Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to review and revise the resident's pain to reflect actual pain instead of at risk for pain for one (1) of seventeen (17) residents reviewed for pain. Resident #44. Findings include: Record review of the facility's Care Plan Process, with a revision date of 12/24, revealed The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to review and revise each resident's comprehensive person-centered plan of care. Record review of Resident #44 ' s Care Plan Report with a date initiated of 12/5/24 revealed Focus: The resident IS AT RISK FOR PAIN. This care plan had not been revised to reflect Resident #44's ACTUAL pain. On 03/30/25 at 11:35 AM, during an observation and interview, Resident #44 stated he is in constant pain due to skin cancer. Resident #44's right arm was wrapped in Kerlix. He stated they only give him Tylenol and that it does not help. He described the pain as feeling like ants are biting him and stated he is in pain all the time. He reported telling the nurse that Tylenol does not help and rated his pain as an eight (8) on a scale of 0-10 with 10 being the greatest pain. On 04/01/25 at 7:52 AM, during an interview, Resident #44 stated his pain level was at a nine (9). He reported calling for pain medication three times before the nurse finally gave him something for pain the previous night. He stated the nurse told him she could not give him anything because it was not time yet. He said he was in pain all night and had trouble sleeping. He repeated that he is in constant pain and all he receives is Tylenol. On 04/01/25 at 03:04 PM, during an interview, Licensed Practical Nurse (LPN) #4 stated that Resident #44 has skin cancer and that's what all the sores are on him. On 04/02/25 at 10:57 AM, Resident #44 was observed lying in bed watching TV. He stated he had received Tylenol that morning and his current pain level was a 7. He stated that without Tylenol, his pain is typically at an eight to nine (8-9). On 04/02/25 at 11:02 AM, during an interview, LPN #3 stated that when Resident #44 complains about pain, she gives him Tylenol. She confirmed Tylenol is now scheduled. She stated the resident was previously receiving Tylenol as needed and that it was changed to a scheduled dose on 03/19/25 to help manage his pain. She could not recall where she had documented the resident's pain relief. On 04/02/25 at 11:32 AM, during an interview, the DON stated the comprehensive care plan should have been updated from at risk for pain to reflect actual pain. She stated she expects nurses to follow up with the resident after administering pain medication and to document the outcome. On 04/02/25 at 12:18 PM, during an interview, Registered Nurse (RN) #1, the MDS/Care Plan Nurse, stated she just noticed the care plan should have been updated. She confirmed that the care plan is used by all staff. Record review of Resident #44's admission Record revealed an admission date of 09/22/23 with diagnoses of localized infection of the skin and subcutaneous tissue, pain, leukemia (unspecified and not in remission), and basal cell carcinoma of the skin (unspecified). Record review of Resident #44's Order Summary Report with active orders as of 4/2/25 revealed a physician order dated 03/19/25 Acetaminophen Tablet 325 mg - Give 2 tablets by mouth three times a day, related to pain. Record review of Resident #44's Physician Consultation Report from Resident #44's Dermatologist dated 10/29/24 revealed Findings: Basal cell carcinoma of the left forearm, excised; Spots of concern x 2 right temple, left chest. Referral to plastic surgery for right forearm for squamous cell carcinoma. Review of the Minimum Data Set (MDS) for Resident #44 with an Assessment Reference Date (ARD) of 02/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section J indicated the resident experienced pain almost constantly and that pain affected sleep almost constantly. Section M documented open skin lesions.

Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to manage the resident's pain to the extent possible in accordance with professional standards and the resident's goals and preferences for one (1) of seventeen (17) residents reviewed for pain, Resident #44. Findings include: Record review of the facility's Pain Screen and Management policy, with a revision date of 12/23, revealed: All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of pain relief is achieved. All residents have the right to treatment for pain. Resident preferences are respected when deciding on methods to be used for pain management. The residents' statements are the most valid measurements of pain. 4.b New or changed medication orders are transcribed per facility standards of practice and a clinical note is documented 4.d. When the resident is medicated with the prescribed medication or treated as ordered, documentation of medication or treatment is done on the electronic Treatment Administration Record (TAR). 4.e. Documentation using the pain scale of a new type of pain, a pain medication and/or treatment change is completed every shift until the pain is managed effectively . 6.a. A pain scale is completed on the Electronic Medication Administration Record (eMAR)/Electronic Treatment Administration Record (eTAR.) . During an observation and interview on 03/30/25 at 11:35 AM, Resident #44 stated he is in constant pain due to skin cancer. Resident #44's right arm was wrapped in Kerlix. He stated they only give him Tylenol and that it does not help. He described the pain as feeling like ants are biting him and stated he is in pain all the time. He reported telling the nurse that Tylenol does not help and rated his pain as an eight (8) on a scale of 0-10 with 10 being the greatest pain. During an interview on 04/01/25 at 7:52 AM, Resident #44 stated his pain level was at a 9. He reported calling for pain medication three times before the nurse finally gave him something for pain the previous night. He stated the nurse told him she could not give him anything because it was not time yet. He said he was in pain all night and had trouble sleeping. He repeated that he is in constant pain and all he receives is Tylenol. During an interview on 04/01/25 at 3:04 PM, during an interview, Licensed Practical Nurse (LPN)# 4 stated that Resident #44 has skin cancer and stated that's what all the sores are on him. She reviewed his diagnoses and confirmed that Resident #44's diagnosis of skin cancer was not in the chart. During an observation, Resident #44 was observed lying in bed watching television on 04/02/25 at 10:57 AM. He stated he had received Tylenol that morning and his current pain level was a 7. He stated that without Tylenol, his pain is typically at eight to nine (8-9). During an interview on 04/02/25 at 11:02 AM, LPN #3 stated that when Resident #44 complains of pain, she gives him Tylenol. She confirmed Tylenol is now routine. She stated the resident previously received Tylenol as needed, and it was changed to routine on 03/19/25 to help with his pain. She could not recall where she documented the resident's pain relief. On 04/02/25 at 11:08 AM, during an interview, the Nurse Practitioner (NP) stated she is in the facility three days a week and sees all residents once a week. She stated she had not seen Resident #44 yet this week but was aware of his skin cancer. She stated he receives routine Tylenol for pain. She added that a pain level of seven (7) while on medication indicates the treatment is not effective. On 04/02/25 at 11:32 AM, during an interview, the DON stated that Resident #44 had been seen by a dermatologist. She confirmed that a pain level of 7 with medication is not effective. She stated that when nurses give pain medication, they are expected to reassess the resident's pain level 30 minutes after administration and document the outcome. She stated the eMAR should have a pain scale attached to the order and that it was not attached in April. She stated the pain scale provides a place for nurses to document the effectiveness of pain medication. She also confirmed that there were no progress notes related to pain and stated this documentation is expected. The DON stated that if the pain medication is not effective, staff must document it and notify the NP for a new order. Record review of Resident #44's admission Record revealed an admission date of 09/22/23 with diagnoses of local infection of the skin and subcutaneous tissue, pain, unspecified leukemia not in remission, and basal cell carcinoma of the skin (unspecified). Record review of Resident #44's Order Summary Report with active orders as of 4/2/25 revealed a physician order dated 03/19/25, Acetaminophen Tablet 325 mg - Give 2 tablets by mouth three times a day, related to pain. Record review of the March 2025, eMAR revealed that from 03/20/25 to 03/31/25, Resident #44 received Acetaminophen 325 mg (milligrams)tablets three times daily; however, pain levels were not documented. This section was left blank. The previous as needed Tylenol order was discontinued on 03/19/25. Record review of the April 2025 eMAR revealed that Resident #44 received Acetaminophen 325 mg tablets three times daily on 04/01/25 and 04/02/25. Pain levels were not documented. Record review of Resident #44's Progress Notes dated from 03/01/25 to 04/02/25 revealed no documentation related to pain. Record review of Resident #44 's Physician Consultation Report from Resident #44's Dermatologist dated 10/29/24 revealed Findings: Basal cell carcinoma of the left forearm, excised Spots of concern x 2 right temple, left chest .Referral to plastic surgery for right forearm for squamous cell carcinoma. Review of the Minimum Data Set (MDS) for Resident #44, with an Assessment Reference Date (ARD) of 02/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact. Section J indicated the presence of pain almost constantly, with pain affecting sleep almost constantly. Section M documented open skin lesions.