**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, physician interview, physician assistant interview, policy review, and the National Library of Medicine review, the facility failed to provide assessments and interventions timely with a change in resident condition for 1 of 3 residents (Resident #3). The facility also failed to comprehensively care plan the need for assessment of impaired circulation following a history of a great toe amputation in June of 2025 which lead to the skilled placement at the facility. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident. The facility reported a census of 37 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/6/25 at 9:50 AM. The IJ began on 8/3/25, when the resident exhibited an increase in her level of pain, along with a change in her activities of daily living (ADL) functional ability. Facility staff removed the IJ on 8/7/25 through the following actions:-Resident # 3 was transferred to the local hospital on 8/4/25 with a diagnosis of critical limb ischemia RLE. A thrombectomy was conducted to improve blood flow. Amputation was discussed with resident. -Residents with atherosclerosis, intermittent claudication and recent amputations and signs of DVT are at risk. All other residents diagnosis' were reviewed by nurse manager on 8/7/25 and no other residents present with signs or symptoms of ischemia. -All residents will be assessed at the time of noted changes with notifications to the physician for further direction/orders. All orders will be followed as provided. Nurses educated on 8/7/2025 by Nurse manager on the symptoms of DVT and circulatory assessments. A quiz was completed by all nurses after education to show understanding. No nurse will work until completing education and quiz. Education will be provided to all Certified Medication Assistants to interview resident for pain level prior to giving a prn and to report to charge nurse resident observed status and level of pain each time a PRN analgesic is given, nurse to assess as needed for any changes or concerns. Education done on 8/7/25 by Nursing Management, no medication assistant will work until education is completed. Quiz for understanding will be completed. Oversight will be provided each business day by the nursing management team to review any changes in resident status and ensure that appropriate assessments and documentation are completed and ongoing as necessary with updates to the physician and responsible party.-All residents will be assessed for signs and symptoms of DVT or atherosclerosis. This will be completed 8/7/2025 by nursing. Any residents with a known history of DVT or atherosclerosis will have circulatory assessments twice daily until face to face visit with physician. If symptoms present doctor will be notified immediately for further direction. This will be implemented 8/7/2025 by nursing.-Resident #3 will be assessed upon return from hospital and care plan updated as needed to provide individualized care. This will include physical and psychosocial needs. -An ad hoc QA meeting held 8/7/25 to review the care of this resident and action plan for education and care going forward.-Daily oversight will be completed each business day M-F beginning 8/8/24. Audit of circulatory assessments will be completed daily x5 days and weekly x3 with results taken to QAPI for further review and recommendation.The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #3 scored 15/15 on the Brief Interview for Mental Status (BIMS) score indicating normal cognitive function. The document revealed diagnoses of amputation, coronary artery disease, atherosclerosis native arteries of extremities with gangrene right leg, atherosclerosis native arteries of extremities with resting pain right leg, atherosclerosis native arteries of extremities with resting pain, left leg, presence of other vascular implants and grafts, occlusion and stenosis of right carotid artery, and congenital renal artery stenosis. The MDS noted the resident took antidepressant, anticoagulant, antibiotic, opioid, antiplatelet, and anticonvulsant medications. The document recorded the resident receiving scheduled and as needed (PRN) pain medication, and no non-medication interventions for pain during the last 5 days of the assessment period. The MDS reflected that the resident required partial/moderate assistance for toileting, sitting to/from standing, transfers and utilized a walker and wheelchair. The Care Plan with the initiated date 8/6/25 revealed a focus area related to impaired circulation related to Atherosclerosis of Native Arteries of right and left legs, Peripheral Artery Disease, exhibited by recent Bypass graft to right (R) and left (L) Femoral popliteal arteries was initiated on 8/6/25. The goal of being free from signs/symptoms of complications of poor circulation through the review period was initiated on 8/7/25. Interventions for staff included observing fingers and lower extremities/stumps for pedal pulses, pain, edema, sensation, movement, temperature and color routinely and notify the nurse of any changes and the nurse to immediately notify the primary care provider (PCP) and document abnormal observations in progress notes. The Care Plan lacked any focus area or directions for staff related to impaired circulation prior to 8/6/25.The Care Plan provided a focus area of the resident being on opioid therapy related to post-surgical pain initiated and revised on 6/13/25. The interventions for staff included observe/record/report to the nurse any signs/symptoms of non-verbal pain: (SPECIFY: Changes in breathing (noisy, deep/shallow, labored, fast/slow), vocalizations (grunting, moans, yelling out, silence), mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion), face (sad, crying, worried, scared, clenched teeth, grimacing) and body (tense, rigid, rocking, curled up, thrashing). A focus area of the resident being on anticonvulsant medication therapy related to chronic neuropathic pain initiated and revised on 6/13/25 provided an intervention to monitor the resident condition based on clinical practice guidelines or clinical standards of practice related to use of Gabapentin. A focus area related to acute pain/discomfort related to the incision to groin and right lower extremity (RLE) initiated and revised on 6/13/25 provided interventions to notify the health care provider if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain, the resident was able to notify staff of pain, rate pain level on 0-10 scale, request intervention and report effectiveness of intervention, and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion (ROM), and withdrawal or resistance to care with an initiation/revision date of 6/13/25. An activities of daily living (ADL) self-care performance related to RLE bypass graft and pain focus area dated 6/13/25 provided staff interventions of ambulation in room with staff assistance and 1 assist with gait belt and front wheeled walker to transfer.The clinical record lacked documentation pertaining to non-pharmacological interventions related to pain.The Wound Data Collection -V2 dated 8/3/25 at 1:10 PM for the unstageable right (R) heel ulcer revealed there were no signs of complications or resident complaint of pain. There was no specific documentation related to a circulatory assessment. The Wound Data Collection -V2 dated 8/4/25 at 1:38 PM for the right groin incision revealed the right lower extremity (RLE) was purple, cold to touch and the resident had extreme pain.The Wound Data Collection - V2 dated 8/4/25 at 1:45 PM for the unstageable R heel ulcer revealed the RLE was purple, mottled, no pedal pulse and the resident had extreme pain in the entire RLE.The Wound Data Collection - V2 dated 8/4/25 at 1:52 PM for the right great toe amputation revealed the RLE was purple, mottled, cold to touch, the resident had extreme pain and was provided pain medication. The Pain Level Summary reviewed from 7/8/25 to 8/4/25 revealed 5/136 entries of the resident having complaints of 10/10 pain. The dates recorded with follow up pain levels included: 7/13/25 at 6:51 PM pain at 10/10 with an entry at 8:07 PM of pain at 5/10 7/14/25 at 2:21 AM, pain at 10/10 with an entry at 8:56 AM of pain 4/10 7/17/25 at 8:30 PM with pain at 10/10 with an entry at 10:12 PM of pain at 0/10 7/24/25 at 6:48 PM with pain at 10/10 with an entry on 7/25/25 at 4:18 AM of pain at 0/10 8/3/25 at 2:35 PM with pain at 10/10, follow up pain level of 10/10 around 4:00 was not documented. The Clinical Physician Orders printed 8/11/25 provided Resident #3 was prescribed: -Acetaminophen Extra Strength Tablet 500 mg 2 tablets every 8 hours PRN for pain not to exceed 3000 mg - start date 7/8/25 -Gabapentin Oral Capsule 100 mg 3 capsules three times a day (TID) for Atherosclerosis of Native Arteries of Extremities with Rest Pain, R leg, Atherosclerosis of Native Arteries of Extremities with Rest Pain, L leg - start date 7/14/25 -Lidocaine Patch 5% apply to affected area topically 1 time a day (QD) for pain - start date 7/9/25 -Lidocaine Path 5% apply to remove patch topically at bedtime for pain - start date 7/8/25 -Oxycodone HCL Oral Tablet 5 mg 1 tablet every 4 hours PRN for pain - start date 8/3/25 The Medication Administration Record (MAR) - Treatment Administration Record (TAR) 8/25 with the Pain Level Summary revealed Resident #3 was provided the following PRN medications and treatment related to pain management from 8/1/25 - 8/4/25: -8/1/25 at 2:23 PM Oxycodone HCL 5 mg 1 tablet every 6 hours PRN for pain (discontinued on 8/3/25) with pain 4/10. -8/1/25 at 3:24 PM pain 0/10 -8/1/25 at 9:20 PM Oxycodone HCL 5 mg 1 tablet every 6 hours PRN with pain 7/10 -8/1/25 at 10:31 PM pain 2/10 -8/3/25 at 11:23 AM Lidocaine Patch 5% bottom L foot -8/3/25 at 11:24 AM Oxycodone HCL 5 mg 1 tablet by mouth every 6 hours PRN with pain 5/10 -8/3/25 at 12:40 PM pain level 2/10 -8/3/25 at 1:21 PM Acetaminophen Extra Strength 500 mg 2 tablets with pain 7/10 -8/3/25 at 2:35 PM Oxycodone HCL 5 mg 1 tablet 1 time only for uncontrolled pain for 1 day (start 8/3/25 2:35 PM) with pain 10/10 -8/3/25 at 7:25 PM pain level 3/10 -8/4/25 at 2:14 AM Acetaminophen Extra Strength 500 mg 2 tablets with pain 5/10 -8/4/25 at 5:04 AM pain level 1/10 -8/4/25 at 8:25 AM OK to send to emergency room (ER) for uncontrolled pain/evaluation of numbness to RLE one time only for pain/numbness for 1 day (start date 8/3/25 2:45 PM) -8/4/25 at 8:26 AM pain level 0/10 -8/4/25 at 8:30 AM Oxycodone HCL 5 mg 1 tablet every 4 hours PRN with pain 4/10 -8/4/25 at 10:20 AM Acetaminophen Extra Strength 500 mg 2 tablets with pain 4/10 The Progress Notes dated 8/3/25 - 8/5/25 revealed the following entries:-8/3/25 at 11:24 AM Oxycodone HCL 5 mg -8/3/25 at 12:40 PM Pain medication was effective pain 2/10-8/3/25 at 1:21 PM Acetaminophen Extra Strength 500 mg 2 tablets. Resident crying, rubbing on R calf.-8/3/25 at 2:30 PM call placed to on-call physician informing of uncontrolled pain, numbness to the R calf. The resident had been provided PRN Oxycodone and Tylenol with no effectiveness. A new order was received for Oxycodone 5 mg now, to increase frequency to every 4 hours, and to send to the emergency room (ER) if pain continues to be uncontrolled, numbness continues to RLE. -8/3/25 at 2:35 PM Oxycodone HCL 5 mg 1 tablet-8/3/25 at 7:25 PM Acetaminophen Extra Strength 500 mg 2 tablets; follow up pain 3/10 and ineffective.-8/4/25 at 2:14 AM Acetaminophen Extra Strength 500 mg 2 tablets -8/4/25 at 5:04 AM PRN administration follow up pain 1/10 and effective. -8/4/25 at 8:30 AM Oxycodone HCL 5 mg 1 tablet-8/4/25 at 9:53 AM PRN administration follow up pain 0/10 and effective.-8/4/25 at 10:20 AM Acetaminophen Extra Strength 500 mg 2 tablets-8/4/25 at 10:30 AM Leg purplish/red in color, cold to touch and no palpable pedal pulse.-8/4/25 at 10:34 AM sent to ER due to RLE being cold to touch.-8/4/25 at 10:38 AM PRN administration follow up pain 4/10 and ineffective.-8/4/25 at 10:39 AM hospital surgical department requesting medication administration record as the resident was going into a surgical procedure to attempt to restore blood flow to RLE.-8/4/25 at 12:33 PM call from ER the resident transferred to a different hospital for Critical Limb Ischemia RLE with no circulation in leg.-8/4/25 at 2:00 PM entry for Transfer to the Hospital Form completion.-8/5/25 at 9:48 AM hospital contacted and a thrombectomy was performed to restore blood flow, with potential amputation in the future. The Point of Care Document Dressing revealed: -8/3/25 8:41 AM independent (no help or staff oversight)-8/3/25 8:05 PM limited assistance (resident highly involved)-8/4/25 8:41 AM total dependence (full staff performance) The Point of Care Document Walk in Room revealed: -8/3/25 8:41 AM (independent)-8/3/25 3:46 PM activity did not occur-8/4/25 8:41 AM extensive assistance The Point of Care Document Personal Hygiene revealed: -8/3/25 8:41 AM independent -8/3/25 3:45 PM independent -8/4/25 8:41 PM total dependence The Point of Care Document Transfers revealed: -8/3/25 8:41 AM independent -8/3/25 3:46 PM limited assistance -8/4/25 8:41 AM extensive assistance The Shift Exchange Documents for 8/1/25 - 8/4/25 disclosed for Resident #3: -8/1/25 Overnight OK -8/1/25 AM pain pill at 2:21 PM -8/2/25 Overnight OK -8/2/25 AM OK -8/2/25 PM OK -8/3/25 Overnight OK -8/3/25 AM 11:25 Oxy, 1:20 PM Tylenol -8/3/25 PM 2:36 PM oxy - new verbal order for increased frequency of Oxy 5 mg to every 4 hours and OK to send to ER if pain remains uncontrolled or numbness to right calf/leg. -8/4/25 Overnight can't stand up will fall -8/4/25 AM pain pill at 8:30 AM, sent to ER, admitted . The Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form (eINTERACT) dated 8/4/25 revealed the resident was transferred to the hospital at 1:58 PM. The document provided a report was called into the hospital at 10:00 AM with the resident's most recent pain medication of Oxycodone HCL 5 mg on 8/4/25 at 8:30 AM. The vital signs provided on the document revealed the last set of vitals was completed on 7/29/25, and pain level was 4/10 on 8/4/25 at 10:38 AM. The document lacked documentation pertaining to the Acetaminophen Extra Strength 500 2 tabs that was provided at 10:20 AM, and the completion of a current set of vitals. The Hospital Medical Record for 8/4/25 revealed Resident #3 arrived at the hospital on 8/4/25 at 11:02 AM via a wheelchair from the facility with chief complaints of right lower leg vein bypass, right big toe amputation, and the resident stating pain had started the previous day, pain was 10/10, sharp and throbbing, the right foot was cool to the touch, and no pedal pulse was found. The document provided the pain was first reported around 2:00 PM on 8/3/25 with orders for additional pain medication provided as ordered. The document reflected that the resident stated that pain continued through the night and into the morning of 8/4/25. The document disclosed the resident stated the RLE is painful, numb, unable to put weight on it without feeling that her leg was collapsing under her. The document's Physical Exam revealed: -The resident's right leg was cool and mottled compared to the left leg extending to just proximal to the knee.-There was neither a Dorsalis Pedis Artery Pulse or Posterior Tibial Pulse obtained by palpation or by Doppler.-The toes were very pale with no cap refill. -A wound VAC was in place at the right groin.-The resident presented with a peripheral heart rate of 73, respirations of 18, blood pressure 184/85 (high). A contrast enhanced computerized tomography scan (CT scan) angiogram of the abdomen and pelvis with bilateral lower extremities dated 8/4/25 recorded: -Occlusion of the R common iliac, internal and external iliac arteries.-Occlusion of the superficial femoral artery bypass graft. The hospital reported that due to the life-threatening nature of the resident's medical problem and the likely delay using ground transportation, air transport was arranged and the resident would go directly to the preop area of the hospital where the Vascular Surgeon practiced. On 8/6/25 at 11:54 AM Staff A, Registered Nurse (RN), stated Resident #3 began complaining of major pain with crying behavior and numbness in the RLE around 2:00 PM on 8/3/25. The staff stated the resident's skin color at the front of the calf where reporting pain was red in color, and a faint pulse was detectable. The staff stated the resident reports of pain previously had been vague, and she had never seen the resident cry with pain even with wound VAC changes. The staff stated she contacted the On-call Physician regarding the uncontrolled pain and not due for another PRN Oxycodone, as well as numbness of the RLE. The staff stated orders were received for a 1 time dose of Oxycodone, increased the frequency of the PRN Oxycodone to every 4 hours from every 6, and to send the resident to the hospital if the uncontrolled pain and numbness continued. The staff stated she did not document in the Progress Notes the resident's crying behavior related to the pain or the complaints of numbness in the RLE, as it was time for shift exchange and she thought she had helped out by calling the physician and getting the new orders. Staff A stated she gave a report to Staff E, RN, and Staff D, Certified Medication Aide (CMA), if the pain medication was not effective or continued numbness there was an order to send the resident to the ER. Staff A indicated that looking back, she wished she would have stayed versus leaving and followed up on the resident's pain since she was crying or even sent the resident to the ER right away. On 8/6/25 at 12:30 PM, Staff B, Certified Nurse Assistant (CNA), stated when she dropped off Resident #3's lunch tray on 8/3/25 the resident had her RLE propped up, complaining of pain, and crying. The staff stated the resident crying with pain was abnormal behavior. The staff stated she recalled the resident having an infection in the lower extremity and did not cry with pain. Staff B stated she contacted Staff A regarding the resident's behavior and complaint of pain. The staff stated when she returned to pick up the resident's tray, it was in the hallway and she heard Staff A state she was sending a fax out to the physician. On 8/6/25 at 12:35 PM, Staff C, CNA, stated the resident began complaining of pain and crying in the afternoon on 8/3/25. The staff stated the resident required more assistance than her normal for transfers in the afternoon on 8/3/25. Staff C stated the resident typically required limited assistance and would self transfer independently, but in the afternoon the resident required moderate assistance. Staff C stated Staff A left around 3:30 PM on 8/3/25 and Staff C took over as the nurse. On 8/6/25 at 12:58 PM Staff D stated she was notified by Staff A of the verbal order for a 1 time dose of Oxycodone HCL 5 mg for pain in the RLE. The staff stated the resident had been crying at the time of the medication dispensing which was unusual for the resident. The staff stated when she returned to the resident around 4:00 PM for medication administration the resident stated her RLE continued to hurt at 10/10 but no longer felt as though someone was stabbing her leg. The staff stated she spoke with the resident again later at an unspecified time, the resident was sitting up and continued to complain of pain. The staff stated she told Staff E if the pain was persisting the resident could be sent to the ER. On 8/6/25 at 1:27 PM the On-call Physician stated he recalled receiving a call from the facility regarding Resident #3 and the resident being anxious and having increased pain. The Physician stated he could not recall if the nurse reported a change in the resident's behavior with crying that was out of the ordinary. The On-call Physician stated he was aware of the resident being in the facility for lower extremity intervention and post-operative care. The Physician stated he was told the resident was on routine pain medications, had taken what was prescribed, and asked for additional medication. The On-Call Physician agreed to provide a 1 time dose of Oxycodone, change the frequency of the PRN Oxycodone medication, and told the nurse if there was any change in the RLE assessment or if the pain medication was not effective the resident needed to go to the hospital. When asked if 10/10 pain at 4:00 PM would be a concern when the additional dose of Oxycodone was provided at 2:30 PM, the On-Call Physician indicated the resident should have gone to the hospital. On 8/6/25 at 2:10 PM Staff E, Registered Nurse, confirmed she worked on 8/3/25. The staff stated she had no contact with Resident 3# as that was not her normal hallway to work. The staff stated she always goes down to listen to the shift exchange report, but did not recall any details about the resident. The staff stated Staff A was on shift until 6:00 PM when the overnight staff came on duty. On 8/6/25 at 2:20 PM the MDS Coordinator stated she completed an assessment on Resident #3 around 10:30 AM on 8/4/25 due to contact by the Wound Care Nurse/LPN stating the resident was crying with pain. The staff stated she requested the Social Services Supervisor/RN to accompany her to assess the resident. Prior to assessing the resident, the staff stated she read the MAR - TAR, saw the orders for sending the resident to the ER, and instructed Staff G to begin the transfer process. The MDS Coordinator stated the resident's RLE present with red/purple color, cold to touch, and no pedal pulse. The staff stated she put her assessment in the Progress Notes, but did not do a formal assessment. The staff reported documentation of the assessment would also be in the SNF/NF Transfer to Hospital Transfer Form dated 8/4/25. When reviewing the document, the MDS Coordinator acknowledged the completion of the document indicating the resident transferred at 1:58 PM when the resident had actually left the facility around 10:34 AM. The staff stated she was unsure if this document was available for the ER review when a resident was transferred from the facility. The MDS Coordinator admitted there was no documentation regarding any assessments on the resident's RLE despite the order from the physician stating to transfer the resident to the ER for uncontrolled pain/evaluation of numbness to the RLE. The MDS Coordinator stated that given the resident's diagnoses assessments should be completed at least once a shift and documented. On 8/6/25 at 2:40 PM the Social Services Supervisor/RN confirmed the Director of Nursing (DON) was on vacation. The staff confirmed she was present with the MDS Coordinator on 8/4/25 when the assessment took place, but could not provide a time except it was after 9:00 AM. The staff acknowledged that Resident #3 was provided a 1 time dose of Oxycodone on 8/3/25 at 2:35 PM, and there was no pain assessment or follow up regarding the pain documented in the clinical record. The staff stated she expected there to be a pain level follow up to ensure the effectiveness of the medication. The staff stated assessments should be completed once per shift and documented. The staff acknowledged there was no documentation of assessments in the Progress Notes. The staff stated Staff A clocked out at 3:11 PM despite being on the schedule until 6:00 PM. The Social Services Supervisor/RN stated it was not uncommon for a nurse to do that if their job duties were done, there was a CMA covering that area, and another nurse on the floor. On 8/6/25 at 2:47 PM Staff F, Wound Care Nurse/Licensed Practical Nurse (LPN), stated when she entered Resident #3's room on 8/4/25 in the morning the resident was crying and complaining of pain in the RLE. The staff stated she obtained Tylenol from Staff G, Registered Nurse (RN), and provided it to the resident. The Wound Care Nurse/LPN stated she could not recall Resident #3 crying previously with pain during treatments. The staff stated she did not consistently complete an assessment that included checking for a pedal pulse when doing the resident's wound care. The staff stated she could not recall a lot about the resident's pedal pulse as she did not complete the admission assessment but felt the pulse was good. The staff could not state what the pulse was like most recently. On 8/6/25 at 6:02 PM Staff G confirmed she worked on 8/4/25. The staff stated she was aware of the resident's order to go to the ER if she had uncontrolled pain and/or numbness in the RLE. The Staff stated the resident complained of pain around 8:00 AM and was provided her PRN Oxycodone. The staff stated a short time later the Wound Care Nurse/LPN contacted her about the resident requesting additional pain medication. Staff G stated as it was too early for additional Oxycodone, PRN Tylenol was dispensed, and provided to the Wound Care Nurse/LPN to provide to the resident. The staff stated she was then contacted by the Administrative Nurse to prepare to send the resident to the hospital as her leg was really cold. Staff G stated she did not recall Staff H, LPN, saying anything about the resident's RLE during shift exchange. The staff stated she discovered the order by reading the TAR as she does every time she comes on shift to ensure knowledge about residents' orders as she only worked 3 days/week. The staff stated she did not do assessments of the RLE on a routine basis unless the resident was complaining of pain. The staff stated if she did an assessment and the resident was skilled she would probably put it on the Skilled Assessment Note. Staff G responded if the resident was not skilled she would put the assessment on the Skin Assessment under the User Defined Assessments (UDAs) if there was something out of the ordinary. The staff continued if it was normal she might put something in the Progress Notes but nothing extensive. The staff stated there was no indication to do pedal pulse assessment. On 8/7/25 at 9:31 PM Staff H confirmed she was the overnight shift staff for 8/3/25 to 8/4/25. The staff stated she was not told anything during the shift exchange report regarding Resident #3 from Staff E. Staff H stated she did not recall anything specific to Resident #3 on the Shift Exchange Document. The staff stated the resident did require pain medication overnight, but that was not uncommon. The staff stated the resident had not cried during her previous shifts when requesting pain medication. The staff stated she was not aware of an order to send the resident to the ER for uncontrolled pain/evaluation of numbness to the RLE. Staff H stated she did not bring anything up to Staff G during the shift exchange on the morning of 8/4/25 as she did not know of the order. On 8/7/25 at 12:00 PM Staff A stated Staff E was aware of the staff leaving early and was the only nurse on the floor. The staff stated during shift exchange on 8/3/25 Staff E asked Staff A to make sure the conversation/order from the physician was written on the Shift Exchange Document. The staff stated she documented the contact with the physician and orders on the Shift Exchange Document. Staff A stated she was really upset that staff had not taken care of the resident, and felt she had done all she could at the end of her shift by calling the physician and getting orders due to the resident's significant complaints of pain and crying behavior. On 8/7/25 at 3:50 PM the Physician Assistant (PA) for the Vascular Surgeon stated Resident #3 had a through the knee amputation on 8/7/25. When asked if sending the resident to the hospital on 8/3/25 instead of 8/4/25 would have made a difference, the PA replied the resident would not have had to suffer as many days in significant pain as the thrombectomy would have been completed sooner as the resident did go immediately into surgery upon admission to the hospital, and the resident had relief from the pain following the procedure. On 8/13/25 at 4:40 PM Staff I, CNA, confirmed she provided care to Resident #3 on the night of 8/3/25 to 8/4/25. The staff stated during that shift the resident turned her call light on and requested to be changed. Staff I disclosed she completed care in bed as the resident was complaining of pain in the RLE. The staff voiced she was careful with moving the resident in bed due to the resident's complaints of pain. Staff I stated Resident #3's normal behavior was to turn her call light on, request to use the bathroom and be changed in the bathroom; the resident's behavior on 8/3/25 to 8/4/25 was outside of her normal behavior. The staff stated the nurse had also been in the resident's room that night to provide pain medication due to the resident's pain in the RLE. The facility policy titled Nursing Documentation Guidelines, Timelines - Rehab/Skilled reviewed/revised 5/7/25 revealed a purpose of systematically and continuously collecting information about the health status of a resident and to ensure appropriate documentation is completed in a timely manner. The document provided that if a change in condition was identified in a resident the nurse would use an eINTERACT Change in Condition Evaluation to collect the data prior to communicating with the medical provider. The document disclosed day-to-day documentation of specific occurrences would be completed in the Progress Notes. The National Center for Biotechnology Information, a service of the National Library of Medicine, National Institutes of Health, revealed the onset of action for Oxycodone is 10 to 30 minutes for immediate-release formulation and 1 hour for the controlled release. The plasma half-life is 3 to 5 hours, and stable plasma levels are reached within 24 to 36 hours. The duration ranges from 3 to 6 hours for immediate release or 12 hours for controlled release.