**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2561232. Based on interview and record review the facility failed to timely and appropriately assess a new onset leg pain for one Resident (R901) of three residents reviewed for quality of care, resulting in R901 experiencing prolonged signs and symptoms of severe pain with subsequent hospitalization to address the pain. Findings include:On 7/23/25 at 12:52 p.m. the complainant was contacted regarding the allegations reported to the state agency. The complainant said on 7/7/25 approximately at 2:45 p.m., R901 could be heard screaming through the hall while receiving care. The hip area was observed by the complainant who stated, It looked like a bone was sticking out of the upper thigh. R901 was crying, screaming, and did not want the area touched. The nurse aid said the resident was complaining of pain to her right leg all weekend. The residents barely ate and didn't want to get out of bed. R901 told the complainant, I fell. The complainant also said they asked the day shift nurse to send the resident to the hospital and the nurse said an x-ray was needed before sending the resident out to the hospital. The nurse manager attempted to look at the leg, but the resident would not allow it and guarded the leg. The complainant said R901 was not sent out to the hospital until approximately 12:00 a.m. The hospital concluded that the resident had a hip fracture and required surgery. Review of the electronic medical record documented R901 was initially admitted into the facility on [DATE] and readmitted on [DATE]. R901 was discharged from facility to the hospital on 7/8/25 with diagnoses that included displaced fracture of upper right femur (7/6/25), neuropathy, non-Hodgkin lymphoma and Leukemia, stage 4 . According to the quarterly Minimum Data Set assessment dated [DATE], R901 was cognitively intact (BIMS-15) and required partial/moderate one-person assistance with self-care and mobility. Review of Pain care plan dated 11/22/24 documented the following:Focus: (R901) at risk for pain and has chronic pain related to Leukemia, history of Non-Hodgin's leg lymphoma Date Initiated: 11/22/2024.Goal: Will not have an interruption in normal activities due to pain through the review date.Interventions: Evaluate characteristics of pain on a scale of (SPECIFY 0-10); Observe for pain presence Q (every) shift as needed; Observe/record: resident complaints of pain or requests for pain treatment. Review of the radiology report dated 7/7/25 documented the following:Examination Date: 7/7/2025 20:59 (8:59 pm)- FINDINGS: There is a mildly displaced fracture of the proximal femoral (hip) diaphysis with apex medial angulation. The osseous margins of the fracture appear somewhat moth-eaten. CONCLUSION: Fracture of the proximal femoral diaphysis with imaging features which may suggest underlying lytic lesion/ pathologic fracture. Review of the nurse's progress notes documented the following: -7/5/2025 15:02 (3:02 pm) Nurses Notes Late Entry: Res is laying in bed alert and awake, c/o back pain yelling and crying.-7/6/2025 16:06 (4:06 pm) Nurses Notes Late Entry: Received res lying in bed alert and awake, c/o pain to lower back ,crying but not yelling loudly resident refused to turn she said she can't.-7/7/2025 14:50 (2:50 pm) Nurses Notes: Resident complaints of pain this shift Motrin and 2 Tylenol given for pain. Stat x-ray ordered; tramadol ordered q 6 hours prn for pain.-7/7/202514:53 Nurses Notes: Radiology notified of order for stat x-ray right femur.-7/7/2025 23:09 (11:09 pm) Nurses Notes: Rt femoral/hip x-ray performed, awaiting results. Prn pain medication is given for pain relief.-7/7/2025 23:23 (11:23 pm) Nurses Notes: Writer spoke with MD. MD ordered to transfer resident out to hospital. Review of the medication administration notes documented the following:-7/6/2025 20:38 (8:38 pm) eMar -Medication Administration Note: hip pain.-7/6/2025 21:48 (9:48 pm) eMar -Medication Administration Note: PRN Administration was: Ineffective resident states she is still in pain. Follow-up Pain Scale was: 4-7/7/2025 12:06 (12:06 am) eMar -Medication Administration Note: pain med given-7/7/2025 18:01(6:01 pm) eMar -Medication Administration Note: pain in right hip/leg. On 7/24/25 at 9:56 a.m. CENA E was interviewed. CENA E said while visiting R901 at the beginning of the day shift (7am-3:30pm), R901 was complaining of pain to the back and right side of the leg. CENA E was in the room with CENA B and the resident. CENA E said R901 always complained of back pain but not to the leg until that day. CENA B was attempting to give the resident care, but she cried out in pain every time she tried to move the resident On 7/24/25 at 10:15 a.m. the Social Service Director (SSD) C was interviewed and said on 7/7/25 approximately 12:00 p.m., upon arriving to the second floor, R901 could be heard screaming and wailing from the elevator and SSD's office which were in the front hall. The resident's room was in the back hall. CENA B requested SSD C to come to R901's room and look at the right leg. R901 was in severe pain and cried. The CENA B came to SSD C because the nurse was not available, and the resident had been in pain all weekend according to CENA B. SSD C said R901 was asked what happened to the leg. R901 reported to SSD C, The girl dropped me, the girl dropped me and hurt my leg. It happened the other day. SSD C said the resident was unable to give many details of the incident. On 7/24/25 at 10:43 a.m. CENA B was interviewed and confirmed caring for R901 over the weekend (7/5-7/6) during the dayshift. CENA B said care could not be given to R901 starting on Saturday (7/5), It was really bad, the resident was in so much pain and would not eat and I couldn't give care. The pain she was having in the leg was not usual. She kept it bent and could not put it down flat. She just cried and said she wanted to die. That's when I told the nurse (RN A). The nurse was in the front hall and the resident could be heard hollering the entire time. Me and the nurse went to the resident's room. The nurse gave her pain medication. I did not see the nurse assess the resident's leg pain before giving pain medication. The resident always had back pain but not in the leg. On Sunday (7/6) the resident was still in pain crying and not wanting me to touch the leg. The resident screamed and cried she didn't want to live anymore. Sunday was also the day I noticed her leg was swollen and I told the nurse (RN A). I decided on Monday (7/7) I was going to tell someone other than the nurse about the resident. I found the Social Worker and told what the resident went through over the weekend. Review of the investigation dated 7/7/25 documented CENA B stated, The resident was screaming in pain and would not let her turn or perform ADL care. I reported to the nurse this weekend that she seemed to have more pain. On 7/24/25 at 11:11 a.m. Registered Nurse (RN) A was interviewed and confirmed being the charge nurse for R901 on the weekend (7/5-7/6) on the dayshift (7am-7:30pm). RN A said R901 did not complain of hip pain at first but was heard screaming and yelling out in pain. Pain medication was given for back pain (chronic). The resident did say the right leg was hurting. It was looked at, but nothing was seen. RN A said the leg was not touched because the resident would not allow the nurse to touch it. The pain was thought to be referred pain meaning pain from the lower back to the leg. RN A said they did not think the resident's reported pain to the leg was factual. RN A did admit the leg pain was a new condition for the resident however did not assess the leg or inform the physician. RN A did not recall CENA B reporting leg pain, however, did report the resident was in pain and crying. RN A could not provide an explanation the reason the resident's leg pain was not documented in R901's medical record. On 7/24/25 at 11:44 a.m. the Director of Nursing (DON) was interviewed and said complaints of hip pain were unknown and knew the resident had chronic back pain. The DON said the resident did not have a fall based on the x-ray conducted on 7/7/25. The DON said it was concerning that R901 needed two- person assistance with turning when the resident required one- person assistance. The DON acknowledged that the resident's hip was not investigated until 7/7. The DON also acknowledged RN A should have documented the resident's hip pain. On 7/24/25 at 12:19 p.m. Unit Manager (UM) D was interviewed and said on 7/7 R901's right thigh area was observed to be swollen. The resident was crying out in pain and would not allow the area to be touched. CENA B reported over the weekend; the resident appeared to be in more pain than usual. RN A was spoken to but reported the resident's pain was normal. On 7/7, the resident's hip pain was considered a change in condition but could not say what happened over the weekend. UM D stated, The amount of pain she was in, I'm not sure how she could tolerate it for twenty-four hours. I can't say what another nurse should do, everybody does things differently, but for me, I need to see for myself, how else would I be able to tell what I saw. UM D said R901 stated, Two staff members were rough with me. Then the resident stated, I fell. Review of witness statements documented on 7/7/25 provided by multiple staff members denied the resident had a fall on their shifts. On 7/24/25 at 2:05 p.m. the Nursing Home Administrator (NHA) was interviewed and queried about the incident. NHA said the SSD C reported the resident was having leg pain and was dropped by staff. Staff interviews were conducted to find out if the resident had a fall over the weekend (7/6-7/7). NHA said the incident was not reported to the state agency due to not being certain there was an injury to report. The injury was confirmed once the x-ray results came back. The x-ray results reported the injury was not of unknown origins. The NHA said the resident screaming out in pain was not normal. On 7/24/25 at 2:24 p.m. CENA G was interviewed via telephone. CENA G confirmed working on 7/6 (Sunday) on the dayshift (7a-3:30pm). CENA G was not R901's nurse aide but assisted CENA B with giving R901 care. CENA G stated, That day, I helped her aide with getting her up. We could barely give her care because she was in too much pain and hurting bad. We could not get her up. Review of the witness statement given on 7/7/25, CENA G stated in part, Yes, she complains of pain daily. Yes, she complains of pain when being turned.Yes, the pain was more intense in the last two weeks. (CENA B) had her yesterday (7/6) and must have identified her leg was swelling. I helped (CENA B) change her because she was in pain. (CENA B) told the nurse (RN A). On 7/24/25 at 2:29 p.m. LPN H was contacted for a telephone interview. LPN H worked on the afternoon shift of 7/6/25 and documented R901 having hip pain and pain medication not effective. LPN H did not return call by the end of the survey. On 7/24/25 at 2:40 p.m. CENA I was contacted for a telephone interview. CENA I was the assigned nurse aide on the afternoon shift on 7/6/25. CENA I did not return call by the end of the survey. On 7/24/25 at 3:16 p.m. CENA F was interviewed. CENA F was confirmed working on the afternoon shift on 7/6/25. CENA F was not the assigned nurse aide for R901, however assisted CENA I with giving care. CENA F said the resident was in a lot of pain and said something about the leg. The resident could not be turned due to pain. The nurse (LPN H) gave the resident pain medication. The nurse was not observed conducting an assessment on the pain before or after giving pain medication. The resident always complained of back pain but not the leg. CENA F said the resident was crying and screaming. Review of the facility's policy titled Pain Management dated 3/5/25 documented in part the following: The facility will evaluate and identify residents for pain, determine the type, location and severity. A comprehensive evaluation of pain include: History of pain and its treatment; characteristics of pain, impact of pain on quality of life; factors such as activities, care, or treatment that precipitate or exacerbate pain; factors that reduce pain. Additional symptoms associated with pain (e.g. nausea, anxiety); physical and psychosocial issues (physical examination of the site of the pain, movement, or activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain). Procedure: Upon admission/re-admission, quarterly, with a significant change in condition and PRN residents will be evaluated for pain by the licensed nurse. Additionally, residents will be monitored for the presence of pain and evaluated when there is a change in condition and whenever new pain, or an exacerbation of pain is suspected. Observe resident for indicators of pain, indicators include: moaning, crying, and other vocalizations, wincing, frowning and other facial expressions, body posture such as guarding or protecting an area of the body, or lying very still and decrease in usual activities. Ask the resident and observe to determine the intensity of pain.Ask the resident and observe to determine the frequency of pain. Ask the resident and observe to determine the location of pain. Following the pain evaluation notify the physician if indicated and implement new orders as received. The licensed nurse will communicate any new onset of resident pain or change in resident pain to the physician/practitioner.