**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, resident, staff, and physician interviews, the facility failed to thoroughly assess and follow through on interventions to maintain Resident #1's highest practical physical well being and function for 1 or 5 residents reviewed (Resident #1). Resident #1 experienced unnecessary pain, due to grossly decayed and non-restorable teeth. Resident #1 reported mouth pain in July 2024. She saw a dentist in August 2024. The dentist referred her to the University dental office at her appointment on 8/16/24. The facility failed to arrange an appointment. Resident #1 continued to have oral pain and saw the dentist again on 9/4/24. At this time, the dentist ordered to send Resident #1 to the University Hospital Emergency Room. On 9/8/24, Resident #1 experienced a change in mental status, difficulty breathing, and heart irregularities. Once she returned from the hospital, the facility still failed to transport Resident #1 to the University Hospital Emergency Room. The only pain relievers Resident #1 received was Tylenol, mouthwash, Orajel, and viscous lidocaine. Resident #1's mouth pain resulted in a change in condition that affected her eating and drinking. The facility reported a census of 72 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed them as independent with eating. The MDS included diagnoses of diabetes, seizure disorder, alcoholic cirrhosis (liver failure), and chronic obstructive pulmonary disease (COPD). Resident #1 rated their pain at a 5 out 10 (0 being no pain, 10 being the worst pain ever). They experienced their pain frequently in the previous 5 days. It affected their sleep and day-to-day activities occasionally. The MDS indicated Resident #1 received a mechanically altered diet. The oral/dental status was not marked, indicating Resident #1 had no mouth or facial pain. The MDS assessment dated [DATE] identified Resident #1 had a BIMS score of 15, indicating cognition intact. The MDS listed Resident #1 independent with eating and oral hygiene. The MDS indicated Resident #1 received a mechanically altered diet and had no mouth or facial pain. The MDS documented Resident #1 had moderate pain frequently that affected her sleep, therapy, and day-to-day activities frequently. The Care Plan Focuses: a. Initiated 9/29/23: related to activities of daily living (ADLs). The Interventions listed Resident #1 as having her own teeth and independent with oral hygiene and eating. b. Revised 1/19/24: indicated Resident #1 had chronic pain related to arthritis all over her body. She reported she learned to live with the pain because she got used to having pain. c. Initiated 10/24/24: Resident #1 had an appointment to have 3 teeth extracted due to pain. The Care Plan lacked information about dental care/services. Resident #1's Medication Administration Records (MAR) included an order to document her pain level every shift. The Order Note dated 7/19/24 at 2:24 PM, identified Resident #1 complained of mouth sores. The facility notified the Physician's Assistant (PA) who gave new orders for magic mouthwash twice a day (BID) for 7 days. The SPN - Focused Evaluation Note dated 7/31/24 at 8:50 AM, indicated Resident #1 continued to complain of mouth pain. The evaluation revealed no open sores in the oral cavity, any redness, or any white patches to back of throat. Resident #1's August 2024 MAR indicated she rated her pain between 0 to 6, with the most frequent ratings at 0 (47 times), 2 (12 times), and 5 (17 times). An Infection Control Surveillance of a Skin and Soft Tissue Infection dated 8/5/24 at 11:47 AM revealed Resident #1 had presence of raised white patches on an inflamed mucosa or plaques on oral mucosa noted in her chart on 8/5/24. The physician prescribed magic mouthwash on 8/5/24. The Order Note dated 8/5/24 at 4:24 PM, reflected the facility notified the PA that Resident #1 complained of mouth pain. The PA gave orders for magic mouthwash 5 milliliters (ml) BID for 7 days. The E Interact Change in Condition Evaluation dated 8/15/24 indicated Resident #1 had new or worsening pain. Resident #1 reported as she ate something, her left upper tooth filling may have fell out. Resident #1 had no redness, drainage, bleeding or any increased swelling to her left outer mouth. The recommendation included a referral to emergency dental appointment for evaluation and repair. The (paper) Physician Order Form noted by Staff A, Licensed Practical Nurse (LPN), on 8/15/24 included an order to refer Resident #1 to the dentist for a routine exam and evaluation of mouth and tooth pain. The SPN - Focused Evaluation dated 8/15/24 at 9:27 PM, indicated the facility monitored Resident #1 for mouth pain related to a left upper tooth filling. She reported pain 4 out of 10, adding her tongue and the left side of her mouth is sore. The evaluation determined no redness or swelling noted. Resident #1 aware of referral to dentist for pain related to filling. The Dental Office Visit Note on 8/16/24 indicated Resident #1 complained of pain to the upper left teeth. Resident thought the fillings fell out a couple of months ago. Area is painful with eating and sensitive to hot and cold. Exam findings revealed non-restorable carious (cavities) teeth #14 and #15. Recommendations for Resident #1 to follow up with oral surgeon at University hospital dentistry due to complexity of treatment and teeth extractions required. The Appointment/Visit Note dated 8/16/24 at 9:28 AM, identified the facility scheduled a dental appointment that day at 2:45 PM due to Resident #1's mouth pain and filling repair. The Appointment/Visit Note dated 8/16/24 at 5:47 PM, reflected Resident #1 left the facility for a dental appointment. She had images (x-rays) taken and received a referral to Iowa City for oral evaluation and teeth extractions. Facility to call back to schedule after 9/1/24. The SPN - Focused Evaluation dated 8/17/24 at 11:24 AM, indicated Resident #1 rated her pain at 7 on a 0 to 10 scale. The evaluation revealed Resident #1's tongue and left side of her mouth appeared red and swollen. Resident #1's September 2024 MAR identified she rated her pain between 0 to 6, with the most frequent pain rating at 0 (31 times), 4 (12 times), and 6 (9 times). The (paper) Physician's Order Form noted by Staff B, LPN, on 9/3/24, reflected a referral for Resident #1 to the dentist and begin Keflex 500 milligrams (mg) PO four times a day (QID) for 7 days. The Encounter Note dated 9/3/24 at 12:00 AM, the PA documented Resident #1 complained of a sore mouth. They noted small white lesions inside of her mouth. The lesions didn't appear raised and could be scrapped. Resident #1 used routine inhales for COPD. The PA educated the nursing staff about the importance of rinsing out her mouth after use. Referral made for Resident #1 to go to the dentist to further evaluate mouth pain but it hasn't been scheduled yet. The PA diagnosed Resident #1 with oral thrush and mouth pain. The PA suspected the oral thrush contributed to Resident #1's mouth discomfort. She gave an order to start nystatin (antifungal medicine) QID for 10 days and rinse mouth after using inhalers. Continue to monitor for new or worsening symptoms. The Nurses Note dated 9/4/24 at 4:20 PM, identified Resident #1 left the facility earlier in the shift to go to a dental appointment and returned at that time with instructions to send her to the University hospital emergency room (ER) to be evaluated by the ER oral surgeon. The Dental Office Visit Note on 9/4/24, reflected Resident #1 still complained of significant pain in the upper left (teeth) with a white coating on her tongue and cheeks. Resident #1 reported no one set up the appointment for her to have the teeth removed in Iowa City and she now had gum pain. The pain prevented her ability to eat. She received a diagnosis of grossly decayed, non restorable teeth #14, #15, and #29, and a potential candida (yeast) infection. Referral sent on 8/16/24 to hospital dentistry for extraction of teeth. Resident #1 didn't receive any contact from the hospital dentistry. The Dentist (local) called hospital dentistry and spoke with the charge nurse. The charge nurse recommended Resident #1 walk into the University hospital ER for evaluation. The oral surgeon on-call could evaluate Resident #1 if needed and do extractions there, or schedule her to come back for the extractions. Written instructions given on the discharge sheet for the nursing home today (9/4/24) on what needed to be done. The Infection Control Surveillance Skin & Soft Tissue Infection assessment dated [DATE] at 7:54 AM reflected Resident #1 started Bactrim DS (antibiotic) on 9/3/24 due to pus at wound, skin, or tissue site with warmth, redness, swelling and pain at the affected site. The Physician Order Form noted by Staff A on 9/5/24 revealed an order to begin nystatin suspension 5 ml PO QID for 10 days. The Report of Consultation on 9/4/24, Resident #1 referred to University hospital dentistry on 8/16/24. Resident #1 didn't hear back to schedule appointment. The Dentist called and spoke with the charge nurse in the hospital dentistry on 9/4/24. The charge nurse recommended sending Resident #1 for evaluation in the University hospital ER and if needed, she may be evaluated by the on call oral surgeon. The Dentist documented Resident #1 needed to go to the University hospital ER for evaluation of severe pain. The SPN - Focused Evaluation dated 9/5/24 at 8:20 PM, indicated Resident #1 started on oral nystatin suspension for thrush (yeast infection in the mouth). Resident complained of pain to mouth and still rated pain a 4 out of 10. Resident's tongue red but no white patches noted. The eInteract SBAR Summary for Providers dated 9/8/24 at 1:29 AM, identified Resident #1 transferred to hospital for high potassium. Resident #1 had abdominal pain and shortness of breath. A Hospital Note dated 9/8/24 at 1:30 AM revealed Resident #1 presented to the ER with hypotension (low blood pressure) and not very responsive. The facility called the Emergency Medical Services (EMS) due to Resident #1 having shortness of breath and diaphoretic (excessive sweating). Resident intubated and pacemaker started due to her being in complete heart block. Resident #1 diagnosed with chronic hypoxic (low blood oxygen levels) respiratory failure, hyperkalemia (high potassium in the blood) and cardiogenic shock (life-threatening condition due to the body not pumping enough blood to meet the body's needs). She had a white blood cell count of 15 (normal 5 10), potassium 7.8 (normal 3.5 5.2), glucose 392 (normal 70 100), and d dimer 1,059 (normal less than 0.5). The hospital admitted Resident #1 to the Coronary Care Unit. The Physician's Orders revealed the following: a. On 7/19/24, magic mouthwash 5 ml PO BID for 7 days for mouth sores. b. On 8/5/24, magic mouthwash 5 ml PO BID for 7 days for mouth pain. c. On 8/15/24 refer to dentist for exam and evaluation of mouth/teeth pain. d. On 9/3/24, refer to dentist. Bactrim DS (antibiotic) BID for 5 days for an abscess. e. On 9/5/25 nystatin suspension QID for 10 days. f. On 9/7/24, transfer to the ER (Emergency Room) for evaluation and treatment. The Nursing Dental Evaluations dated 4/14/24, 7/15/24, and 9/13/24 reflected Resident #1's upper and lower teeth in good condition, without loose teeth or decay present. The gums, tongue and cheeks were pink and the mouth had no sores present. The SPN - Admit/Readmit Note dated 9/13/24 at 12:33 PM identified Resident #1 readmitted to the facility. Staff L, LPN, documented Resident #1's upper and lower teeth in good condition. The Encounter Note dated 9/16/24 at 12:00 AM, reflected the PA evaluated Resident #1 following her recent hospitalization. She went to the hospital on 9/8/24 with shortness of breath. While there, they diagnosed her with acute pulmonary edema, hyperkalemia with potassium of 7.8, and noted to have complete heart block. They started her on transcutaneous pacing and transferred to another hospital for a cardiology evaluation. She was transitioned to transvenous pacing (external technique used in emergencies to treat severe low heart rate or heart blockages). They treated her hyperkalemia (high potassium) with medication. The listed her as in cardiogenic shock. She developed a fever and had blood cultures positive for Pseudomonas (infection). They started her on cefepime (antibiotic) and IV fluids. Her hospitalization was complicated by respiratory failure requiring intubation (a tube down the throat to help with breathing), anemia (low iron in the blood) requiring a blood transfusion, and hypertension (high blood pressure). Resident #1 eventually improved and the hospital discharged her back to the facility on 9/13/24 in stable condition. Resident #1's October 2024 MAR indicated her pain ratings increased from 4 to 9. 4 (10 times), 5 (15 times), 6 (4 times), 7 (4 times), 8 (3 times), and 9 (2 times). Resident #1's MAR reflected the following orders: a. Magic mouthwash 5 milliliters (ml) by mouth (PO) two times a day (BID) for mouth pain for 7 Days had a start date 7/19/24. b. Magic mouthwash 5 ml by mouth BID for mouth pain for 7 Days had a start date 8/5/24. c. Bactrim DS (antibiotic) one tablet PO BID for an abscess for 5 Days had a start date 9/3/24, and on hold 9/7/24 to 9/9/24. d. Lidocaine viscous (mouth throat) solution 15 ml PO every 4 hours as needed (PRN) for mouth pain had a start date 8/11/23 and on hold 9/7 9/13/24. - Resident #1 received the medication once on 8/16, 8/25, 8/30, 9/1, and 10/22/24. e. Tylenol 650 mg PO every 4 hours PRN for pain had a start date 9/13/24. - The [DATE]/1/24 to 10/24/24 revealed Tylenol administered on 8/28, 10/1, 10/15, 10/18, 10/21, and 10/22. f. Orajel 2X Toothache and Gum Gel to buccal (inside the mouth/cheek) every 4 hours PRN for mouth pain started on 9/16/24. - The MAR revealed no PRN Orajel documented 9/16/24 to 10/29/24. g. Orajel 2X Toothache & Gum gel every 2 hours PRN for tooth/mouth pain had a start date 10/16/24. The MAR documented - Resident #1 received the medication on 10/21 at 8:25 PM. h. Warm salt water rinse every 4 hours PRN for oral discomfort had a start date 9/16/24. - The MAR revealed no PRN warm salt water rinses documented 9/16/24 to 10/29/24. The Order Note dated 10/16/24 at 11:26 AM reflected Resident #1 had a new order for Orajel toothache and gum/mouth gel every 2 hours as needed (PRN) The Nurses Note labeled Late Entry documented on 10/18/24 at 3:22 PM, identified the facility made an appointment with a local dentist for 10/23/24. The Nurses Note dated 10/22/24 at 5:00 AM, identified Resident #1 complained of left sided tooth pain throughout the night. She requested Orajel twice, Tylenol once, and viscous lidocaine once. She had her cheek slightly swollen but didn't have drainage noted. She had an appointment scheduled to see the dentist on 10/23/24. The Orders - Administration Note dated 10/23/24 at 12:57 PM, indicated Resident #1 saw the local dentist related to increased tooth pain. Resident #1 received referral for extraction of 3 teeth immediately at the University hospital. A call placed to University (hospital) and the soonest they can schedule Resident #1 is 1/16/25 at 11 AM. They will call the facility if anything else becomes available sooner. The Report of Consultation on 10/23/24, resident has had pain since 8/16/24, and now had significant pain and difficulty eating. She was diagnosed with grossly decayed, and non restorable teeth and recommended Resident #1 be immediately referred to the University hospital dentistry for immediate extraction of teeth #14, #15, and #29. The dentist made a referral on 8/16/24 and 9/4/24. The Dental Office Visit Note on 10/23/24, Resident #1 still having pain to the upper left teeth and a sharp tooth cutting her tongue. She complained of having a hard time eating. Resident #1 referred to have teeth removed at the University hospital dentistry but the nursing home hadn't set up the appointment yet. Resident #1's teeth #14, #15, and #29 grossly decayed and non restorable and needed to be extracted. Oral surgery referral required for extractions due to the complexity of treatment. Teeth #14, #15 and #5 smoothed due to sharp edges cutting her tongue. Consultation report filled out and sent back to the nursing home stating Resident #1 needed transported to the University hospital dentistry immediately for extraction of teeth. The Orders - Administration Note dated 10/24/24 at 7:04 PM identified Resident #1 went to the Iowa City ER related to a broken tooth. The Orders - Administration Note dated 10/24/24 at 7:51 PM, reflected Resident #1 went to the Iowa City ER related to dental concerns. The Nurses Note dated 10/24/24 at 10:02 PM identified Resident #1 returned from the University hospital. They reported they didn't do anything and didn't get any new orders. An E Interact Change in Condition Evaluation dated 10/24/24 revealed Resident #1 broke a tooth and had uncontrolled pain since 10/24/24. Resident #1 saw a dentist on 10/23/24 and the dentist recommended a referral to the ER in Iowa City. An E Interact Change in Condition Evaluation dated 10/26/24 revealed Resident #1 had a blood glucose reading of 51 (low - expected 70-100). Blood sugar rechecked after Resident #1 consumed a glass of orange juice and ate supper, with a result of 165. On 10/24/24 at 4:05 PM, observed Resident #1 self propel her wheelchair from her room to the nurse's station and requested Tylenol for pain. Resident #1 opened her mouth and showed the CMA where it hurt. Resident #1 rated her pain at a 5. During an interview on 10/29/24 at 8:25 AM, Resident #1 reported she couldn't eat or drink because she had pain in her mouth and teeth. She had 2 upper left and 1 lower right back teeth that hurt. Resident #1 reported the pain got worse in the past 1 2 weeks since the tooth cracked and broke off. Resident #1 stated she saw a dentist but the dentist wanted her to go to Iowa City to see the dentist there but she needed a referral. She didn't know if she could wait a few months to have her teeth removed. She couldn't eat or drink, and it hurt a lot. Resident #1 reported she took Tylenol and used Orajel for the pain but it is not helping. Resident #1 reported having the pain there all of time, throbbing. Resident #1 reported she stay in the hospital in September 2024, because her heart stopped, they had to shock her heart back, and put a pacemaker in. During an interview on 10/29/24 at 10:15 AM, the Dentist reported he saw Resident #1 on 8/16/24 because she had pain in her left upper teeth and had a filling fall out of her tooth. He described her upper left teeth as decayed and sensitive to cold. He explained the teeth needed to be extracted. He referred her to the hospital dentistry but no one at the facility made her an appointment. He saw Resident #1 again on 9/4/24. Resident #1 told him she didn't have an appointment set up for her. Resident #1 had significant pain to her gums, upper left teeth, and lower right teeth. She reported she couldn't eat due to the pain. By that time, she had another tooth (#29) that needed extracted. She had a white coating with sores in her mouth. The upper molars were decayed. He couldn't retract the gum to look at her tooth due to her having too much pain. He spoke to the charge nurse in the University hospital ER and wrote an order on the yellow form to send her directly to the ER, but nobody took her to the ER. He saw her again on 10/23/24, Resident #1 had pain to her upper left teeth. He observed her teeth broken, sharp, and cutting her tongue. He smoothed off the area so it wasn't so sharp. She had significant pain in her left upper and right lower mouth. Resident #1 complained she had a hard time eating. He referred her to go to the University hospital but no one set up the appointment. He wrote on the yellow consult report (orders for the facility) Resident #1 was in pain and needed transported directly to the University hospital ER immediately for extraction of teeth. The facility needed to expedite her to go to the University hospital ER, and then the dentist/surgeon could possibly see her that day or the following day. During an interview on 10/29/24 at 12:30 PM, Staff A, LPN, reported the provider wrote the summary of their visit and orders on the yellow consultation form. The yellow consultation form is given to the nurse when Resident #1 returned to the facility, and then they entered any orders into the computer. Staff A reported Resident #1 went to the dentist because she had thrush and had different things going on in her mouth. She was supposed to have teeth extractions done. She called Iowa City (dentistry) when she got a referral from the local dentist office. The dentist in Iowa City asked her to send information to them, and then they would call back to set things up. The surveyor advised Staff A of the progress note she wrote on 8/16/24 about resident out for a dental appointment and was referred to hospital dentist for oral evaluation and teeth extraction. The surveyor inquired as to which facility was to call back to schedule after 9/1, Staff A responded the nursing home staff was to call the hospital dental office back after 9/1/24. Staff A stated she knew it was written on a paper for the (nursing home) facility to call back after 9/1/24. She stated she didn't know for sure what happened. Staff A stated she would have to look at Resident #1's chart for documentation and dates. Staff A reported whenever a resident had a change in condition, she filled out a change in condition assessment and notified the provider. On 10/29/24 at 1:00 PM, Staff A confirmed she just charted whatever note was written on the form from the dentist office. The note written on the After Visit Summary showed Facility to call back to schedule after 9/1. She didn't know what happened. The facility was supposed to call back after 9/1 but she didn't know if it happened. She passed it on in report but didn't know if someone followed up. During an interview 10/29/24 at 11:55 PM, Staff B, LPN, reported Resident #1 went to a dentist in August 2024 and again in October 2024. After the 8/16/24 dental appointment, they didn't follow up like they should have when the dentist referred Resident #1 to see a provider in Iowa City. She called to let the dentist know Resident #1 went to the ER on [DATE]. On 8/16/24 the facility staff called Iowa City but the staff dropped the ball. Someone was supposed to call them back but it didn't get done. Resident #1 had orders for Orajel, lidocaine swish, and nystatin mouth rinse for pain. Staff B said Resident #1 ate a lot of ice and she told her not to chew on ice because she didn't think that helped her teeth. During an interview 10/29/24 at 12:40 PM, the Director of Nursing (DON) reported Resident #1 saw the dentist on 8/16/24. The DON explained whenever someone made a referral to Iowa City, they had to wait 7 days to call for a referral. She didn't know for sure when they made the appointment to Iowa City dentist. When the surveyor advised no one made the appointment and asked her if she knew why, the DON responded she couldn't answer why no one followed up. Resident #1 went back to see the local dentist two weeks later (on 9/4/24). She went to the hospital ER for shortness of breath and abdominal pain. While there they found she had a heart blockage. During an interview 10/29/24 at 2:10 PM, the Director of Clinical Services (DCS) reported to the surveyor when she saw a dental concern listed on the letter the facility received from the State Department on 10/24/24, she began to do some follow up on things at the facility, and then began to provide staff education on 10/25/24. A systemic change was made in the past week for staff to write any pending appointments on the communication page (dashboard) in the computer. Staff education included to contact the physician if a resident had new swelling or edema to the face in addition to pain. During an interview 10/30/24 at 11:30 AM, Staff C, LPN, reported they placed the order in the appointment whenever the resident had an appointment when they processed the orders. Staff C reported she passed it on in report to set up Resident #1's appointment or transportation because she didn't usually make those calls at night. Staff C reported Resident #1 complained of a sore mouth. Staff C thought the soreness was related to dental stuff. She didn't know how long Resident #1 had the pain, but she gave her magic mouthwash and lidocaine to use for the pain. During an interview 10/30/24 at 2:45 PM, Staff D, certified medication aide (CMA), reported she told the nurse if she noticed a change in a resident's condition. During an interview 10/31/24 at 2:20 PM, Staff E, PA, reported she saw residents at the facility every Tuesday and Thursday. Staff E reported she assessed a resident's pain by getting a good history and then determined if the pain is new or chronic. She checked what medications Resident #1 took, and looked at her kidney function. Staff E stated she tried to offer different pain modalities besides medications. She offered scheduled or PRN pain medications but asked Resident #1 what they wanted to do. She tried to ask Resident #1 about pain when she saw her. Staff E reported Resident #1 had tooth pain recently and got canker sores in her mouth. The sores in her mouth went on a little bit longer than the tooth pain. She talked to her about doing Orajel, magic mouthwash, and a lidocaine solution. Staff E reported she provided education to Resident #1 to stay away from acidic foods. She also had Tylenol she could take for the pain. The goal for pain level management is hard to put a number on it because residents perceive pain differently. She expected staff to call her if Resident #1 had worsening pain, if there she had anything new going on, and for more urgent concerns. She saw Resident #1 when she had mouth pain, she made the initial referral to the dentist in August 2024. Staff E reported a resident experiencing tooth pain could get an infection, end up with a worsened condition if not cared for, and/or the resident could end up going to the ER. During an interview 10/31/24 at 3:05 PM, the DON reported she expected staff to call the provider for new orders if a resident had a change in condition, if a resident needed to go to the ER, or any complaints of chest pain. The DON reported they documented pain assessments under the evaluation tab in the computer, as well as on the MAR whenever staff gave a PRN pain medication. In addition, the system generated a progress note whenever someone documented an assessment. The DON explained Resident #1's pain level goal may be listed on the Care Plan but every resident's pain is different. A resident may rate pain at a 3 daily, which may be Resident #1's normal pain level but another resident's normal pain level could be a 5. The DON reported she doesn't do much with Resident #1 and preferred the surveyor talk to Staff F, ADON. The DON acknowledged Resident #1 went to the hospital for her heart. When she came back from the hospital, she saw Staff E on 9/3/24. Resident #1 went to the dentist again on 9/4/24. The facility sent her to the ER in Iowa City last week (October 2024), they didn't do anything, and they sent her back. They didn't get any paperwork from the ER visit and she is trying to get it. During an interview 10/31/24 at 3:30 PM, Staff F, Assistant Director of Nursing (ADON) reported when staff called to set up an appointment at the University hospital, they often got a recording to wait 5 to 7 days and then call back for a referral. The recording also directed the caller to stay on the line to talk to someone if it had been after 7 days. Staff F reported Resident #1 complained about something every day. If the nurse inquired about what hurt or asked her if a certain area hurt such as her abdomen or another area, she always told the nurse yes. Staff F stated you don't know with her, it's something new every day. Resident #1 could tell the nurse whenever she had pain too. Resident #1 saw a number of specialists. She had a lot of complaints about having pain. She took Lyrica and used to take tramadol but when they switched providers, they discontinued the tramadol. She is not on Tylenol due to a history of cirrhosis. They just got a new order for ibuprofen. She also had Orajel (pain medicine applied to the gums), lidocaine, and magic mouthwash (a mouthwash with lidocaine to ease pain) for her mouth pain. Resident #1 had to ask for medication when she needed them. Staff F reported assessments and pain assessments documented in a focused evaluation on the computer under the evaluations tab. They reviewed the Care Plan quarterly and updated it with things such as pain. Staff F reported pain is different for different people so no set rate or goal for pain level, as pain is resident specific. A Change in a Resident's Condition or Status policy revised [DATE] revealed the facility promptly notify the resident, their attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident attending physician or the on call physician when they to transfer the resident to a hospital/treatment center. An Orders for Consultants policy revised September 2017 revealed residents will receive appropriate and timely consultations when needed. A Resident Examination and Assessment policy revised February 2014 revealed the physician notified of any abnormalities such as, but not limited to worsening pain as reported by the resident. A Pain Assessment and Management policy revised March 2020 revealed the procedure to help the staff identify pain in the resident, and to develop interventions consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes recognizing the presence of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, monitoring the effectiveness of interventions, and modifying approaches as necessary. The policy also revealed to ask the resident if he/she is experiencing pain and be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, or numbness/tingling. Prolonged, unrelieved pain despite Care Plan interventions reported to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1 out of 3 residents was transferred properly per the resident's Care Plan (Resident #1). The facility failed to provide assistance of 1 Nursing Staff to transfer the resident in and out of the facility's transport van, resulting in a fall with injury. An untrained driver attempted to transfer Resident #1 into the van when her leg gave out. The facility reported a census of 74 residents. Findings Include: A Minimum Data Set (MDS) Assessment Tool dated 8/1/22, documented that Resident #1's diagnoses included history of fracture, arthritis and diabetes. Resident #1 documented with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The resident identified needing limited assist of 1 staff for transfers. A Care Plan for Resident #1 had a focus area revised on 10/11/21, which directed staff that Resident #1 was at risk for falls. She had several back surgeries and had back pain. She had two left shoulder surgeries and continued to have pain in her left shoulder and back. She was non-compliant with waiting for assistance with transfers, as she didn't like to wait more than a few minutes. Resident #1 voiced no desire to ambulate with all of her arthritis and back/shoulder problems. She had no desire to participate in a Restorative Program since in too much pain. The Care Plan had a goal revised on 8/15/22, which documented Resident #1 would have no injury related to fall. An intervention dated 6/11/21, directed staff to transfer this resident with assist of one, wheelchair pivots.(assist resident to stand and pivot into and out of wheelchair). An Incident Report dated 10/20/22 at 10:59 a.m., documented the resident was stepping up on a curb at another facility and her leg gave out, the resident lost her balance and the Van Driver lowered the resident to the ground. It documented this resident was not taken to the hospital. A Progress Note dated 10/20/2022 at 11:45 p.m., documented that Resident #1 transferred to Emergency Department (ED) around 6:50 p.m A staff member at the ED called the facility and stated Resident #1 was being admitted related to an urinary tract infection (UTI) and pneumonia. On 12/19/22 at 3:30 p.m., the Administrator and the Director of Nursing (DON), stated Resident #1 required assistance of 1 staff to transfer. They stated that the Van Driver failed to assist the resident to transfer and was not trained to transfer the resident. They stated Resident #1 was transferring back into the van after visiting a resident at another facility when her leg gave out and the Van Driver eased her to the ground. Both reported the resident did not tell the driver that she needed assistance when transferring. On 12/20/22 at 4:24 p.m., Resident #1 stated she remembered the fall well. She stated that the Driver helped her get into the van at the facility and out of the van at a local facility, then back into the van from the local facility and out of the van when they arrived back to the facility. Resident #1 explained she was trying to get into the van and her leg gave out and never knows when that was going to happen. She stated the Driver was behind her and helped her to the ground. When asked if he assisted her to transfer from her wheelchair (W/C) into the van, she stated he had her walk from the facility in which she was visiting back to the van as he had parked the van near the curb. She stated the driver had her sit up front as he thought it would be easier that way. She stated he had her do the same thing the week before. When asked if she normally walks or transfers independently, she stated no. When asked how long it had been since she had transferred independently, she stated it had been a very long time. She stated that the van accommodates a wheelchair. She reported she hadn't been in the van for over a year, but the last time she went in the van was to another city and she rode in her wheelchair all the way there. Resident #1 stated she preferred to ride in the van in her wheelchair and it was difficult for her to get up into the van. The resident stated she did not want to get this driver in trouble. On 12/21/22 at 10:59 a.m., Staff A, Van Driver, stated he had taken Resident #1 before to another facility as she had a cousin there. He stated he thought this was around 3 weeks to 1 month prior to the day that she fell. Staff A stated on the day of the fall he had put Resident #1's foot pedals on her wheelchair (W/C) and then pushed her out to the van. Staff A stated Resident #1 then got up into the van, he put the W/C in the van and drove Resident #1 to the other facility. Staff A then got the W/C out of the van and brought it to the van door and Resident #1 transferred herself into the W/C. Staff A stated he did not have to help the resident transfer at all and he had only showed Resident #1 where the bar was inside the van to grab a hold of when she was getting into the van. Staff A stated the resident was waiting at the door in her wheelchair both times he took her to the other facility. Staff A explained the van had 2 spots that could be buckled down with a resident in his or her wheelchair. Staff A reported that he had taken Resident #1 on a trip before and she transferred into the van by herself. It was probably 3-4 months before this incident. Staff A stated he normally was in contact with the nurse in charge if he had any questions about transferring a resident. Staff A stated this incident was partially his fault. He stated he had taken Resident #1 on a trip before and they had gone to a different city. He stated on that trip there were 2 Certified Nurse Aides (CNA's) that went along. He stated the CNAs had assisted with getting the residents going on that trip into the van and assisted getting Resident #1 in and out of the van. He stated when the other facility that was in town trips came up, he just remembered that Resident #1 wasn't in her wheelchair for the trip they had went on to another city. In hindsight, Staff A stated he realized that the CNAs were there to help with the transfer. Staff A stated he should have checked with the Charge Nurse to see how Resident #1 transferred. Staff A stated that Resident #1 and he did not have a conversation with the local trips about how she transferred. Staff A stated he had just assumed that she could transfer. He reported when he picked her up from the local facility he had pulled the van up so she could get into the passenger side. He explained there was like a metal running board piece that she stepped on to get into the van. He stated Resident #1 then put her other leg into the van, and one of her legs gave out. Staff A was not sure which leg gave out but he guessed it was the one leg on the running board because that's where most of her weight would have been. Staff A stated he then grabbed a hold of Resident #1 from behind as he was standing behind her when she was getting into the van. Staff A said he asked this resident what she wanted him to do and she said just put her down on the ground and then go get a nurse or someone to help from the local facility she had visited. He stated he lowered her to the ground and then went and got help from the facility that this resident was visiting. He stated the transfer back into the vehicle was a little rough because she said the leg that gave out on her was hurting. Staff A stated the person who had came out to help transfer this resident back into the van had a gait belt. He stated he did not help Resident #1 into the van. Staff A stated the only help that he did was to hold the door open and then he moved the wheelchair out of the way. Staff A then drove back to the facility, went into the building and got a CNA. Staff A stated the CNA came out and transferred Resident #1 into the wheelchair utilizing a gait belt. Staff A did not believe this resident complained of any more pain. He stated he got her back to her room in her wheelchair. He stated the next time he heard anything about her complaining of pain was a day or two later. Staff A stated he went directly to a Charge Nurse when they had returned to this facility to let the nurse know what happened and they had him fill out an Incident Report. Staff A stated he had told the nurse that Resident #1 didn't really fall, but the nurse said yes, but it is still considered a fall. Staff A stated the facility had several meetings after this incident and implemented a Sign Out Sheet and a piece of paper that is written down how a resident transfers. Staff A stated he had never transferred anybody, and it is not in his job description. He stated he was not licensed to do so and he can just put the W/c onto the lift and into the van, that's all he can do. In a Hospital Discharge summary dated [DATE], documented Resident #1 admitted on [DATE] and was discharged on 10/24/22. The Discharge Summary documented the resident admitted for acute respiratory failure with hypoxia. The Summary documented the resident was confused during the ER visit and the resident reported she had a fall while visiting a friend but did not hit her head or lose consciousness. The Summary documented that an x-ray of her left leg middle thigh showed a possible hematoma (bruise), and a new T 9 (thoracic vertebrae) compression fracture and possible UTI. The Summary showed the resident was treated inpatient for UTI and did have an abnormal Computed Tomography (CT) Scan of the chest with a compression fracture involving the T 9 as well as a chronic T 12 fracture and possible left thigh small hematoma. The Summary documented the resident's pain was much better than it was on admission and she was ready for discharge. A Safe Lifting and Movement of Residents Policy revised on 7/2017, directed the following: a. In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: a. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. b. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the Care Plan. Such assessments shall include: a. Resident's preferences for assistance. b. Resident's mobility (degree of dependency). c. Resident's size. d. Weight-bearing ability. e. Cognitive status. f. Whether the resident is usually cooperative with staff. g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Safe lifting and movement of residents is part of an overall facility Employee Health and Safety Program, which involves the following: a. Employees in identifying problem areas and implementing workplace safety and injury-prevention strategies. b. Addresses reports of workplace injuries. c. Provides training on safety, ergonomics and proper use of equipment. d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. The facility corrected the deficient practice on October 28, 2022 by conducting training and education to the Nursing Staff and any personnel involved in transporting residents, as well as updated the process to improve communication between Nursing and the Van Drivers to improve sharing of transfer status information when a resident needed to be transported. Because the facility corrected the deficient practice prior to the Facility Self-Reported Incident investigation, the situation was identified as Past Non-Compliance.