/28/23 revealed, - Famotidine 20 mg- give 1 tablet by mouth one time a day for acid reflux ordered on 06/27/23 with a start date of 06/28/23. - Morphine Sulfate 15 mg- give 1 tablet by mouth every 12 hours for pain ordered on 06/27/23 with a start date of 06/28/23. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours for pain ordered on 06/27/23 with a start date of 06/28/23 - Simvastatin 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia (high cholesterol) ordered on 06/27/23 with a start date of 06/28/23 - Metronidazole 500 mg- 1 tablet by mouth every 8 hours ordered on 06/27/23 with a start date of 06/28/23 - Hydralazine 50 mg - 1 tablet by mouth four times a day for high blood pressure ordered on 06/27/23 with a start date of 06/28/23 Record review of Resident #235's June MAR printed 06/28/23 at 12:50 PM revealed, her medications were not started until 06/28/23. - Simvastatin 20 mg- 1 tablet by mouth at bedtime for hyperlipidemia due at 08:00 PM on 06/27/23. The start date not scheduled till 06/28/23. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days due at 06/27/23 at 08:00 PM. Start date entered as 06/28/23 at 12:00 AM. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days scheduled for 06/28/23 at 12:00 AM. Reason not administered- medication not available. - Hydralazine 50 mg- give 1 tablet by mouth four times a day for high blood pressure due at 06/27/23 at 09:00 PM. Start date entered as 06/28/23 at 08:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours due at 06/28/23 at 12:00 AM. The start date was not entered until 06/28/23 at 06:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours scheduled for 06/28/23 at 06:00 AM. Reason not administered- medication not available. - Morphine Sulfate 15 mg ER- give 1 tablet by mouth every 12 hours for pain due at 06/27/23 at 09:00 PM. The Order was entered incorrectly as Morphine Sulfate 15 mg (IR) with a start date of 06/28/23 at 08:00 AM Record review of Resident #253's Progress Note dated 06/28/23 revealed - 01:16 AM- resident came in after 9 pm, [automated dispensing system] does not have name. - 04:19 AM - complaint of pain to legs - 05:25 AM- no medication on hand - 05:56 AM- Resident #235 was informed that the MD was notified for prescriptions to be sent to the pharmacy. Resident #235 informed the facility that she had her Morphine and Oxycodone at home and she asked if her son brought them to the facility could the facility staff administer it. Record review of Resident #235's June MAR dated 06/28/23 at 12:50 PM revealed the following pain scores: - 05 out of 10 on 06/28/23 at 04:19 PM - 10 out of 10 when Resident was administered her Morphine 15 mg scheduled for 08:00 AM. - 08 out of 10 when Resident was administered her Oxycodone 10 mg scheduled for 12:00 PM. Record review of Resident #235's Physician's Notes from 06/27/23 to 07/18/23 revealed, no documentation of reported ineffective pain management, uncontrolled pain or pain scores that remained the same after medication administration by nursing staff. Record review of Resident #235's Progress Notes dated 07/14/23 at 01:50 PM signed by LVN B revealed, the facility ran out of Resident #235's Oxycodone on 07/14/23 and LVN B was awaiting delivery of the medication from the pharmacy. Record review of Resident #235' June Progress Notes revealed, no documentation of unchanged or increased pain scores which indicate ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER June MAR revealed, - increased pain recorded on 06/28/23 between 06:00 AM and 12:00 PM doses from an 3 to an 8 out of 10. - unchanged pain recorded on 06/28/23 between 12:00 PM and 08:00 PM doses at an 8 out of 10. - unchanged pain recorded on 06/29/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. - increased pain recorded on 06/29/23 between 06:00 AM and 12:00 PM doses from an 5 to a 7 out of 10. increased pain recorded on 06/29/23 between 12:00 AM and 06:00 PM doses from an 7 to an 8 out of 10. - unchanged pain recorded on 06/30/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. Record review of Resident #235' July Progress Notes revealed, no documentation of unchanged or increased pain scores which indicate ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER July MAR revealed, - increased pain from a 0 to a 4 out of 10 on 07/03/23 between 06:00 PM to 07/0/423 at 12:00 AM doses. - increased pain from a 0 to a 5 out of 10 on 07/04/23 between 12:00 Pm to 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/06/23 between 12:00 PM to 06:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/07/23 between 12:00 PM to 06:00 PM doses. - unchanged pain at 5 out of 10 recorded on 07/08/23 between 12:00 AM and 06:00 AM doses. - unchanged pain at 5 out of 10 recorded on 07/09/23 between 12:00 AM and 06:00 AM doses. - increased pain from a 5 to an 6 out of 10 on 07/09/23 between 06:00 AM to 12:00 PM doses. - unchanged pain at 6 out of 10 recorded on 07/09/23 between 12:00 PM and 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/11/23 between 06:00 AM to 12:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/12/23 between 06:00 AM to 12:00 PM doses. Record review of Resident #235's Medication Administration Audit from 06/27/23 to 07/18/23 dated 08/03/23 revealed, the resident received her Oxycodone and Morphine outside of scheduled administration times on 23 different occasions during her stay: 1- Morphine ER 15 mg scheduled for 06/28/23 at 08:00 AM, administered at 09:15 PM; The medication was not available 2- Morphine ER 15 mg scheduled for 06/30/23 at 08:00 PM, administered at 9:33 PM; There was no documented reason for the late administration. 3- Morphine ER 15 mg scheduled for 07/01/23 at 08:00 AM, administered at 09:05 PM; There was no documented reason for the late administration. 4- Oxycodone 10 mg scheduled for 07/02/23 at 06:00 PM, administered at 7:11 PM; There was no documented reason for the late administration. 5- Morphine ER 15 mg scheduled for 07/02/23 at 08:00 PM, administered at 11:32 PM; There was no documented reason for the late administration. 6- Morphine ER 15 mg scheduled for 07/03/23 at 08:00 PM, administered at 09:58 PM: There was no documented reason for the late administration. 7- Oxycodone 10 mg scheduled for 07/04/23 at 06:00 AM, administered at 7:05 AM; There was no documented reason for the late administration. 8- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 AM, administered at 09:15 AM; There was no documented reason for the late administration. 9- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 PM, administered at 10:44 PM: There was no documented reason for the late administration. 10- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 AM, administered at 09:19 AM; There was no documented reason for the late administration. 11- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 PM, administered at 09:20 PM; There was no documented reason for the late administration. 12- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 AM, administered at 11:53AM; There was no documented reason for the late administration. 13- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 PM, administered at 09:03 PM; There was no documented reason for the late administration. 14- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 AM, administered at 11:03AM; There was no documented reason for the late administration. 15- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 PM, administered at 10:07 PM; There was no documented reason for the late administration. 16- Morphine ER 15 mg scheduled for 07/09/23 at 08:00 AM, administered at 09:30AM; There was no documented reason for the late administration. 17- Morphine ER 15 mg scheduled for 07/10/23 at 08:00 PM, administered at 09:05 PM; There was no documented reason for the late administration. 18- Oxycodone 10 mg scheduled on 07/12/23 at 12:00 AM, administered at 3:16 AM; There was no documented reason for the late administration. 19- Oxycodone 10 mg scheduled for 07/14/23 at 12:00 PM, administered at 02:17 PM; The medication ran out of refills. 20- Morphine ER 15 mg scheduled for 07/16/23 at 08:00 AM, administered at 10:05 AM 21- Oxycodone 10 mg scheduled for 07/17/23 at 06:00 PM, administered at 07:30 PM; There was no documented reason for the late administration. 22- Morphine ER 15 mg scheduled for 07/17/23 at 08:00 PM, administered at 09:12 PM; There was no documented reason for the late administration. 23- Morphine ER 15 mg scheduled for 07/18/23 at 08:00 AM, administered at 09:03 AM; There was no documented reason for the late administration. Record review of Resident #235's Progress Notes dated 07/18/23 revealed resident discharged home with home health care. An observation on 06/28/23 at 08:45 AM revealed, Resident #235's family member approaching RN B while she prepared for medication administration to Resident #235. He said that he was very upset with the facility because prior to admission he was assured that Resident #235's medication would be available upon her admission but it was not. He said Resident #235 called him multiple times overnight to inform him that she had not received any of her medication since she arrived at the facility and she was in severe pain. Resident #235's family member then handed RN B 2 bottles of medication (Morphine ER 15 mg and Oxycodone 10 mg) and said he brought only a 2 days' supply to cover Resident #235 until the medication arrived at the facility. After Resident #235's family member entered the resident's room, RN B alerted the Interim DON to the arrival of the media[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 5 of 10 residents (Resident #26, Resident #235, Resident #236, Resident #237 and Resident #270) reviewed for pharmaceutical services. - The facility failed to acquire, dispense, and timely administer medications to Resident #235 including Morphine ER 15 mg and Oxycodone 10 mg, medications used for pain; leaving the resident's pain uncontrolled on a pain scale ranging from 08 to 10 out of 10. - The facility failed to acquire, dispense, and timely administer Hydrocodone/Acetaminophen 75 mg- 325 mg to Resident #237 upon admission leaving the resident's pain uncontrolled on a pain scale up to 07 out of 10. - The facility failed to acquire, dispense, and timely administer medications to Resident #26, Resident #236 and Resident #270. On 08/01/23 04:22 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/09/23 at 12:53 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain. Findings included: Resident #235 Record review of Resident #235's face sheet dated 06/28/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, UTI and unspecified fall. The resident discharged on 07/18/23. Record review of Resident #235's secondary Face Sheet dated 06/28/23 at 10:28 AM revealed, Resident #235 admitted to the facility on [DATE] at 09:01 PM. Record review of Resident #235's Baseline Care Plan dated 06/27/23 revealed, the resident was alert & oriented generalized aching pain Record review of Resident #235's Hospital Discharge Record dated 06/27/23 at 03:45 PM revealed, Resident #235's next scheduled dose of pain medications as follows: - Morphine 15 mg ER- 1 tablet be mouth every six hours with next dose due on 06/27/23 at 09:00 PM. - Oxycodone 10 mg- 1 Tablet by mouth every 6 hours with next dose due on 06/27/23 at 06:00 PM. - Metronidazole 500 mg- 1 tablet by mouth every 8 hours with next dose scheduled on 06/27/23 at 08:00 PM. - Simvastatin 20 mg- 1 tablet by mouth at bed time with next dose scheduled on 06/27/23 at bedtime. - Hydralazine 50 mg- 1 tablet by mouth 4 times daily with next dose scheduled on 06/27/23 at 09:00 PM. - Budesonide-Formoterol- 2 puffs 2 times a day for 14 days with next dose scheduled on 06/28/23 at 09:00 AM. - Famotidine 20 mg- 1 tablet by mouth daily with next dose scheduled on 06/28/23 at 09:00 AM. - Fiber tablets with next dose scheduled as directed. Record review of Resident #235's Order Summary Report dated 06/28/23 revealed, - Acetaminophen 650- 1 tablet by mouth every 8 hours as needed for pain starting 06/27/23 at 10:45 PM. - Morphine Sulfate 15 mg- give 1 tablet by mouth every 12 hours for pain ordered on 06/27/23 with a start date of 06/28/23. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours for pain ordered on 06/27/23 with a start date of 06/28/23 - Simvastatin 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia (high cholesterol) ordered on 06/27/23 with a start date of 06/28/23 - Metronidazole 500 mg- 1 tablet by mouth every 8 hours ordered on 06/27/23 with a start date of 06/28/23 - Hydralazine 50 mg - 1 tablet by mouth four times a day for high blood pressure ordered on 06/27/23 with a start date of 06/28/23 - Budesonide-Formoterol inhalation solution- 2 puffs by mouth two times a day for 14 days for SOB; ordered on 06/27/23 with a start date of 06/28/23. - Famotidine 20 mg- give 1 tablet by mouth for acid reflux ordered on 06/27/23 with a start date of 06/28/23. - Fiber one- give 1 tablet by mouth one time a day for supplement ordered on 06/27/23 with a start date of 06/28/23. - Nystatin External Powder- apply to groin topically two times a day for rash for 10 days ordered on 06/27/23 with a start date of 06/28/23. Record review of Resident #235's Progress Note dated 06/28/23 revealed - 01:16 AM- resident came in after 9 pm, automated dispensing system does not have name. - 04:19 AM - complaint of pain to legs - 05:25 AM- no medication on hand - 05:56 AM- Resident #235 was informed that the MD was notified for prescriptions to be sent to the pharmacy. Resident #235 informed the facility that she had her Morphine and Oxycodone at home and she asked if her son brought them to the facility could the facility staff administer it. Record review of Resident #235's June MAR printed 06/28/23 at 12:50 PM revealed, her medications were not started until 06/28/23 and the following medications were not administered: - Famotidine 20 mg- give 1 tablet by mouth for acid reflux scheduled for 06/28/23 at 08:00 AM. The MAR was left blank, no reason for non-administration documented. The medication was located in the E-Kit but it was not pulled. - Fiber one- give 1 tablet by mouth one time a day for supplement scheduled for 06/28/23 at 08:00 AM. Reason not administered- medication not available. - Simvastatin 20 mg- 1 tablet by mouth at bedtime for hyperlipidemia due at 08:00 PM on 06/27/23. The start date not scheduled till 06/28/23. - Budesonide-Formoterol inhalation solution- 2 puffs by mouth two times a day for 14 days for SOB scheduled for 06/28/23 at 08:00 AM. Reason not administered- medication not available. - Nystatin External Powder- apply to groin topically two times a day for rash for 10 days scheduled for 06/28/23 at 08:00 AM. Reason not administered- medication not available. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days due at 06/27/23 at 08:00 PM. Start date entered as 06/28/23 at 12:00 AM. The medication was located in the E-Kit but it was not pulled. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days scheduled for 06/28/23 at 12:00 AM. Reason not administered- medication not available. The medication was located in the E-Kit but it was not pulled. - Hydralazine 50 mg- give 1 tablet by mouth four times a day for high blood pressure due at 06/27/23 at 09:00 PM. Start date entered as 06/28/23 at 08:00 AM. The medication was located in the E-Kit but it was not pulled. - Hydralazine 50 mg- give 1 tablet by mouth four times a day for high blood pressure scheduled for 06/28/23 at 08:00 AM. Reason not administered- medication not available. The medication was located in the E-Kit but it was not pulled. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours due at 06/28/23 at 12:00 AM. The start date was not entered until 06/28/23 at 06:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours scheduled for 06/28/23 at 06:00 AM. Reason not administered- medication not available. - Morphine Sulfate 15 mg ER- give 1 tablet by mouth every 12 hours for pain due at 06/27/23 at 09:00 PM. The Order was entered incorrectly as Morphine Sulfate 15 mg (IR) with a start date of 06/28/23 at 08:00 AM Record review of Resident #235's June MAR dated 06/28/23 at 12:50 PM revealed the following pain scores: - 05 out of 10 when Resident was administered her only dose of Acetaminophen 650 mg on 06/28/23 at 04:19 AM - 10 out of 10 when Resident was administered her Morphine 15 mg scheduled for 08:00 AM. - 08 out of 10 when Resident was administered her Oxycodone 10 mg scheduled for 12:00 PM. Record review of Resident #235's Pharmacy Records dated 06/28/23 revealed, MD A did not submit electronic prescriptions for Resident #235's Oxycodone 10 mg and Morphine ER 15 mg until 06/28/23 at 05:31 PM, over 20 hours after the resident's admission. Record review of the facility E-kit Inventory revealed dated 06/28/23 at 03:09 PM revealed, - the kit contained Metronidazole 500 mg - the kit contained Hydralazine 25 mg - the kit contained Famotidine 20 mg Record review of Resident #235's Progress Notes dated 07/14/23 at 01:50 PM signed by LVN B revealed, the facility ran out of Resident #235's Oxycodone on 07/14/23 and LVN B was awaiting delivery of the medication from the pharmacy. Record review of Resident #235's Medication Administration Audit from 06/27/23 to 07/18/23 dated 08/03/23 revealed, the resident received her Oxycodone and Morphine outside of scheduled administration times on 23 different occasions during her stay: 1- Morphine ER 15 mg scheduled for 06/28/23 at 08:00 AM, administered at 09:15 PM. There was no documented reasons for late administration. 2- Morphine ER 15 mg scheduled for 06/30/23 at 08:00 PM, administered at 9:33 PM. There was no documented reasons for late administration. 3- Morphine ER 15 mg scheduled for 07/01/23 at 08:00 AM, administered at 09:05 PM; There was no documented reasons for late administration. 4- Oxycodone 10 mg scheduled for 07/02/23 at 06:00 PM, administered at 7:11 PM; There was no documented reasons for late administration. 5- Morphine ER 15 mg scheduled for 07/02/23 at 08:00 PM, administered at 11:32 PM; There was no documented reasons for late administration. 6- Morphine ER 15 mg scheduled for 07/03/23 at 08:00 PM, administered at 09:58 PM; There was no documented reasons for late administration. 7- Oxycodone 10 mg scheduled for 07/04/23 at 06:00 AM, administered at 7:05 AM; There was no documented reasons for late administration. 8- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 AM, administered at 09:15 AM; There was no documented reasons for late administration. 9- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 PM, administered at 10:44 PM; There was no documented reasons for late administration. 10- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 AM, administered at 09:19 AM; There was no documented reasons for late administration. 11- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 PM, administered at 09:20 PM; There was no documented reasons for late administration. 12- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 AM, administered at 11:53AM; There was no documented reasons for late administration. 13- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 PM, administered at 09:03 PM; There was no documented reasons for late administration. 14- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 AM, administered at 11:03AM; There was no documented reasons for late administration. 15- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 PM, administered at 10:07 PM; There was no documented reasons for late administration. 16- Morphine ER 15 mg scheduled for 07/09/23 at 08:00 AM, administered at 09:30AM; There was no documented reasons for late administration. 17- Morphine ER 15 mg scheduled for 07/10/23 at 08:00 PM, administered at 09:05 PM; There was no documented reasons for late administration. 18- Oxycodone 10 mg scheduled on 07/12/23 at 12:00 AM, administered at 3:16 AM; There was no documented reasons for late administration. 19- Oxycodone 10 mg scheduled for 07/14/23 at 12:00 PM, administered at 02:17 PM; There was no documented reasons for late administration. 20- Morphine ER 15 mg scheduled for 07/16/23 at 08:00 AM, administered at 10:05 AM; There was no documented reasons for late administration. 21- Oxycodone 10 mg scheduled for 07/17/23 at 06:00 PM, administered at 07:30 PM; There was no documented reasons for late administration. 22- Morphine ER 15 mg scheduled for 07/17/23 at 08:00 PM, administered at 09:12 PM; There was no documented reasons for late administration. 23- Morphine ER 15 mg scheduled for 07/18/23 at 08:00 AM, administered at 09:03 AM; There was no documented reasons for late administration. An observation on 06/28/23 at 08:45 AM revealed, Resident #235's family member approaching RN B while she prepared for medication administration to Resident #235. He said that he was very upset with the facility because prior to admission he was assured that Resident #235's medication would be available upon her admission but it was not. He said Resident #235 called him multiple times overnight to inform him that she had not received any of her medication since she arrived at the facility and she was in severe pain. Resident #235's family member then handed RN B 2 bottles of medication (Morphine ER 15 mg and Oxycodone 10 mg) and said he brought only a 2 days' supply to cover Resident #235 until the medication arrived at the facility. After Resident #235's family member entered the resident's room, RN B alerted the Interim DON to the arrival of the mediation at which point they both counted the medications and logged them into individual control sheets. In an interview on 06/28/23 at 10:10 AM, RN B said Resident #235 admitted to the facility on the night shift of 06/27/23. She said the patient's medications had not yet arrived from the pharmacy and the night shift nurse said Resident #235's family member would be bringing her pain medication so she was waiting for its arrival. When asked if RN B could have pulled the rest of Resident #235's unavailable medication from the facility EKit (floor stock of prescription medications available for emergency use), she said she administered the OTC medications as well as the pain medication brought in by the family member but she would have to check the facility EKit for the rest of Resident #235's medications. RN B said she immediately administered Morphine ER 15 mg to Resident #235 once it was delivered by the resident's family member but the Oxycodone was not due yet. She could not say when Resident #235 received her last dose of Oxycodone. RN B said failure to administer medications as ordered could place residents at risk for uncontrolled disease states such as uncontrolled pain. In an interview on 06/28/23 at 10:35 AM, the Interim DON said when a resident arrived at the facility the admitting nurse is expected to review the hospital paperwork to verify the last dose of medications received as well as when the next dose is due. She said the nurse then enters the order into the system and verifies it with the physician. The Interim DON said Resident #235 admitted to the facility on [DATE] at around 08:30 PM so her medications were not yet delivered by the pharmacy. She said that the expectation was for residents to receive their medications as ordered and that the nurse should have taken into consideration Resident #235's last doses to determine when the next dose was due and to at least get an order for a one-time dose to ensure that the resident received her medications. The interim DON said if a CII medication ( scheduled 2 controlled substances that require additional care because of the potential to intentionally or unintentionally abuse the drug) was unavailable nursing staff are expected to request an appropriate alternative treat the patients pain and most other medications could be found in the e-kit until the medication arrived. The Interim DON said that failure to administer medication to residents as ordered could place residents at risk for uncontrolled disease states and pain. In an interview on 06/28/23 at 11:11 AM, Resident #235 said she discharged from the hospital on [DATE] at 04:00 PM but she did not get picked up by the transport company until after 08:00 PM so by the time she arrived at the facility her medications were already due. She said when she arrived at the facility she explained to the staff that since she was discharged from the hospital at 4:00 PM the hospital was unable to administer any of her medications due after 4:00 PM. Resident #235 said she asked for her medications especially her pain medication but she was told the medication was not available at the facility. She said she specifically asked for her pain medications Morphine and Oxycodone because her pain was a 10 out of 10 but it was unavailable so her son had to bring in her pain medication in the morning (06/28/23). Resident #235 said she was in severe pain rendering her unable to do anything and writhing in pain prior to receiving her Morphine morning. She said after receiving her Morphine her pain was at 08 out of 10 but she had still not received her Oxycodone. In an interview on 08/02/23 at 01:56 PM, LVN B said Resident #235 was generally pleasant and she had been taking Oxycodone for a long time., LVN B said nursing staff are expected to reorder medications at least 6 days before the medication runs out but 07/14/23 the resident did not have Oxycodone 10 mg available for administration for her 12:00 PM dose. She said she contacted the pharmacy to check on the delivery of the medication and she was informed the medication was on route. She said medications must be administered within 1 hour of the scheduled time and pain should be assessed 1 hour following oral pain medication administration. LVN B said failure to administer medication on time could place residents at risk for uncontrolled health conditions. In an interview on 08/13/23 at 08:03 AM, RN E said she was the admitting nurse for Resident #235 on 06/28/23. She said when the resident admitted to the facility she entered reconciled the medications with the provider, including the Resident #235's pain medications Oxycodone and Morphine. She said when she notified the provider, the provider stated that late admissions always resulted in problems with CII medication acquisition because they were unable to electronically prescribe the medications. She said she asked for an alternative and the provider gave an order for Tylenol and nothing else. RN E said Acetaminophen was not sufficient pain control for patients on opioid medications but that was the medication ordered for the resident upon admission. RN E said she thought the provider would send the prescription for Oxycodone and Morphine Immediately so she was not concerned of the need for alternative pain coverage. Resident #237 Record review of Resident #237's Nurse report dated 07/26/23 revealed, Resident #237 arrived at the facility at 7 pm. Record review of Resident #237's Face Sheet dated 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses of: atrial fibrillation (irregular heartbeat), acute kidney failure, opioid dependence, anemia, hypertension (high blood pressure) and type 2 diabetes. The resident discharged from the facility on 08/05/23. Record review of Resident #237's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel. Yes- resident received scheduled and PRN pain medication in the last 5 days as well as received non-medication intervention for pain. Resident #237 reported frequent pain and the worst pain reported was a 5 out of 10. Record review of Resident #237's Baseline Care Plan dated 07/26/23 and signed by RN F revealed, admission goals to return to the family home, one person assist with most ADLs, wheelchair use, always continent of both bladder and bowel. Physician orders for opioids was not selected, presence of pain was documented as no. Record review of Resident #237's Hospital Discharge Instructions dated 07/26/23 revealed, the resident discharged with orders for Hydrocodone/Acetaminophen (Norco) 5mg/325mg take 1 tablet by mouth every 6 hours as needed for pain score 1-3. Record review of Resident #237's Physician's Order dated 07/26/23 revealed, Acetaminophen 325 mg- 2 tables by mouth every 6 hours as needed. The order was had a start date of 07/26/23 at 08:15 PM and a stop date of 07/27/23 at 12:37 PM. Record review of Resident #237's Physician's Order dated 07/27/23 revealed, Norco (Hydrocodone-Acetaminophen) 7.5 mg/325 mg- give 1 tabled by mouth three times a day. The start date of the order was 07/27/23. Record review of Resident #237's Progress Notes dated 07/27/23 at 11:06 PM signed by RN F revealed, RN F reconciled/reviewed the resident's hospital medications with MD C who ordered to continue all hospital discharge orders. MD C gave new orders for Acetaminophen 325 mg (2 tabs) every 6 hours for pain. Record review of Resident #237's July MAR revealed, Resident #237 never received Norco on 07/26/23 and her first dose was administered on 07/27/23 for a dose scheduled at 4:00 PM (approximately 21 hours after admitting to the facility). At the administration of the first dose Resident #237 reported pain at 07 out of 10. Record review of Resident #237's Pharmacy Records dated 07/27/23 revealed, MD B did not send in Resident #235's prescription for Norco 7.5/325 mg on 07/26/23. The prescription was not electronic prescribed to the pharmacy until 07/27/23 at 03:30 PM, over 20 hours after the resident arrived at the facility. Record review of Resident #237's Medication Administration Audit from 07/26/23 to 08/05/23 revealed, Resident #237 received her Norco outside of scheduled administration times on 4 different occasions during her stay: 1. 07/27/23 scheduled for 04:00 PM but administered at 05:25 PM. 2. 07/27/23 scheduled for 08:00 PM but administered at 10:21 PM 3. 07/29/23 scheduled for 04:00 PM but administered at 05:06 PM. 4. 07/30/23 scheduled for 08:00 PM but administered at 09:24 PM In an interview on 08/02/23 at 2:55 PM, the Administrator said that after pain medication administration nursing staff are expected to do a post administration assessment of the residents pain 30 minutes following medication administration to determine its efficacy. She said if the pain is the same the doctor must be notified and the communication and assessment must be documented in the progress notes. In an interview on 08/02/23 at 03:10 PM, Resident #237 said there were some discrepancies in her medication when she admitted to the facility. She said she admitted into the facility in the evening and the facility didn't have her medications. Resident #237 said she was told that her pain medication was sent to a local pharmacy but by the time her brother tried to pick it up the pharmacy had closed at 7 PM. She said she could not verbalize her pain on a scale but at around 08:30 PM her pain was so severe that she could not focus and it impaired her activities. Resident #237 said her brother picked up her pain medications and brought it to the facility the next morning (07/27/23) but she felt that the facility should have provided her the medication and it was inappropriate for residents to bring their own medication for administration in the facility. In an interview on 08/03/23 at 01:45 PM, the Interim DON said medications are to be administered as ordered +/- 1 hour of the scheduled time and residents are to be assessed for pain 1 hr. after administration of medication. She said if a residents pain remains the same or increases the MD must be notified that pain control is ineffective and the nursing staff must continue to monitor the resident. She said failure to administer medications as ordered or assess the effectiveness of the medications is places residents at risk for uncontrolled pain. The Interim DON said upon admissions the facility has to be ready for the Resident including CII medications. She said if a facility does not have a patients CII pain medication the nurse must call the provider to get an alternative such as tramadol and Tylenol #3 since the medication was located in the medication e-kit. The interim DON said acetaminophen was not a temporary alternative for pain control in patient with a history of opioid use. In an interview on 08/03/23 at 02:22 PM, MD B said there are issues whenever a resident admits into the facility over the weekend or evening because the providers are not able to send an electronic prescription as required to the pharmacy for CII medications. She said CII orders have to be sent through an electronic prescribing system to the pharmacy which might cause some delays. MD B said she to her knowledge there were no hold orders on any of Resident #237's medications including the hydrocodone. She said she has evaluated Resident #237 and determined that a scheduled dose every 6 hours instead of PRN pain medication regimen was more appropriate to control the residents pain. MD B said she expects pain medications to be administered on time as ordered and nurses to reassess patients following the administration of pain medications and if the medication was ineffective nurses must notify the provider. She said she was never notified of ineffective pain management for Resident #237. In an interview on 08/04/23 at 1:10 PM, RN F said she was Resident #237's admission nurse and Resident #237 arrived she called the MD C to verify the resident's medication and to request her Norco prescription. She said she was expecting the resident's Hydrocodone to arrive the same day so she did not request an alternative. RN F said she saw that Resident #237's medications, including the Norco, was called into a local pharmacy so she informed the resident and Resident #237's brother was supposed to pick up the medication. She said the facility is expected to fill all medications for residents during their stay but sometimes it is faster to use the resident's supply while waiting for the facility to fill the prescription. RN F said she did not notify the MD that Resident #237's Hydrocodone did not come in, she did not ask for an alternative, did not ask for a stat order and does not remember if she notified the provider of Resident #237's uncontrolled pain. She said failure to administer medications to residents as ordered could place resident's at risk for uncontrolled pain or untreated health conditions. Resident #236 Record review of Resident #236's admission Nurse Report dated 07/28/23 revealed the resident admitted to the facility on [DATE] at approximately 04:00 PM. Record review of Resident #236's Face Sheet dated 08/11/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified fracture of right femur, UTI, hypertension, chronic kidney disease and BPH. The resident discharged home on [DATE]. Record review of Resident #236's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Hospital Discharge Records dated 07/28/23 at 03:14 PM revealed, Resident #236 received his last dose of Amlodipine 10 mg (used to treat high blood pressure) ordered daily, Azathioprine 50 mg (used to prevent transplant rejection) ordered daily and Finasteride 5 mg (used to treat BPH) ordered daily on 07/27/23 between 09:21 and 09:22 PM. The next dose of these medications were due on the evening of 07/28/23. Record review of Resident #236's Order Summary Report dated 08/11/23 revealed, - Amlodipine and Azathioprine were not started/administered until 07/29/23 at 08:00 AM - Finasteride was incorrectly entered by RN F for morning administration instead of evening administration starting 07/29/23. The order was corrected on 07/31/23 for night time administration. Record review of Resident #236's admission Progress Note dated 07/28/23 at 9:30 PM signed by RN F revealed, the MD gave orders for all the residents discharge meds to be continued and for labs to be performed in the morning. There was no documented reason to skip Resident #236's evening Azathioprine and Amlodipine or delay the start of the residents Finasteride until 07/31/23. Record review of Resident #236's July MAR revealed, - Finasteride 5 mg was not administered on 07/28/23. - Amlodipine 10 mg was not administered on 07/28/23. - Azathioprine 50 mg was not administered on 07/28/23. - Amlodipine 10 mg was first administered on 07/29/23 at 08:00 AM. - Azathioprine 50 mg was first administered on 07/29/23 at 08:00 AM. - Finasteride 5 mg was administered in the morning on 07/29/23 and 07/30/23. - Finasteride 5 mg was first administered in the evening at 08:00 PM on 07/31/23. In an interview on 08/01/23 at 12:43 PM, NP A said she was Resident #236's NP. She said upon admission nursing staff were expected to review the hospital discharge orders to determine when the resident is due for their next dose. NP A said she was not aware that Resident #236's medications were started the morning after his arrival in the facility and she didn't know the resident did not receive his finasteride for several days. An observation and interview on 08/02/23 at 11:26 PM revealed, Resident #236 lying in bed well dressed in no immediate distress. He said he had no issues receiving his medications. Resident #236 was unable to answer any other surveyor questions due to hearing difficulty. In an interview on 08/04/23 at 12:10 PM, RN F said she was the admitting nurse for Resident #236 and when the resident admitted some of his medications were not available. She said when nurses reconciled admissions medications they determine the start date and time of the medications based on the hospital discharge information. RN F said she did not tell the admitting NP the times Resident #236 received his last dose of medications and when his next doses were due. She said she entered Resident #236's medications to start in the morning and the NP B did not give any instructions to hold or delay the start of the resident's medications. Resident #26 Record review of Resident #26's face sheet dated 08/01/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: cellulitis (bacterial skin infection), depression, malignant neoplasm (cancerous tumor), hypocalcemia (low calcium), acidosis (, disorders of electrolyte, other disorders of electrolyte and fluid balance not elsewhere, essential ( primary) Hypertension, (coronary artery disease ( plaque buildup in the wall of the arteries that supply blood to the heart), Chronic Obstructive pulmonary disease, acute respiratory failure, acute kidney failure, colon cancer and intercostal pain (pain along the ribs, chest or abdomen). Record review of Resident #26's secondary Face Sheet dated 08/01/23 at 10:28 AM revealed, Resident #26 was re admitted to the facility on [DATE] at 06:00 PM. Record review of Resident #26 admission MDS dated [DATE], revealed his BIMS score was 15 out of 15, indicating that Resident #26 was not cognitively impaired. Record review of Resident #26's Hospital Discharge Record dated 07/24/23 at 06:00 PM revealed he transferred to the facility. Record review of Resident #26's July MAR printed 07/28/23 at 5:50 PM revealed, his medications were not started until 07/24/23 and the following medications were not administered 07/25/23 - Atorvastatin Calcium 10mg ( used to treat high cholesterol) - 1 tablet be mouth at bedtime with next dose due on 07/24/23 at 08:00 PM. - Gabapentin 300 mg (used to treat nerve pain)- give 1 tablet by mouth every 12 hours for pain with next dose on 07/24/23 at 08:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 of 7 residents (Resident #238) reviewed for diagnostic services in that. - RN C failed to read Resident #238's x-ray results and failed to notify the provider of the resident's femur fracture using the facility's approved notification methods leaving Resident #238 in an undiagnosed/untreated fracture and in pain for 6 days (07/28/23 to 08/03/23). On 08/07/23 at 05:02 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 03:48 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal This failure could place residents who required radiology services at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, suffering and death. Findings included: Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Accident/Incident Report dated 07/28/23 revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w and as notified and she gave orders for a STAT xray and administration of Acetaminophen. Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not corporative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continues to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider places an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad but she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. She said she notified the provider who ordered multiple stat xrays. In an interview on 08/09/23 at 09:16 AM, RN C said that during the week of 07/28/23 Resident #238 complained of pain in her thighs and legs. She said earlier in the morning of 07/28/23 an x-ray tech came to the resident's room to perform an x-ray of Resident #238's hips but the resident wasn't cooperative so a CNA had to assist the x-ray tech. RN C said since the resident was non-complaint during the previous x-ray the resident had to be taken to the hospital on the evening of 07/28/23. She said when the results came back, she took pictures of the x-ray results and sent it to NP A who reviewed the results and said everything was ok. RN C said she never read the x-ray results and only relied on the assessment given by NP A. RN C said the facility policy was that all nurses were expected to read the results and then notify the provider of the findings. She said she was not supposed to send pictures of the results to NP A but she was busy so she just sent pictures of the results without reading them. In an interview on 08/09/23 at 11:04 PM, the PT Director said Resident #238 experienced a decline in therapy due to her pain so when she was discussed in the morning meeting on 08/02/23 he requested another x-ray be performed. He said he talked to NP A who said she would enter in an order for an x-ray but she did not so he followed up with MD A. He said MD A said she would enter in an order for an x-ray on 08/02/23, so on the morning of 08/03/23 he logged on to the radiology portal in anticipation of the results and that was when he saw the report dated 07/28/23 that identified Resident #238's left femur fracture. The Therapy Director said he immediately printed out the results and turn it over to the IP and Administrator. In an interview on 08/09/23 at 11:40 AM, the IP said the Therapy Director brought it to her attention on 08/03/23 that Resident #238 had an unidentified femur fracture from an xray performed on 07/28/23. Once notified she took it to the nurse responsible (RN C) who then notified the doctor right away. The IP said she had no lab or radiology review responsibility but instead did what any prudent nurse would do. In an interview on 08/11/23 at 11:09 AM, the Medical Director said the facility has designated nurses/DON to communicate results of a fracture or any negative acute findings verbally to the provider. He said failure to timely identify and notify the provider of an acute fracture could place residents at risk for a decreased quality of life, uncontrolled pain, infection and psychological distress. In an interview on 08/14/23 at 09:03 AM , NP A said on 07/28/23 she received a group of texts from RN C with results from Resident #238's x-rays as well as others. She said she briefly looked over it and missed the left femur fracture that was identified on one of the many pictures RN C sent. NP A said following the fall Resident #238 showed symptoms of a fracture and she wanted to perform additional x-rays but the resident refused so she did not enter in another order. She said Resident #238 appeared confused, had swelling in her leg with pain. NP A said Resident #238 was complaining off and on of pain and she was treated with pain medication. She said Resident #238 did not give the impression that she did not have a fracture but since the resident refused further radiology scans she did not enter new orders for x-rays even though the resident was symptomatic. NP A said RN C probably didn't call her with Resident #238's fracture results and the fracture was missed by all. She said the results she received did not have an alert stamp and the results were on the bottom and not the top of the report, so she missed the result. NP A said Resident #238's fracture was not identified until 08/03/23 (6 days after the fall). NP A said unidentified fracture results can happen and the facility staff are trying their best. She said failure to identify a fracture could place residents at risk for pain until the fracture is addressed, a further decrease in quality of care. She said the facility policy requires nurses to read the results, then verbally notify the provider of the results, nurses do not text results. Record review of the facility policy titled Test Results revised on 04/2007 revealed, 1- results of laboratory, radiological and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2- should the tests be provided to the facility, the attending physician shall be promptly notified of the results. 3- the DON or the charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. This was determined to be an Immediate Jeopardy (IJ) on 08/07/23 at 05:02 PM. The Administrator and was notified and provided the IJ template on 08/07/23 at 05:44 PM; a Plan of Removal (POR) was requested at that time The following plan of removal was approved on 08/10/23 at 02:22 PM and the immediacy was removed on 08/12/23 at 03:48 PM F-777 Radiology/Diagnostic Services Ordered/Notify Result [Facility name] has implemented the following Plan confirming systems are in place to ensure that radiology/diagnostic tests for residents are appropriately ordered, the results of the tests obtained and placed in the residents' medical records, and that the ordering physician is aware of the test results and took appropriate action. Immediate Action: Document here the action taken by the facility to ensure there are no residents in jeopardy or threat of harm. This could include assessing residents, reviewing records, assessing environmental concerns, provide training to immediate staff. Date each task and if needed when task will be completed and who is responsible for completing the task (if a contractor or supplies need coordinated what day the service of goods available to the facility). 1. The facility undertook corrective action with regards to Resident #238 to confirm that all radiology/diagnostic tests were appropriately ordered, the results obtained and placed in her medical records, and the ordering physician made aware of the results. Resident #238 was discharged from the facility on August 3, 2023. 2. The Interim Director of Nursing/Designee will audit all residents (as of August 1, 2023) to confirm that all ordered radiology/diagnostic tests were performed, results placed in the paper and electronic medical records, the physician notified of the results, and the physician reviewed the tests and took appropriate action, as necessary. See the details of the plan for continued auditing/monitoring outlined on page 5. 3. The facility identified that it had a process in place for ordering, obtaining the results, reviewing the results, and notification of the physician for radiology/diagnostic tests. The process includes: o Confirming that there is a physician order for the diagnostic/radiology test; o Confirming that the diagnostic/radiology test is completed as ordered by the physician; o Accessing the Care4 electronic medical record to obtain the diagnostic/radiology report; o Identifying and reviewing the diagnostic/radiology report; o Printing the diagnostic/radiology report; o Entering the diagnostic/radiology report into the electronic medical record; o Notifying the physician of the diagnostic/radiology result; o Ordering physician reviewing the diagnostic/radiology result and taking appropriate action; and o Nursing staff will document the notification of the physician and any orders given in the EMR. The Interim Director of Nursing/Designee has reinforced and re-educated all nursing staff on the process for ordering, obtaining the results, reviewing the results, and notification of the physician for radiology/diagnostic tests. For the details on the measures implemented, see the section below entitled Facility's Plan to Ensure Compliance Quickly. (Completed: August 10, 2023) 4. The Medical Director has issued a written communication to physicians reeducating them on the expectations with respect to the ordering and reviewing of results of radiology/diagnostic tests for residents. 5. The Interim Director of Nursing/Designee will audit all incident/accident reports of falls for the past thirty (30) days to ensure that proper nursing assessments were completed following the fall. 6. The Interim Director of Nursing/Designee has re-educated staff members on recognizing the risk factors for falls, fall precautions, resident assessment, appropriate documentation, and how to properly escalate following falls. 7. The Interim Director of Nursing/Designee has re-educated staff members (nurses and therapists) on the assessment and documentation of changes in resident's condition and escalation to physician, as necessary. In addition, the Interim Director of Nursing/Designee has re-educated nursing staff on the timely performance and documentation of pain assessments (within thirty minutes for IV medications and one (1) hour for oral medications), as well as the administration of pain medications in accordance with physician orders. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. Completion Date: August 10, 2023 Facility's Plan to Ensure Compliance Quickly: How will the facility ensure compliance efficiently and timely? This could involve developing policies and procedures, training staff, repairing equipment, contacting physicians, having a QAIP meeting, developing forms, making repairs, or developing a new system. Be sure to document who provides the training, dates of training and how competency of staff of learning and training (return demonstrations, testing, competency checks). Please make sure dates of trainings are documented and if staff involvement is required that the staff member will not assume any job responsibilities until training has been received by them. Please make sure all audits, policies, notifications or services provided by outside contractors to remove the potential harm are dated. 1. The Interim Director of Nursing/Designee will audit all current residents (as of August 1, 2023) to confirm that all ordered radiology/diagnostic tests were performed, results placed in the electronic medical record, the physician notified of the results, and the physician reviewed the tests and took appropriate action, as necessary. See the details of the plan for continued auditing/monitoring outlined on page 5. 2. The Interim Director of Nursing/Designee and the Director of Operations are reviewing relevant facility policies and procedures to determine whether revisions are necessary to be consistent with the outlined measures in this Plan. 3. The facility Medical Director will re-educate all physicians via written communication about the process for ordering and reviewing the results of radiology/diagnostic tests. 4. By August 8, 2023, the Interim Director of Nursing/Designee is re-educating of all nursing staff members on the following topics: a) The end-to-end process for the ordering and completion of all radiology/diagnostic tests: o Confirming that there is a physician order for the diagnostic/radiology test; o Confirming that the diagnostic/radiology test is completed as ordered by the physician; o Accessing the Care4 electronic medical record to obtain the diagnostic/radiology report; o Identifying and reviewing the diagnostic/radiology report; o Printing the diagnostic/radiology report; o Entering the diagnostic/radiology report into the electronic medical record; o Notifying the physician of the diagnostic/radiology result; o Ordering physician reviewing the diagnostic/radiology result and taking appropriate action; and o Nursing staff will document the notification of the physician and any orders given in the EMR. b) Effective hand-off communication between shifts. This communication will include whether there are any pending orders for radiology/diagnostic tests; whether any radiology/diagnostic tests were performed; whether the results of any radiology/diagnostic tests are available; whether the final radiology/diagnostic test results have been printed and entered into the electronic medical records; whether the physician has been notified of the results of the radiology/diagnostic tests; and whether the physician gave any follow-up orders based on the radiology/diagnostic tests. c) The timely performance and documentation of pain assessments (within thirty minutes for IV medications and one (1) hour for oral medications), as well as the administration of pain medications in accordance with physician orders. d) The assessment and documentation of changes in a resident's condition and escalation to the physician, as necessary. e) The process for notifying the resident's physician if there are issues with pain control. f) The facility's existing policy on fall prevention. g) The facility's incident and accident reporting policy. h) The re-assessment of residents including, but not limited to, neurovascular checks up to 72 hours following a fall. ***All staff members will be educated on the topics outlined above before being allowed to work a shift. Completion Date: August 10, 2023 Monitoring: In an interview on 08/11/23 at 02:48 PM, CNA A said she had received training on 08/09/23 about the accident/incident reporting process as well as the fall procedure. CNA understood the trainings and she was able to explain the actions to be taken. In an interview on 08/12/23 at 09:05 AM, RN D said she received one-on-one training with the IP on radiology and laboratory reports/shifts to shift communications, facility fall policy, accident/incident reporting expectations, pain assessment, pain management and physician escalation. RN E understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 08:03 AM, RN E said she did not receive one-on-one training on the facility fall policy, radiology and laboratory reports/shift to shift communications. accident/incident reporting expectations, abuse and neglect, documentation and physician escalation, . She said she was informed by RN D that training needed to be completed and she reviewed the papers left at the nursing station. RN E understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:02 PM, RN G said she received one on one in servicing falls, MD escalation, accident/incident reporting, pain assessments, change of conditions, radiology/laboratory reports, physician escalations and shift to shift communications. RN G understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:16 PM, RN D said she received one on one in servicing, falls, MD escalation, accident/incident reporting, radiology/laboratory reports, physician escalations, pain management. documentation and changes of condition. RN D understood the trainings and she was able to explain the actions to be taken. In an interview on 08/13/23 at 07:24 PM, RN I said she received one on one in servicing on , falls, MD escalation, radiology/laboratory reports, accident/incident reporting, change of conditions and documentation. RN I understood the trainings and she was able to explain the actions to be taken. In an interview on 08/14/23 at 11:40 AM, the DON said she had not completed a full audit of the accident/incidents specifically falls. She said she just confirmed that she had taken action on the fall, she had not thoroughly reviewed each fall to ensure that the proper nursing assessments were completed following the fall as stated in the approved POR. In an interview on 08/15.23 at 09:49 AM, the DON said she completed a full audit on all falls in the last 30 days the previous evening (08/14/23) to ensure appropriate action/nursing assessments were completed following falls. She said her audit identified consistent deficiencies in completion of neuros/assessments, documentation and follow up after these incidents. Record review of facility Order Listing Report, dated 08/08/23, revealed all pending radiology/diagnostic orders and results were reviewed and appropriate action taken by the DON. Record review of facility in-services records revealed facility staff were trained on the following: 08/07/23 TO 08/08/23 Accidents and Incidents, attendees included- RN E, LVN E, LVN A, LVN B, RN A, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Change in condition Assessment and Reporting, attendees included- RN A, LVN B, RN C, LVN E, LVNA, LVN G, RN F, LVN F, RN G - 08/08/23 to 08/09/23 Escalation/Chain of Command Procedure, attendees included- RN C, RN A, LVN B, LVN E, RN F, LVN F, LVN G, RN G, RN E, LVN A - 08/08/23 Following MD orders for Medication Administration Parameters, attendees included- LVN A, LVN B, LVN D, LVN E, LVN F, LVN G, RN A, RN E, RN F, RN G - 08/08/23 Falls Program and Incident Report, attendees included- LN E, LVN B, RN A, RN F, LVN F, LVN G, RN G - 08/09/23 Pain Assessment and Reassessment, attendees included- RN A, RN C, LVN A, - 08/09/23 Falls Program, attendees included- LVN B, RN C, RN E, RN C, RN B,, LVN A - 08/09/23 Reviewing, Printing out & filing diagnostic reports, attendees included- RN A, RN C, RN E, LVN A, LVN F, RN D, LVN B - 08/11/23 Fall Procedure, attendees included- RN C, RN D, LVN E, RN A - 08/11/23 Documentation (Admission; Fall Risk Assessment; Pain Tool, Transfer Form, SBAR, Change of Condition), attendees included- RN C, RN D, LVN E, RN A Record review of facility email titled Immediate Attention to Radiology/Diagnostic Services Results dated 08/08/23 at 05:15 PM and signed by the Medical Director revealed, the Medical Director notified the facility affiliated physicians the following: 1- for newly admitted patients, radiology/diagnostic services orders must address the patient's immediate needs. 2- results for routine radiology/diagnostic service must be reviewed within 24 hours of being notified that results are available 3- for stat orders, results must be reviewed within 2 hours of being notified that results are available. 4- acknowledgement of receipt and review of results must be documented in the patients EMR and a note of the plan of care must be included, Record review of a facility email titled Policies Reviewed UP dated 08/11/23 at 10:44 PM revealed the following policies were reviewed for needed changes by facility management: Pain assessment/reassessment and management, admission process, medication administration, incidents/accidents, medication reconciliation, escalation/chain of command, acute condition changes, ANE, administrating pain medications, standard medication administration times and critical results reporting policy. Record review of the facility Accident/Incident Audit revealed, the facility had identified failures in assessments following incidents, documentation or follow up on 10 out of 11 falls in the last 30 days. The Administrator was informed the IJ was removed on 08/15/23 at 03:48 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 out of 5 residents (Resident #235, Resident #237 and Resident #238) reviewed for administration. - The facility administration failed to thoroughly investigate immediately following Resident #238's fall leading to the resident having an unidentified fall for 6 days and failed to report an allegation of neglect following the identification of the fracture. - The facility administration failed to have a system in place to audit pending/missed laboratory/radiology findings resulting in Resident #238 in pain for 6 days following a fall - The facility administration failed to have systems to audit resident medication entry/acquisition/administration and pain management for accuracy and efficacy resulting in Resident #235 and Resident #237 experiencing pain on a scale of 07-10 out of 10. On 08/09/23 12:15 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/15/23 at 02:10 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could affect residents at risk for delayed identification of health conditions/treatment, severe injury, delated treatment and death. Findings include: Resident #238 Record review of Resident #238's Face Sheet date 08/11/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included; type 2 diabetes, UTI, unspecified fall and back fracture. The resident transferred to an acute care facility on 08/03/23. Record review of Resident #238's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #238's Baseline Care Plan dated 07/21/23 revealed, the resident planned to return to her own home following rehabilitation, one person physical assist with most ADLs, always continent of both bladder and bowel, and a history of falls. Record review of Resident #238's Accident/Incident Report dated 07/23/23 signed by LVN A revealed, the resident was found on the floor of the restroom besides the toilet. The patient said she fell while trying to wash her hands, she hit her butt pretty hard and her back really hurts, hell everything hurts. Record review of Resident #238's Progress Notes dated 07/23/23 at 05:18 AM signed by LVN A revealed, the resident was found on the bathroom floor and reported her butt and back really hurt. The resident was assessed for new injuries and none were discovered. The resident reported pain at 9 out of 10 and NP A gave an order for Acetaminophen 500 mg to be administered for pain. There was no documentation of the resident's ROM or initiation of Neurochecks. Record review of Resident #238's Accident/Incident Report dated 07/28/23 signed by LVN A revealed, the resident was found on the floor screaming in pain. Resident #238 could not remember how she got to the floor. Record review of Resident #238's Progress Notes dated 07/28/23 at 05:38 AM signed by LVN A revealed, Resident #238 was found lying on the floor near her walker and the vacant bed. Resident was screaming in pain and was assisted into a chair by staff members and the resident complained of left leg and hip pain. NP A w as notified and she gave orders for a STAT xray and administration of Acetaminophen. There was no documentation of neuro checks being initiated, specific of a head-to-toe assessment or assessment of Resident #238's ROM. Record review of Resident 238's paper and electronic chart revealed, LVN A did not perform any neuro checks on the resident following her falls on 07/23/23 or 07/28/23. There was no follow-up documented following Resident #238's fall on 07/23/23. LVN A did not complete a fall risk assessment for Resident #238's fall on 07/28/23. There was no follow-up documented following Resident #238's fall on 07/28/23 Record review of Resident #238's Progress Notes dated 07/28/23 at 3:09 PM signed by RN C revealed, Resident #238 complained of pain to right thigh/leg and then complained about severe pain to left thigh and leg. The resident was seen by the NP and new orders were given for Tramadol (pain medication) and labs. The xray tech reported Resident #238 was not cooperative during the first xray so the patient had to be taken to the xray department. Record review of Resident #238's Xray Final Report printed on 07/28/23 at 05:33 PM revealed, Xray left femur- left femur intertrochanteric (where the leg bone meets the hip bone) fracture. Record review of text conversation between RN C and NP A dated 07/28/23 revealed, RN C sent pictures to NP A of Resident #238's xray report that indicated a left femur fracture at 06:24 AM. At 07/28/23 a 06:38 PM NP A responded back with looks normal. Record review of Resident #238's Physician's Order written 07/28/23 revealed, X-ray Right Femur and Right Leg for post fall pain one time only until 07/28/23 at 23:59 PM. There was no order entered for the left leg/hip and there was only 1 order entered on 07/28/23. Record review of Resident #238's Progress Notes from 07/28/23 to 08/02/23 revealed, no documentation of the resident's xray finding of left femur fracture and no documented notification to the physician of the pending xray results. Record review of Resident #238's OT Daily note dated 07/31/23 revealed, Resident #238 refused to get out of the room to do therapy in the gym. The resident reported pain to her left leg 9/10 on the pain scale. Resident #238 refused to do any standing exercises or activities and was highly sensitive with lower extremity movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/01/23 revealed, Resident #238 continued to report pain to her left leg at 9/10 on the pain scale. Any slight movement intensifies pain. Increased lower extremity swelling and pain to the left leg restricts movement. There was no documentation of the resident having a fracture. Record review of Resident #238's OT Daily note dated 08/02/23 revealed, Resident #238 refused to do any standing or lower extremities exercises/movement. The resident was agreeable to perform upper extremity exercises. Resident #238 refused to do toilet training and upper body/lower-body ADLs due to her pain being unbearable. The resident said it's worse than having a baby. There was no documentation of the resident having a fracture. Record review of Resident #238's PT Daily note dated 08/02/23 revealed, patient unable to move lower left extremity due to increase pain. Patient unable to stand due to increase pain in left hip and knee. Resident #238 stated 9/10 pain on left hip, knee, and below knee nursing notified about the pain. There was no documentation of the resident having a fracture. Record review of Resident #238's Physician Notes dated 08/02/23 revealed, Resident #238 had edema (swelling) to left lower leg and reported pain when examined. Ongoing edema with the pain, concerned about bone/soft tissue involvement, requested a stat x-ray but resident declined. Resident continues to report pain to the left leg but phone call, previous x-ray was negative. The note was signed by NP A on 08/08/23 at 12:00 AM. Record review of Resident #238's Physician Notes dated 08/03/23 revealed, X-ray reviewed showed left hip fracture, Resident #238 continued to have pain and had difficulty putting weight on the left leg. The resident was on tramadol and ibuprofen on an alternating schedule with no benefits. The note was signed by MD A on 08/06/23 at 3:07 PM. In an interview on 08/07/23 at 12:36 PM, MD A said Identification of Resident #238's femur fracture from 07/28/23 was missed from top to bottom. She said once the fracture was identified on 08/03/23 the resident was sent out to the hospital immediately because the facility cannot manage a hip fracture without first receiving an orthopedic consult. MD A said NP A was responsible for receiving the xray results from 07/28/23 and was managing the patient with Tramadol and Ibuprofen scheduled every 6 hours. In an interview on 08/07/23 at 12:50 PM, NP A said Resident #238. NP A said on Friday 07/28/23 she received a call saying Resident #238's x rays were negative for fracture and she did not receive a second call notifying her of the fracture. She said during her clinical assessment the resident presented with a swollen leg which was suspicious for a fracture and was also experiencing a decline in function and increased pain. NP A said when a provider places an order for an Xray, nursing staff are expected to enter the orders and once the test are completed notification must be provided to the NP/MD by phone notification. In an interview on 08/07/23 at 02:06 PM, the Therapy Manager said upon admission Resident #238 was not bad and she experienced falls on 07/23/23 and 07/28/23. He said there was no change in the resident after her fall on 07/23/23 but when she sustained a fall on 07/28/23 which led to a drastic change in function. He said Resident #238 went from just requiring supervision with ADLs/ambulation at admission to requiring 2 people maximum assistance following the fall, and the resident reported pain on a scale from 06-9 with movement. In an interview on 08/07/23 at 4:58 PM, the Administrator said Resident #238's fall was not reported on 08/03/23 because she only had to report injury of unknown origin and the resident's fracture was from a fall. In an interview on 08/07/23 at 05:23 PM, the Administrator said the DON was responsible for completing retrospective reviews of lab/radiology reports to ensure that the results are read, fractures identified, notifications are completed and action is taking immediately on any acute negative radiological findings. She said the DON was responsible for starting an investigation immediately following an accident/incident like a fall. The Administrator said it was the DON's responsibility to review the incident to ensure that all assessments were completed, all MD specified orders were entered, all radiology/laboratory tests were performed with the results communicated to the provider. In an interview on 08/07/23 at 5:34 PM, the DON said after Resident #238's fall on 07/28/23 the resident received 2 xray results but there was no order entered for the 2nd xray so she couldn't track it. She said all xray results should be reviewed by the nurse and the physician should be notified via a phone call of the findings. The DON said failure to identify xray results timely could result in a delay in treatment, the resident developing a clot from the fracture and uncontrolled pain. The [NAME] said she was unaware that LVN A did not complete neuro checks and all necessary assessments for Resident #238 following the fall on 07/28/23. In an interview on 08/08/23 at 06:58 AM, LVN A said on 07/28/23 she walked into the room and found Resident #238 on the floor by the unoccupied resident's bed. She said Resident #238 didn't know what happened. She said the facility policy requires a head to toe assessment including the resident's ROM prior to moving the resident as well as neuro checks. LVN A said she did not initiate neuro checks on Resident #238 after the fall because she forgot and the fall occurred almost at the time of her shift. She said she was unable to assess Resident #238's left leg ROM because the resident would not allow her to touch it. LVN A said Resident #238 said it hurt and told the staff not to move her. She said Resident #238 said the pain was really bad in her hip and when the staff tried to get her to lie down she refused. LVN A said in retrospect the resident should not have been moved from the floor since she was in severe pain and her ROM could not be assessed. She said failure to assess residents properly following a fall could place residents at risk for fracture, infection, discomfort, neurological issues if the resident hit their heat and development of a blood clot at the site of the fracture. LVN A said she could not remember the specifics of Resident #238's fall on 07/23/23. In an interview on 08/09/23 at 08:40 AM, the Interim DON said following a fall nursing staff must immediately assess residents for injury including ROM assessments prior to moving the resident, any bleeding and initiation of neurological checks. She said the resident must be followed for 72 hours to ensure no injuries occurred. She said the DON is responsible for immediately reviewing the residents chart to make sure all of the information regarding the accident/incident is correct and appropriate action/follow up was performed. The interim DON said she reviewed Resident #238's fall the next day (07/29/23) but she did not go into detail so she did not identify LVN A did not initiate neuro checks on Resident #238 following her falls on 07/23/23 and 07/28/23 and assessments were not completed as required by the fall protocol. She said looking at the situation now Resident #238 was not assessed appropriately following the fall, no neuros were performed and documentation did not indicate the residents ROM. The Interim DON said she was still working on the investigation into Resident 238's fall with injury so she did not know who was responsible for the failure but the incomplete assessments and missed fracture should have been caught. She said she did not perform retrospective review of pending labs or accident/incidents and Resident #238's unidentified fracture seemed to have resulted from a multi system failure. In an interview on 08/09/23 at 09:40 AM, the Interim DON said she was notified of Resident #238's fall and complaint of pain 07/28/23 and she before she left in the evening she was aware that the resident had a pending x-ray result. She said she did not properly investigate Resident #238's fall and she did not go back to check on the pending xray results. The DON said she did not review the residents paper and electronic chart to determine if all necessary notifications and assessments were completed but instead interviewed the staff about the incident. The DON said she did not go through the facility fall protocol when reviewing Resident #238's fall on 07/28/23. The Interim DON said on 08/03/23 she was notified by the IP that Resident #238 's xray from 07/28/23 resulted in a left femur fracture so she started looking into the investigation. She said she didn't think she was properly trained to perform her DON roll because she was unaware of her obligation to perform retrospective reviews on nursing services. In an interview on 08/09/23 at 10:24 AM, the Administrator said she was notified of Resident #238's fall on 07/28/23 and the DON is responsible for investigating all reported incidents to ensure the appropriate action and follow up is performed. The Administrator said all accidents/incidents must be reviewed by nursing within 24 hours and on the weekend there is a manager on duty and a nurse on call, and on 07/28/23 the Interim DON was the nurse on call thus making her responsible for investigating the incident. She said she was made aware of the unidentified fracture on 08/03/23 by the Therapy Director and after reviewing the chart the accident/incident and falls policy was not followed, the incident was not investigated, the resident was not followed up immediately and for 72 hours following the incident. The Administrator said failures should have been caught on day 1 and it is clear that these things did not occur when referring to proper investigation on accident/incidents. She said neglect does not have to be done intentionally and when asked if failure to promptly identify Resident #238's fracture leaving the resident in pain for 6 days was a form of neglect she said it was not because the injury resulted from a fall and was not an injury of unknown origin. When asked what action should have been taken on 08/03/23 when she was notified of the fall, the Administrator said the facility took appropriate action by sending the resident to the hospital. The administrator said the quality department was made aware of the 6 day late unidentified fracture and they made the decision on how to handle the incident. In an interview on 08/09/23 at 11:54 PM the VP of Ambulatory Care said that there is an incident reporting triage process. She said first the facility staff notify the Administrator/DON of the incident, who the notify the quality department. She said in corroboration with the quality and legal department the Administrator/designee reports the incident to the state. The VP of ambulatory services said she was only made aware of the incident involving Resident #238 after the IJ for radiology was called on 08/07/23 and that the Administrator did not report Resident #238's fall with fracture to the quality team. She said the administrator was solely responsible for the failure to report the incident to the state. Resident #235 Record review of Resident #235's face sheet dated 06/28/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, UTI and unspecified fall. The resident discharged on 07/18/23. Record review of Resident #235's secondary Face Sheet dated 06/28/23 at 10:28 AM revealed, Resident #235 admitted to the facility on [DATE] at 09:01 PM. Record review of Resident #235's Baseline Care Plan dated 06/27/23 revealed, the resident was alert & oriented and experiencing generalized aching pain Record review of Resident #235's Hospital Discharge Record dated 06/27/23 at 03:45 PM revealed, Resident #235's next scheduled dose of pain medications as follows: - Famotidine 20 mg (used to treat acid reflux) 6/28/23 at 8:00 AM. - Morphine 15 mg ER (an opioid pain medication)- 06/27/23 at 09:00 PM. Oxycodone 10 mg (an opioid pain medication)- 06/27/23 at 06:00 PM. - Metronidazole 500 mg (an antibiotic)- 06/27/23 at 08:00 PM. - Simvastatin 20 mg (used to treat high cholesterol)- 06/27/23 at bedtime. - Hydralazine 50 mg ( used to treat high blood pressure)- 09:00 PM. Record review of Resident #235's Order Summary Report dated 06/28/23 revealed, - Morphine Sulfate 15 mg- give 1 tablet by mouth every 12 hours for pain ordered on 06/27/23 with a start date of 06/28/23. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours for pain ordered on 06/27/23 with a start date of 06/28/23 - Simvastatin 20 mg- give 1 tablet by mouth at bedtime for hyperlipidemia (high cholesterol) ordered on 06/27/23 with a start date of 06/28/23 - Metronidazole 500 mg- 1 tablet by mouth every 8 hours ordered on 06/27/23 with a start date of 06/28/23 - Hydralazine 50 mg - 1 tablet by mouth four times a day for high blood pressure ordered on 06/27/23 with a start date of 06/28/23 - Famotidine 20 mg (used to treat acid reflux)- give 1 tablet by mouth for acid reflux scheduled for 06/28/23 at 08:00 AM. Record review of Resident #235's Progress Note dated 06/28/23 revealed, the residents medications had not been delivered by the pharmacy and her name was not in the automated dispensing machine so medication could not be pulled from the e-kit. When Resident #235 was notified that her medication was not available, the resident informed the facility that she had her Morphine and Oxycodone at home and she asked if her son brought them to the facility could the facility staff administer it. Record review of Resident #235's June MAR printed 06/28/23 at 12:50 PM revealed, her medications were not started until 06/28/23 and the following medications were not administered: - Famotidine 20 mg (used to treat acid reflux)- give 1 tablet by mouth for acid reflux scheduled for 06/28/23 at 08:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours due at 06/28/23 at 12:00 AM. The start date was not entered until 06/28/23 at 06:00 AM. - Oxycodone 10 mg- give 1 tablet by mouth every 6 hours scheduled for 06/28/23 at 06:00 AM. Reason not administered- medication not available. - Morphine Sulfate 15 mg ER- give 1 tablet by mouth every 12 hours for pain due at 06/27/23 at 09:00 PM. The Order was entered incorrectly as Morphine Sulfate 15 mg (IR) with a start date of 06/28/23 at 08:00 AM - Simvastatin 20 mg- 1 tablet by mouth at bedtime for hyperlipidemia due at 08:00 PM on 06/27/23. The start date not scheduled till 06/28/23. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days due at 06/27/23 at 08:00 PM. Start date entered as 06/28/23 at 12:00 AM. - Metronidazole 500 mg- give 1 tablet by mouth every 8 hours for cellulitis( bacterial skin infection) for 7 days scheduled for 06/28/23 at 12:00 AM. Reason not administered- medication not available. - Hydralazine 50 mg- give 1 tablet by mouth four times a day for high blood pressure due at 06/27/23 at 09:00 PM. Start date entered as 06/28/23 at 08:00 AM Record review of Resident #235's Pharmacy Records dated 06/28/23 revealed, MD A did not submit electronic prescriptions for Resident #235's Oxycodone 10 mg and Morphine ER 15 mg until 06/28/23 at 05:31 PM, over 20 hours after the resident's admission. Record review of Resident #235's June MAR dated 06/28/23 at 12:50 PM revealed the following pain scores: - 05 out of 10 on 06/28/23 at 04:19 PM - 10 out of 10 when Resident was administered her Morphine 15 mg scheduled for 08:00 AM. - 08 out of 10 when Resident was administered her Oxycodone 10 mg scheduled for 12:00 PM. Record review of Resident #235's Physician's Notes from 06/27/23 to 07/18/23 revealed, no documentation of reported ineffective pain management, uncontrolled pain, or pain scores that remained the same after medication administration by nursing staff. Record review of Resident #235's June Progress Notes revealed, no documentation of unchanged or increased pain scores which indicated ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER June MAR revealed, - increased pain recorded on 06/28/23 between 06:00 AM and 12:00 PM doses from a 3 to an 8 out of 10. - unchanged pain recorded on 06/28/23 between 12:00 PM and 08:00 PM doses at an 8 out of 10. - unchanged pain recorded on 06/29/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. - increased pain recorded on 06/29/23 between 06:00 AM and 12:00 PM doses from a 5 to a 7 out of 10. increased pain recorded on 06/29/23 between 12:00 AM and 06:00 PM doses from a 7 to an 8 out of 10. - unchanged pain recorded on 06/30/23 between 12:00 AM and 06:00 AM doses at a 5 out of 10. Record review of Resident #235' July Progress Notes revealed, no documentation of unchanged or increased pain scores which indicate ineffective pain management and no documentation of MD notification of inefficient pain management. No documentation of post medication administration pain assessments to determine if the medication administered was effective. Record review of Resident #235's Oxycodone 10 mg ER July MAR revealed, - increased pain from a 0 to a 4 out of 10 on 07/03/23 between 06:00 PM to 07/0/423 at 12:00 AM doses. - increased pain from a 0 to a 5 out of 10 on 07/04/23 between 12:00 Pm to 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/06/23 between 12:00 PM to 06:00 PM doses. - increased pain from a 2 to an 9 out of 10 on 07/07/23 between 12:00 PM to 06:00 PM doses. - unchanged pain at 5 out of 10 recorded on 07/08/23 between 12:00 AM and 06:00 AM doses. - unchanged pain at 5 out of 10 recorded on 07/09/23 between 12:00 AM and 06:00 AM doses. - increased pain from a 5 to 6 out of 10 on 07/09/23 between 06:00 AM to 12:00 PM doses. - unchanged pain at 6 out of 10 recorded on 07/09/23 between 12:00 PM and 06:00 PM doses. - increased pain from a 3 to an 8 out of 10 on 07/11/23 between 06:00 AM to 12:00 PM doses. - increased pain from a 2 to a 9 out of 10 on 07/12/23 between 06:00 AM to 12:00 PM doses. Record review of Resident #235's Medication Administration Audit from 06/27/23 to 07/18/23 dated 08/03/23 revealed, the resident received her Oxycodone and Morphine outside of scheduled administration times on 23 different occasions during her stay: 1- Morphine ER 15 mg scheduled for 06/28/23 at 08:00 AM, administered at 09:15 PM; The medication was not available 2- Morphine ER 15 mg scheduled for 06/30/23 at 08:00 PM, administered at 09:33 PM; There was no documented reason for the late administration. 3- Morphine ER 15 mg scheduled for 07/01/23 at 08:00 AM, administered at 09:05 PM; There was no documented reason for the late administration. 4- Oxycodone 10 mg scheduled for 07/02/23 at 06:00 PM, administered at 07:11 PM; There was no documented reason for the late administration. 5- Morphine ER 15 mg scheduled for 07/02/23 at 08:00 PM, administered at 11:32 PM; There was no documented reason for the late administration. 6- Morphine ER 15 mg scheduled for 07/03/23 at 08:00 PM, administered at 09:58 PM: There was no documented reason for the late administration. 7- Oxycodone 10 mg scheduled for 07/04/23 at 06:00 AM, administered at 07:05 AM; There was no documented reason for the late administration. 8- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 AM, administered at 09:15 AM; There was no documented reason for the late administration. 9- Morphine ER 15 mg scheduled for 07/04/23 at 08:00 PM, administered at 10:44 PM: There was no documented reason for the late administration. 10- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 AM, administered at 09:19 AM; There was no documented reason for the late administration. 11- Morphine ER 15 mg scheduled for 07/06/23 at 08:00 PM, administered at 09:20 PM; There was no documented reason for the late administration. 12- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 AM, administered at 11:53AM; There was no documented reason for the late administration. 13- Morphine ER 15 mg scheduled for 07/07/23 at 08:00 PM, administered at 09:03 PM; There was no documented reason for the late administration. 14- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 AM, administered at 11:03AM; There was no documented reason for the late administration. 15- Morphine ER 15 mg scheduled for 07/08/23 at 08:00 PM, administered at 10:07 PM; There was no documented reason for the late administration. 16- Morphine ER 15 mg scheduled for 07/09/23 at 08:00 AM, administered at 09:30AM; There was no documented reason for the late administration. 17- Morphine ER 15 mg scheduled for 07/10/23 at 08:00 PM, administered at 09:05 PM; There was no documented reason for the late administration. 18- Oxycodone 10 mg scheduled on 07/12/23 at 12:00 AM, administered at 3:16 AM; There was no documented reason for the late administration. 19- Oxycodone 10 mg scheduled for 07/14/23 at 12:00 PM, administered at 02:17 PM; The medication ran out of refills. 20- Morphine ER 15 mg scheduled for 07/16/23 at 08:00 AM, administered at 10:05 AM 21- Oxycodone 10 mg scheduled for 07/17/23 at 06:00 PM, administered at 07:30 PM; There was no documented reason for the late administration. 22- Morphine ER 15 mg scheduled for 07/17/23 at 08:00 PM, administered at 09:12 PM; There was no documented reason for the late administration. 23- Morphine ER 15 mg scheduled for 07/18/23 at 08:00 AM, administered at 09:03 AM; There was no documented reason for the late administration. An observation on 06/28/23 at 08:45 AM revealed, Resident #235's family member approaching RN B while she prepared for medication administration to Resident #235. He said that he was very upset with the facility because prior to admission he was assured that Resident #235's medication would be available upon her admission but it was not. He said Resident #235 called him multiple times overnight to inform him that she had not received any of her medication since she arrived at the facility and she was in severe pain. Resident #235's family member then handed RN B 2 bottles of medication (Morphine ER 15 mg and Oxycodone 10 mg) and said he brought only a 2 days' supply to cover Resident #235 until the medication arrived at the facility. After Resident #235's family member entered the resident's room, RN B alerted the Interim DON to the arrival of the mediation at which point they both counted the medications and logged them into individual control sheets. In an interview on 06/28/23 at 10:10 AM, RN B said Resident #235 admitted to the facility on the night shift of 06/27/23. She said the patient's medications had not yet arrived from the pharmacy and the night shift nurse said Resident #235's family member would be bringing her pain medication so she was waiting for its arrival. When asked if RN B could have pulled the rest of Resident #235's unavailable medication from the facility EKit (floor stock of prescription medications available for emergency use), she said she administered the OTC medications as well as the pain medication brought in by the family member but she would have to check the facility EKit for the rest of Resident #235's medications. RN B said she immediately administered Morphine ER 15 mg to Resident #235 once it was delivered by the resident's family member but the Oxycodone was not due yet. She could not say when Resident #235 received her last dose of Oxycodone. RN B said failure to administer medications as ordered could place residents at risk for uncontrolled disease states such as uncontrolled pain. In an interview on 06/28/23 at 10:35 AM, the Interim DON said she was notified by RN B and the Surveyor about the delay in receiving Resident #235's medication and the resident's family member had to bring in a 5 days supply. She said she notified the MD to get an immediate order. In an interview on 08/01/23 at 12:43 PM, the Interim DON said nursing staff are expected to call the physician with all delayed control substances to expediate the process. Once the physician has been notified nursing must then call the pharmacy for a stat order which takes about 2 hours to deliver once the prescription is sent. The surveyor once again notified the Interim DON of the delay is prescriptions from the prescriber. In an interview on 08/13/23 at 08:03 AM, RN E said she was the admitting nurse for Resident #235 on 06/28/23. She said when the resident admitted to the facility she entered reconciled the medications with the provider, including the Resident #235's pain medications Oxycodone and Morphine. She said when she notified the provider, the provider stated that late admissions always resulted in problems with CII medication acquisition because they were unable to electronically prescribe the medications. Resident #237 Record review of Resident #237's Nurse report dated 07/26/23 revealed, Resident #237 arrived at the facility at 7[TRUNCATED]