Health inspection·September 4, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required it for 1 of 8 residents (Resident #1) reviewed for pain. The facility failed to make sure that each resident's clinical record contains the physician's signed and dated orders that also were handled appropriately if any changes were made for 1 (Resident #1) of 8 Residents reviewed for physician orders in that: - Facility failed to obtain physician orders for [[NAME]] Cold Therapy Unit which was used to provide cold therapy to reduce pain and swelling for Resident #1. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records Findings included: Record review of Resident #1's admission record dated 09/04/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of unspecified hyperlipidemia (this is elevated lipid levels in the body without a clearly identifiable cause). admission record did not have other diagnoses. Record review of Resident #1's hospital discharge date d 08/29/25, revealed Resident #1 was a [AGE] year-old female who had Type II Diabetes mellitus [uncontrolled blood sugars], Atrial fibrillation [heart irregularity and arrhythmia], Hyperlipidemia, GERD [heart burn/irritation], and Chronic low back pain. [Resident #1] presents with a chief complaint of left knee pain. She has had the symptoms for 2 years. She was previously diagnosed with osteoarthritis in 2006 [(a degenerative joint diseases that primary affects the left knee joint causing pain. Stiffness, and reduced mobility)] and underwent an arthroscopic debridement [(this a surgical procedure that involves removing damaged tissue from a joint)]. She had relief for 1-2 years. She has had progressive pain in the knee over time. She has had multiple steroid injections with temporary relief. Her last steroid injection was in February 2025. She did not have any relief with [name] supplementation. She has been receiving home physical therapy, which has been helping her mobility and strength, but pain persists. She still has popping in the knee, as well as deep pain. She has been receiving Oxycodone [(pain medication)] and Lyrica [(nerve pain medication)] for chronic pain from [Physician name], a pain management specialist. Record review Resident #1's admission MDS on 09/04/25, revealed document was in progress status. Record review of Resident #1's active physician orders on 09/04/25 did not reflect physician order for ICTU therapy. Record review of Resident #1's care plan initiated on 09/03/25 did not reflect focus, goals, or interventions for use of ICTU therapy. Observation and interview with Resident #1 and Medication Aide on 09/04/25 at 07:50 AM, revealed Resident #1 was in bed with both legs uncovered. The left leg had a black knee immobilizer brace on and on top of her knee opening was a blue ice pad of the [[NAME]] Cold Therapy Unit in place connected. The ICTU cooler box was placed on the floor at the end of the bed. She said that she had the ICTU since she admitted [9/2/25], and the ice was only refilled yesterday [09/03/25] at 7 pm. Resident #1 stated that the nurse had already administered pain Residents Affected - Few Page 1 of 2 676139 676139 09/04/2025 Green Oaks Nursing & Rehabilitation 3033 W Green Oaks Blvd Arlington, TX 76016

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, however she was still having some knee pain. At this time of observation, MA administered Aspirin 81 mg, 1 tablet, Diazepam 10 mg tablet [antianxiety], take 1 tab by mouth 2 a day, Pregabalin 75 mg capsule [nerve pain medicine], take 1 cap oral route 3 times a day- 1 cap given, Divalproex DR 250 MG [depression medication], give 1 tablet by mouth 2 times a day-1 tab given, Metformin ER 500 MG TAB [controls blood sugar], give 1 tablet by mouth one time a day-1 tab given, Trintellix 20 mg Tab [antidepressant], give 1 tab by mouth 1 time a day-1 tab given, and Vraylar 1.5 MG[antipsychotic], Capsule, take 1 cap by mouth every day, 1 tab given. The MA stated that it was the nurse and the CNAs who were responsible for the resident's equipment's such as the ICTU and she would let them know that the machine needed ice and that the resident was still in pain. In an interview with RN A on 09/04/25 at 08:00 AM, revealed she had administered pain medication at 6 AM to Resident #1. She stated she did not check the [[NAME]] to see if there was ice water in it. She said herself and the CNA were responsible for monitoring that the machine had ice water in it. She said she was not sure who had ordered the [[NAME]], but it had been on Resident #1's knee for pain management. She said the orders might have come from the hospital, but she was not sure because the resident was new to the facility. She stated the admitting nurse was responsible for entering the physician orders at admission. RN said that she was monitoring Resident #1's circulation every 4 hours. She said the risk to resident not having ice water in her [[NAME]] was increased pain. In an interview with CNA on 09/04/25 at 09:42 AM, revealed she was not responsible for monitoring for Ice water in the ICTU machine. She said that was the nurse's responsibility. She said prior to today [09/4/25], the nurse nor the resident had not asked her to check the machine for ice water but she passed ice in the hydration cups this morning. She said the nurse (RN A) asked for her help a little while ago to get something to discard the old water from the machine. She said she did not know how to operate the ICTU but it looked easy. In an interview on 09/04/25 at 01:33 PM, the DON stated her expectation was all orders were transcribed correctly, and every nurse was trained to make sure that all physician orders were clarified. She said THE [[NAME]] was used to help with pain control. She stated the nurses were responsible for obtaining physician orders and the nurse managers should make sure all orders were in and accurate. The DON said she was unaware of who had ordered the [[NAME]] or how long Resident #1 had it for. The DON said the risk of not having orders was not knowing how long to keep the [[NAME]] on and off. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment . Record review of facility policy titled, Pain Assessment and management, revision date April 2009, revealed4. The physician and staff will establish a treatment regimen based on consideration of the following:a. The resident's medical condition;b. Current medication regimen;c. Nature, severity and cause of the pain;d. Course of the illness; ande. Treatment goals. Reference www.midline.com/ [[NAME]]-classic, DJO Global [[NAME]]-CLASSIC-.PDF Product Description The [[NAME]] CLASSIC cold therapy unit helps reduce pain and swelling, speeding up rehabilitation. The [[NAME]] provides extended cold therapy for a variety of indications and protocols as directed by a medical professional. Using DonJoy's patented semi-closed loop recirculation system, [[NAME]] delivers more consistent and accurate temperatures than other cold therapy units. The DonJoy [[NAME]] features a semi-closed loop recirculation system that allows water warmed after flowing through the pad to be preserved and remixed with cooler ice water at a constant flow rate, providing consistent cool water distribution throughout the cold pad. 676139 Page 2 of 2