**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the physician when a need to alter treatment significantly due to adverse consequences for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds.On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #1 went to the hospital on 8/11/25 with a diagnosis of groin infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. An Immediate Jeopardy (IJ) situation was identified on 8/14/25 at 1:00 p.m. While the IJ was removed on 8/15/25 at 3:22 p.m., the facility remained out of compliance at a potential for not actual harm with a potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for pain and suffering. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a readmission date of 8/5/25. He had diagnoses of peripheral vascular disease (PVD) (a condition where the arteries and veins in the arms, legs, and feet become narrowed or blocked reducing blood flow.) and a history of stroke. Record review of Resident #1's admission MDS assessment dated [DATE] indicated his cognition was intact with a BIMS score of 13. The MDS indicated he used a walker and a wheelchair, but required supervision or touching assistance with most ADLs. Record review of Resident #1's care plan dated 6/2/25 indicated he was incontinent of bowel and bladder. Some of the interventions were to assist to toilet as needed, provide weekly skin checks to monitor for redness, circulatory problems, breakdown or skin concerns, and report any new skin conditions to the physician. Record review of Resident #1's computerized physician orders dated 8/11/25 indicated no orders for treatment to his groin incisions were listed. Record review of Resident #1's After Visit Summary dated 8/4/25 provided instructions to call the provider if redness, tenderness or signs of infection (pain, swelling, redness, odor or green/yellow discharge around incision site, and for severe uncontrolled pain. Record review of Resident #1's Admit/Readmit Evaluation dated 8/5/25 at 1:32 a.m. indicated he had surgical incision wounds on the left groin, right groin, and left front knee. There were no other descriptions. Record review of Resident #1's Admit/Readmit note dated 8/5/25 at 1:32 a.m. indicated he was admitted from the hospital with a diagnosis of deep vein thrombosis, and PVD. He needed limited assistance with transfers, self-performance. He was continent of urine and bowels and needed limited assistance with toileting, self-performance. He had pitting edema to both lower extremities. He complained of pain and was given pain medications. (no mention of surgical wounds) Record review of Resident #1's nursing notes dated 8/5/25 indicated he had a telehealth visit. The resident was readmitted last night with bilateral groin stent placement for PVD. He reported difficult urinating and severe incisional pain. He was requesting to be sent back to the ER and was transferred at 6:12 a.m. to the hospital. At 8:00 a.m. the resident returned from the hospital and was given pain medications. Record review of Resident #1's nursing notes dated 8/7/25 at 1:14 p.m. indicated Resident has open wounds; vascular and surgical. The resident received wound care with no changes in skin condition noted, and there were no signs and symptoms of infection. Record review of Resident #1's Skilled Observation note dated 8/10/25 at 9:37 p.m. indicated no infection was present the wound had redness and inflammation. The skin was warm and dry. The surgical incision was open with wound care and notable changes in skin condition. The observation described the incision with staples on the left side of the groin to have a foul-smelling drainage. The area was red and inflamed, it was cleansed with wound cleanser and was tender to touch. The groin on the right side had no visible signs and symptoms of infection. The note indicated would report to the oncoming charge nurse. Written by LVN E (there was no indication the physician was notified. Record review of Resident #1's nursing notes dated 8/11/25 at 5:50 p.m. the resident was sent to the hospital due to altered mental status. No other information was documented. Record review of Resident #1's hospital records dated 8/11/25 revealed the resident was admitted due to generalized weakness. He had bilateral groin incisions with staples that were irritated, with redness to the left and right groin and a foul smell. It appeared yeasty in nature. He stated his groin infections hurt and itched. His diagnosis was surgical incision infection. He was prescribed Cephalexin 500 mg two times a day for 7 days and Nystatin cream apply to groin area two times a day for 7 days. He returned to the facility on 8/11/25 at 11:14 p.m. and new orders were noted. Record review of Resident #1's nursing note dated 8/11/25 at 11:14 p.m. indicated he was readmitted to the facility with diagnoses of generalized weakness, yeast infection, and incisional infection. He had new orders for cephalexin 500 mg three times a day for 7 days and Nystatin Cream 100,000 units to bilateral groin two times a day for 7 days. Record review of Resident #1's computerized physician orders indicated an order with a start date of 8/12/25 at 8:00 a.m. for Nystatin External cream 100,000 units to bilateral groin area two times daily. An order with a start date of 8/12/25 at 8:00 a.m. for Cephalexin Oral Capsule 500 mg by mouth three times daily for 7 days.After Investigator intervention a treatment administration record was generated on 8/13/25, and indicated his treatment was to start on 8/13/25 at 6 p.m. During a telephone interview on 8/11/25 at 12:06 p.m., an Anonymous staff said Resident #1 had staples to his right and left groin area. The staff said on 8/10/25, a nurse had gone to look at the surgical incisions and they looked infected. The staff said that an unidentified nurse had not called the physician. She stated she had cleansed the area with wound cleanser and wound care was supposed to be done today, 8/11/15 by the treatment nurse. During an observation and interview on 8/11/25 at 3:20 p.m., Resident #1 was noted with EMS in his room. LVN A said Resident #1 was going to the hospital due to a change in his level of consciousness. She said he had staples in his right and left groin area and the left groin area was inflamed. She said it had yellow slimy drainage. She stated she told EMS his blood pressure was 88/56. Resident #1 was noted to be able to ambulate from the bed to the stretcher and was taken by EMS. LVN A said Resident #1's surgical incision appeared infected. During an interview on 8/11/25 at 5:59 p.m., LVN C/Treatment nurse said Resident #1 had surgical incisions on both sides of his groin. She said she was informed the right side of Resident #1's groin was red and inflamed. She was going to reach out to see if they wanted to remove the staples, but had not done so yet. She said they had orders to monitor the areas and put on a dry dressing. (There was no order noted) During an interview on 8/13/25 at 10:46 a.m., the DON said Resident#1 did not have any orders to treat his surgical incisions. The DON said LVN D was on duty when Resident #1 was readmitted to the facility on [DATE], and she should have passed his information on to the oncoming nurse. The DON said LVN D sent Resident #1 back out the same night and did not get an order for his surgical incisions. She said her staff were trained to go by the hospital After Visit Summary for orders. However, if a resident came in as a new admit or a readmit and did not have an order, they were to call the doctor to get an order. The DON said since Resident #1 did not have an order to treat the surgical incisions, someone should have followed up with the physician. After review of the Resident #1's observation note dated 8/10/25, the DON said LVN E should have contacted the physician when she noted Resident #1's wound looked infected. During an interview on 8/13/25 at 1:54 p.m., the RN Weekend Supervisor said she filled in for the treatment nurse on the weekends, and when the treatment nurse was out. She said Resident#1 did not have an order to treat his surgical incisions on the groin area. She said if a resident did not have an order or treatment in place, she was not aware they had any areas. The RN Weekend Supervisor stated when Resident #1 came from the hospital with surgical wounds and did not have anything down to treatment the areas . She said the nursing staff should have called the doctor to see what he wanted done. She said good nursing judgment indicated they should have called the hospital for orders or called the doctor to at least see what the physician wanted done with the wounds. During an interview on 8/13/25 at 2:30 p.m., LVN E said she worked on Friday 8/10/25 and had seen Resident #1's wounds, but did not provide any treatment. She said she was under the impression the treatment nurse was providing treatments to his groin area. She said she asked LVN C/Treatment nurse earlier in the week, and she said Resident #1's wound was getting cleaned and left to open air. LVN E said on the afternoon of Sunday 8/10/25, Resident #1's family brought to her attention that they thought Resident #1's groin area was infected. She said they sent pictures, and she had gone to look at the wound. LVN E said she cleaned the wounds on Resident #1's groin and noted in an observation note the left side was inflamed and red. She said the area could have been infected; it had an odor, and yellow drainage, it was red and inflamed . She said she had not contacted the physician; she passed the information on to the oncoming shift. During an interview on 8/14/25 at 9:45 a.m., the MD said he was not told Resident #1's surgical wound was infected prior to his discharge. He said he expected staff to call him and let him know of changes that occurred with residents. He said when a resident came back from the hospital they needed orders in place. He said if the facility does not have any orders, they should reach out to him for orders. He said the facility usually did a skin assessment and would call him for an order. He said especially if a resident was a readmitted and did not have a previous order for wound care. He said he expected to be notified of Resident conditions. Resident #2 Record review of Resident #2's face sheet dated 8/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission date of 8/12/25. She had diagnoses of stroke, end stage renal disease, chronic respiratory failure, heart disease, diabetes, and bipolar disorder. Record review of Resident# 2's admission MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 14. Resident #2 required partial to substantial assist with ADLs. She required supervision with bed mobility, partial to moderate assist with sit to laying, and did not attempt to stand or transfer due to medical condition. The MDS indicated she was at risk for a pressure ulcer. Review of Resident #2's care plan dated 5/19/15 indicated she was at risk for pressures ulcers. One of the interventions was to monitor for redness, circulation problems, pressure sores, open areas, and changes in skin integrity. Review of Resident #2's computerized physician orders dated 8/13/25 at 4:00 p.m. did not reveal an order for treatment to her sacrum wound. Review of Resident #2's nursing notes dated 7/31/25 at 6:00 a.m. revealed the resident was sent to the hospital due to her calling EMS and stating she was having difficulty breathing. Record review of Resident #2's hospital records dated 7/31/25 indicated the resident was admitted to the hospital on [DATE] after a ground level fall. She was discharged to the facility on 7/30/25 and readmitted to the hospital on [DATE] with complaints of shortness of breath and pain associated with groin buttock wounds. Review of Resident #2's hospital After Visit Summary dated 8/12/25 indicated the primary diagnoses for hospitalization was pressure injury of sacral region stage 4, end stage renal disease, uncontrolled diabetes, and fluid overload. There was no order for the care of the pressure injury of the sacrum. Record review of Resident #2's Admit Readmit Evaluation 8/12/25 at 10:00 p.m. indicated skin integrity with wounds present on admission, with bruising, discoloration, and an open wound. The comments indicated a pressure injury of the sacral region, stage 4, and bruising to the hands and front of the elbow. Record review of the facility's 24-hour report for 8/12/25 indicated Resident #2 returned from the hospital at 9:35 p.m., and she had a stage 4 pressure wound on her sacrum. During an interview on 8/13/25 at 6:01 p.m., the Administrator said they did not have any treatment orders for Resident #2's treatments, and she did not have a TAR generated at the current time due to no orders being in place. During an interview 8/14/25 at 11:00 a.m., the RN Weekend Supervisor said whoever admitted Resident #2 should have gotten orders from the hospital. She said if not, they should've gotten orders from the doctor regarding resident service. She said she completed the wound care on Resident #2 yesterday evening.During an interview on 8/13/25 at 4:50 p.m., the DON said Resident #2 had been in the hospital for 45 days. She said every time Resident #2 came to the facility, she was only there for a day or a few hours and then back to the hospital. The DON said normally when a resident was admitted or readmitted , the admitting nurse contacted the hospital for additional orders or contacts the physician for orders. She stated if it was during the night, the treatment nurse would be notified and the next day to do a skin assessment, notify the physician . She said at that time if a resident had wounds or if they needed any kind of treatment, they would get orders. She said she did not know why there were no orders for Resident #2. Record review of the facility's Notification of Changes policy last revised 2/10/21 indicated their policy to provide guidance on when to communicate acute changes in status to the MD, NP and responsible party. The will would immediately inform the resident: consult with the resident's physician, and responsible party for any significant change in physical, mental, or psychosocial status of the resident. The facility documents resident assessments, interventions, physician and family notification on the SBAR, Nursing Progress Note, or Telephone order form as appropriate. This was determined to be an Immediate Jeopardy (IJ) on 8/14/25 at 1:00 p.m. The Administrator, DON, and RNC were informed of the IJ situation on 8/14/25 at 1:00 p.m. a copy of the IJ template was emailed to them at 1:00 p.m. A POR was requested and accepted on 8/15/25 at 10:45 a.m. [The facility failed to implement policies and procedures regarding physician notification to prevent the hospitalization of Resident #1 due to a surgical wound infection.Immediate Action Taken:On 08/14/2025 at 2:30 PM, the attending physician for Resident #1 and #2 was notified of the status of the surgical incision, wounds and the lack of prior communication regarding wound condition. Resident #1and #2 were immediately assessed by the facility's wound care nurse and physician. Orders were received and implemented, including wound care protocols and infectious disease consult. 2. Identification of Residents Affected or Likely to be Affected:A head-to-toe skin and wound assessment was completed on all residents by the Director of Nursing (DON) and Wound Nurse on 08/14/2025. A facility-wide audit was initiated on 08/14/2025 by the DON/Designee to ensure all residents have current wound descriptions, physician orders, and proper documentation of physician notification using skin observation sheets and any discrepancies will be documented in the nurse's notes. Any discrepancies were immediately corrected, and responsible nurses were given additional education by DON/Designee. Telehealth and/or physician will be notified after hours and on weekends. Notification to physician will be documented in the nurse's notes by the licensed nurses. DON/designee educated all licensed nurses on policy/procedure on Change of condition notification. Licensed nurses will use the 24-hour report, the care plan, and Treatment administration record to communicate from shift to shift for all resident's change of conditions and care needs. 3. Actions to Prevent Occurrence/Recurrence:Staff Education On 08/14/2025, all licensed nurses received personized education on: Physician notification requirements will be upon admission/readmission and any change of condition License nurses will contact physicians to clarify admission or readmission orders when there are discrepancies with hospital records, change of conditions of wounds and signs of infection and ensure orders transferred to computer, MAR and TAR,Documentation of wound assessments. Use of SBAR (Situation-Background-Assessment-Recommendation) communication tool upon change of condition prior to physician notification. DON/Designee educated staff on notification of physician and staff were required to demonstrate understanding via return demonstration or post-education quiz. Education will be completed on 8/14/25. Staff unavailable to attend in service on 08/14/2025 will receive personalized in service prior to assuming their duties. Wound Communication Process A daily Wound Rounds Checklist was implemented to ensure: Each wound has documented assessment, treatment orders, and notification status. Any change is reported immediately to DON/Designee and documented in progress notes DON/Designee will complete a weekly interdisciplinary wound rounds initiated as of 08/14/2025 with physician participation (in person or telehealth). Monitoring and Oversight PlanDaily audits of physician notification for any changes in condition by DON or designee for 14 days (08/14-08/28/2025), then weekly x4 weeks. DON/Designee will review all new admissions and readmissions within 24 hours to ensure physician orders and wound care protocols are in place by DON/ Weekend Supervisor/ Designee. Review will be documented on the admission Audit tool.DON or designee will: Review progress notes, nurse notes, and MARs for compliance. Validate timely physician notifications. Audit results will be reported weekly to the Quality Assurance & Performance Improvement (QAPI) committee for 3 months. Continued noncompliance will trigger retraining or disciplinary action. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/14/25] On 8/15/25 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of facility skin assessments, facility audit of records to include wound descriptions, physician orders, and documentation in the nursing notes. The skin assessments were reviewed for all residents in the facility and noted two residents were found with redness to the buttocks, one resident with an open area to the buttocks, and one resident with redness to an ostomy site. There were orders noted to be placed, a description of the areas, and the physician was notified. Review of documentation showed Resident #1 and Resident #2 had descriptions of their wounds and treatment orders in place. Review of the facility Wound Daily Audit dated 8/14/25 through 8/24/25 indicated 3 newly admitted residents with skin assessments completed, the physician notified, a wound order in place, the wound care physician notified, and family notified. Record review of in-service dated 8/14/25 indicated nurses were educated on Change in Condition, completing the SBAR when a resident has a change in condition. When a nurse was notified or identified a change in condition they were to immediately, assess the resident gather vital signs, ask specific questions, if possible, notify MD, responsible part, DON and then document in the computer and add to the 24-hour report. Record review of in-service dated 8/14/25 indicated 19 nurses were educated on pressure ulcers/wounds upon admission or readmission. They were instructed to complete a head-to-toe assessment, measure wounds or open areas, complete the skin assessment, document in the computer system on admission or readmission, call the physician or use the [NAME]- health after hours to receive wound care orders, notify family about the wounds and the wound care company, wounds will be care planned, and to call the DON regarding any wounds found on admission or readmission. A copy of the skin management policy was attached. Record review indicated the facility had conducted skilled nursing facility nursing competency testing on nursing staff dated 8/14/25. Some of the questions indicated the physician should be notified as soon as a change was identified, when a resident is admitted with a pressure sore, the responsibility was to notify the MD, after receiving Wound care orders, put them in the computer and initiate care protocol. When observations showed increased redness or drainage from a wound, notify the MD and request updated wound care orders. There were also true and false questions. During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments. She said one resident was up and 1 resident refused, and they are going to try and get them later. She said they did the in services and had a return demonstration test for the nurses. They were not able to have all nurses do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital. They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds. On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. An Immediate Jeopardy (IJ) situation was identified on 8/14/25 at 1:00 p.m. While the IJ was removed on 8/15/25 at 3:22 p.m., the facility remained out of compliance at a potential for not actual harm with a potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for pain and suffering.Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a readmission date of 8/5/25. He had diagnoses of peripheral vascular disease (PVD) (a condition where the arteries and veins in the arms, legs, and feet become narrowed or blocked reducing blood flow.) and a history of stroke. Record review of Resident #1's admission MDS assessment dated [DATE] indicated his cognition was intact with a BIMS score of 13. The MDS indicated he used a walker and a wheelchair, but required supervision or touching assistance with most ADLs. Record review of Resident #1's care plan dated 6/2/25 indicated he was incontinent of bowel and bladder. Some of the interventions were to assist to toilet as needed, provide weekly skin checks to monitor for redness, circulatory problems, breakdown or skin concerns, and report any new skin conditions to the physician. Record review of Resident #1's computerized physician orders dated 8/11/25 indicated no orders for treatment to his groin incisions were listed. Record review of Resident #1's After Visit Summary dated 8/4/25 provided instructions to call the provider if redness, tenderness or signs of infection (pain, swelling, redness, odor or green/yellow discharge around incision site, and for severe uncontrolled pain. Record review of Resident #1's Admit/Readmit Evaluation dated 8/5/25 at 1:32 a.m. indicated he had surgical incision wounds on the left groin, right groin, and left front knee. There were no other descriptions. Record review of Resident #1's Admit/Readmit note dated 8/5/25 at 1:32 a.m. indicated he was admitted from the hospital with a diagnosis of deep vein thrombosis, and PVD. He needed limited assistance with transfers, self-performance. He was continent of urine and bowels and needed limited assistance with toileting, self-performance. He had pitting edema to both lower extremities. He complained of pain and was given pain medications. (no mention of surgical wounds) Record review of Resident #1's nursing notes dated 8/5/25 indicated he had a telehealth visit. The resident was readmitted last night with bilateral groin stent placement for PVD. He reported difficult urinating and severe incisional pain. He was requesting to be sent back to the ER and was transferred at 6:12 a.m. to the hospital. At 8:00 a.m. the resident returned from the hospital and was given pain medications. Record review of Resident #1's nursing notes dated 8/7/25 at 1:14 p.m. indicated Resident has open wounds; vascular and surgical. The resident received wound care with no changes in skin condition noted, and there were no signs and symptoms of infection. Record review of Resident #1's Skilled Observation note dated 8/10/25 at 9:37 p.m. indicated no infection was present the wound had redness and inflammation. The skin was warm and dry. The surgical incision was open with wound care and notable changes in skin condition. The observation described the incision with staples on the left side of the groin to have a foul-smelling drainage. The area was red and inflamed, it was cleansed with wound cleanser and was tender to touch. The groin on the right side had no visible signs and symptoms of infection. The note indicated would report to the oncoming charge nurse. Written by LVN E (there was no indication the physician was notified. Record review of Resident #1's nursing notes dated 8/11/25 at 5:50 p.m. the resident was sent to the hospital due to altered mental status. No other information was documented. Record review of Resident #1's hospital records dated 8/11/25 revealed the resident was admitted due to generalized weakness. He had bilateral groin incisions with staples that were irritated, with redness to the left and right groin and a foul smell. It appeared yeasty in nature. He stated his groin infections hurt and itched. His diagnosis was surgical incision infection. He was prescribed Cephalexin 500 mg two times a day for 7 days and Nystatin cream apply to groin area two times a day for 7 days. He returned to the facility on 8/11/25 at 11:14 p.m. and new orders were noted. Record review of Resident #1's nursing note dated 8/11/25 at 11:14 p.m. indicated he was readmitted to the facility with diagnoses of generalized weakness, yeast infection, and incisional infection. He had new orders for cephalexin 500 mg three times a day for 7 days and Nystatin Cream 100,000 units to bilateral groin two times a day for 7 days. Record review of Resident #1's computerized physician orders indicated an order with a start date of 8/12/25 at 8:00 a.m. for Nystatin External cream 100,000 units to bilateral groin area two times daily. An order with a start date of 8/12/25 at 8:00 a.m. for Cephalexin Oral Capsule 500 mg by mouth three times daily for 7 days.After Investigator intervention a treatment administration record was generated on 8/13/25, and indicated his treatment was to start on 8/13/25 at 6 p.m. During a telephone interview on 8/11/25 at 12:06 p.m., an Anonymous staff said Resident #1 had staples to his right and left groin area. The staff said on 8/10/25, a nurse had gone to look at the surgical incisions and they looked infected. The staff said that an unidentified nurse had not called the physician. She stated she had cleansed the area with wound cleanser and wound care was supposed to be done today, 8/11/15 by the treatment nurse. During an observation and interview on 8/11/25 at 3:20 p.m., Resident #1 was noted with EMS in his room. LVN A said Resident #1 was going to the hospital due to a change in his level of consciousness. She said he had staples in his right and left groin area and the left groin area was inflamed. She said it had yellow slimy drainage. She stated she told EMS his blood pressure was 88/56. Resident #1 was noted to be able to ambulate from the bed to the stretcher and was taken by EMS. LVN A said Resident #1's surgical incision appeared infected. During an interview on 8/11/25 at 5:59 p.m., LVN C/Treatment nurse said Resident #1 had surgical incisions on both sides of his groin. She said she was informed the right side of Resident #1's groin was red and inflamed. She was going to reach out to see if they wanted to remove the staples, but had not done so yet. She said they had orders to monitor the areas and put on a dry dressing. (There was no order noted) During an interview on 8/13/25 at 10:46 a.m., the DON said Resident#1 did not have any orders to treat his surgical incisions. The DON said LVN D was on duty when Resident #1 was readmitted to the facility on [DATE], and she should have passed his information on to the oncoming nurse. The DON said LVN D sent Resident #1 back out the same night and did not get an order for his surgical incisions. She said her staff were trained to go by the hospital After Visit Summary for orders. However, if a resident came in as a new admit or a readmit and did not have an order, they were to call the doctor to get an order. The DON said since Resident #1 did not have an order to treat the surgical incisions, someone should have followed up with the physician. After review of the Resident #1's observation note dated 8/10/25, the DON said LVN E should have contacted the physician when she noted Resident #1's wound looked infected. During an interview on 8/13/25 at 1:54 p.m., the RN Weekend Supervisor said she filled in for the treatment nurse on the weekends, and when the treatment nurse was out. She said Resident#1 did not have an order to treat his surgical incisions on the groin area. She said if a resident did not have an order or treatment in place, she was not aware they had any areas. The RN Weekend Supervisor stated when Resident #1 came from the hospital with surgical wounds and did not have anything down to treatment the areas . She said the nursing staff should have called the doctor to see what he wanted done. She said good nursing judgment indicated they should have called the hospital for orders or called the doctor to at least see what the physician wanted done with the wounds. During an interview on 8/13/25 at 2:30 p.m., LVN E said she worked on Friday 8/10/25 and had seen Resident #1's wounds, but did not provide any treatment. She said she was under the impression the treatment nurse was providing treatments to his groin area. She said she asked LVN C/Treatment nurse earlier in the week, and she said Resident #1's wound was getting cleaned and left to open air. LVN E said on the afternoon of Sunday 8/10/25, Resident #1's family brought to her attention that they thought Resident #1's groin area was infected. She said they sent pictures, and she had gone to look at the wound. LVN E said she cleaned the wounds on Resident #1's groin and noted in an observation note the left side was inflamed and red. She said the area could have been infected; it had an odor, and yellow drainage, it was red and inflamed . She said she had not contacted the physician; she passed the information on to the oncoming shift. During an interview on 8/14/25 at 9:45 a.m., the MD said he was not told Resident #1's surgical wound was infected prior to his discharge. He said he expected staff to call him and let him know of changes that occurred with residents. He said when a resident came back from the hospital they needed orders in place. He said if the facility does not have any orders, they should reach out to him for orders. He said the facility usually did a skin assessment and would call him for an order. He said especially if a resident was a readmitted and did not have a previous order for wound care. He said he expected to be notified of Resident conditions. Resident #2 Record review of Resident #2's face sheet dated 8/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission date of 8/12/25. She had diagnoses of stroke, end stage renal disease, chronic respiratory failure, heart disease, diabetes, and bipolar disorder. Record review of Resident# 2's admission MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 14. Resident #2 required partial to substantial assist with ADLs. She required supervision with bed mobility, partial to moderate assist with sit to laying, and did not attempt to stand or transfer due to medical condition. The MDS indicated she was at risk for a pressure ulcer. Review of Resident #2's care plan dated 5/19/15 indicated she was at risk for pressures ulcers. One of the interventions was to monitor for redness, circulation problems, pressure sores, open areas, and changes in skin integrity. Review of Resident #2's computerized physician orders dated 8/13/25 at 4:00 p.m. did not reveal an order for treatment to her sacrum wound. Review of Resident #2's nursing notes dated 7/31/25 at 6:00 a.m. revealed the resident was sent to the hospital due to her calling EMS and stating she was having difficulty breathing. Record review of Resident #2's hospital records dated 7/31/25 indicated the resident was admitted to the hospital on [DATE] after a ground level fall. She was discharged to the facility on 7/30/25 and readmitted to the hospital on [DATE] with complaints of shortness of breath and pain associated with groin buttock wounds. Review of Resident #2's hospital After Visit Summary dated 8/12/25 indicated the primary diagnoses for hospitalization was pressure injury of sacral region stage 4, end stage renal disease, uncontrolled diabetes, and fluid overload. There was no order for the care of the pressure injury of the sacrum. Record review of Resident #2's Admit Readmit Evaluation 8/12/25 at 10:00 p.m. indicated skin integrity with wounds present on admission, with bruising, discoloration, and an open wound. The comments indicated a pressure injury of the sacral region, stage 4, and bruising to the hands and front of the elbow. Record review of the facility's 24-hour report for 8/12/25 indicated Resident #2 returned from the hospital at 9:35 p.m., and she had a stage 4 pressure wound on her sacrum. During an interview on 8/13/25 at 6:01 p.m., the Administrator said they did not have any treatment orders for Resident #2's treatments, and she did not have a TAR generated at the current time due to no orders being in place. During an interview 8/14/25 at 11:00 a.m., the RN Weekend Supervisor said whoever admitted Resident #2 should have gotten orders from the hospital. She said if not, they should've gotten orders from the doctor regarding resident service. She said she completed the wound care on Resident #2 yesterday evening.During an interview on 8/13/25 at 4:50 p.m., the DON said Resident #2 had been in the hospital for 45 days. She said every time Resident #2 came to the facility, she was only there for a day or a few hours and then back to the hospital. The DON said normally when a resident was admitted or readmitted , the admitting nurse contacted the hospital for additional orders or contacts the physician for orders. She stated if it was during the night, the treatment nurse would be notified and the next day to do a skin assessment, notify the physician . She said at that time if a resident had wounds or if they needed any kind of treatment, they would get orders. She said she did not know why there were no orders for Resident #2. Record review of the facility's Notification of Changes policy last revised 2/10/21 indicated their policy to provide guidance on when to communicate acute changes in status to the MD, NP and responsible party. The will would immediately inform the resident: consult with the resident's physician, and responsible party for any significant change in physical, mental, or psychosocial status of the resident. The facility documents resident assessments, interventions, physician and family notification on the SBAR, Nursing Progress Note, or Telephone order form as appropriate. This was determined to be an Immediate Jeopardy (IJ) on 8/14/25 at 1:00 p.m. The Administrator, DON, and RNC were informed of the IJ situation on 8/14/25 at 1:00 p.m. a copy of the IJ template was emailed to them at 1:00 p.m. A POR was requested and accepted on 8/15/25 at 10:45 a.m. [The facility failed to implement policies and procedures to prevent the hospitalization of Resident #1 due to a surgical wound infection.Immediate Action Taken:On 08/14/2025 at 2:30 PM, the attending physician for Resident #1 and #2 was notified of the status of the surgical incision, wounds and the lack of prior communication regarding wound condition. Resident #1and #2 were immediately assessed by the facility's wound care nurse and physician. Orders were received and implemented, including wound care protocols and infectious disease consult. 2. Identification of Residents Affected or Likely to be Affected:A head-to-toe skin and wound assessment was completed on all residents by the Director of Nursing (DON) and Wound Nurse on 08/14/2025. A facility-wide audit was initiated on 08/14/2025 by DON/Designee to ensure all residents have current wound descriptions, physician orders, and proper documentation of physician notification and will be completed by 8/15/25. Any discrepancies were immediately corrected, and responsible nurses were given additional education by DON/Designee.DON/Designee reviewed the last 5 admissions and completed an audit for any missing ordersDON/Designee provided education to licensed nurses on admission and readmission orders3. Actions to Prevent Occurrence/Recurrence:Staff Education On 08/14/2025, the DON/Designee educated all licensed nurses on: Documentation of wound assessments will be located in the progress notes and include descriptions of the wounds, skin tears, bruises, surgical incisions, sizes, measurements, drainage, and colors.Use of SBAR (Situation-Background-Assessment-Recommendation) communication tool will be completed upon identification of change in condition by the charge nurse immediately upon identification of change in conditionStaff were required to demonstrate understanding via return demonstration or post-education quiz. Staff unavailable to attend in service on 08/14/2025 will receive personalized in service prior to assuming their duties. Wound Communication Process A daily Wound Rounds Checklist was implemented to ensure: The DON/Designee audited each resident to ensure wound has documented assessment, treatment orders, orders transferred to computer, MAR and TAR, and notification status. The DON/Designee educated all licensed nurses on wound assessment, documentation, treatment orders, documentation on 24 hour report for shift to shift communication and notification to physicians . Any change is reported immediately to the physician and documented in progress notes.Weekly interdisciplinary wound rounds initiated as of 08/14/2025 with physician participation (in person or telehealth). Monitoring and Oversight PlanDaily audits of physician notification for any changes in condition by DON or designee for 14 days (08/14-08/28/2025), then weekly x4 weeks. All new admissions and readmissions will be reviewed within 24 hours to ensure physician orders and wound care protocols are in place by DON/ Weekend Supervisor/ Designee. Review will be documented on the admission Audit tool.DON or designee will: Review progress notes, nurse notes, and MARs for compliance. Validate timely physician notifications. Audit results will be reported weekly to the Quality Assurance & Performance Improvement (QAPI) committee for 3 months. Continued noncompliance will trigger retraining or disciplinary action. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/14/25] On 8/15/25 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of facility skin assessments, facility audit of records to include wound descriptions, physician orders, and documentation in the nursing notes. The skin assessments were reviewed for all residents in the facility and noted two residents were found with redness to the buttocks, one resident with an open area to the buttocks, and one resident with redness to an ostomy site. There were orders noted to be placed, a description of the areas, and the physician was notified. Review of documentation showed Resident #1 and Resident #2 had descriptions of their wounds and treatment orders in place. Review of the facility Wound Daily Audit dated 8/14/25 through 8/24/25 indicated 3 newly admitted residents with skin assessments completed, the physician notified, a wound order in place, the wound care physician notified, and family notified. Record review of in-service dated 8/14/25 indicated nurses were educated on Change in Condition, completing the SBAR when a resident has a change in condition. When a nurse was notified or identified a change in condition they were to immediately, assess the resident gather vital signs, ask specific questions, if possible, notify MD, responsible part, DON and then document in the computer and add to the 24-hour report. Record review of in-service dated 8/14/25 indicated 19 nurses were educated on pressure ulcers/wounds upon admission or readmission. They were instructed to complete a head-to-toe assessment, measure wounds or open areas, complete the skin assessment, document in the computer system on admission or readmission, call the physician or use the [NAME]- health after hours to receive wound care orders, notify family about the wounds and the wound care company, wounds will be care planned, and to call the DON regarding any wounds found on admission or readmission. A copy of the skin management policy was attached. Record review indicated the facility had conducted skilled nursing facility nursing competency testing on nursing staff dated 8/14/25. Some of the questions indicated the physician should be notified as soon as a change was identified, when a resident is admitted with a pressure sore, the responsibility was to notify the MD, after receiving Wound care orders, put them in the computer and initiate care protocol. When observations showed increased redness or drainage from a wound, notify the MD and request updated wound care orders. There were also true and false questions. During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments. She said one resident was up and 1 resident refused, and they are going to try and get them later. She said they did the in services and had a return demonstration test for the nurses. They were not able to have all nurses do the testing because they had called some on the phone. She said they would do their testing later. The RNC said they had done chart audits and had the monitoring tool in place. She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system. During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission. The staff were given a test to determine if they knew what to do for a new admission and when to follow up. She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained. The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound. She had in-serviced 20 nurses. She had 12 full time nurses and 8 PRN nurses. The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building. She said Resident #2 had gone back to the hospital. They were doing paper charting on today. During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way. Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 reviewed for pain. The facility failed to contact the physician in a timely manner regarding Resident #1's pain medication. The facility failed to provide Resident #1 with pain medication for 20 hours after admitting with pain at a 9 out of 10 (0 being no pain at all and 10 being the worst pain you have ever experienced). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 7/13/23 at 11:40 a.m. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could put residents at risk for experiencing unnecessary pain and discomfort that could affect their health, behaviors, and quality of life. Findings Included: Record review of the consolidated physician orders dated 7/12/23 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] at 9:13 p.m. with a diagnosis including gastric ulcer with hemorrhage (internal bleed of a stomach ulcer), hypertension (high blood pressure), chronic pain syndrome, overactive bladder, and gastroesophageal reflux disease (heart burn). The physician orders indicated Resident #1 had orders for Morphine Sulfate (medication for pain) by mouth every morning and at bedtime starting 7/06/23 and Hydrocodone (medication for pain) 10-325mg by mouth every 6 hours as needed for pain starting 7/06/23. Record review of the MAR dated July 2023 indicated Resident #1 received her first dose of Morphine Sulfate on 7/06/23 at 7:00 p.m. and was experience pain of 7 out of 10 (0 being no pain and 10 being severe pain) The MAR indicated Resident #1 received her first dose of Hydrocodone on 7/06/23 at 7:30 p.m. and was experience pain of 9 out of 10. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #1 had moderate pain occasionally. Record review of the care plan dated 7/06/23 indicated Resident #1 was on a pain management regimen and takes analgesics routinely or as needed. The care plan indicated interventions included administer medications as ordered, monitor for side effects and effectiveness, and attempt non-pharmacological pain interventions when not contraindicated. Record review of the Admit/Readmit Evaluation dated 07/05/23 at 10:10 p.m. indicated Resident #1 had pain of 9 out of 10 with non-verbal pain indicator of restlessness. The Admit/Readmit Evaluation indicated interventions implemented were narcotics and quiet/relaxation. Record review of the Pain assessment dated [DATE] at 11:39 p.m. indicated Resident #1 reported having pain in her hip and back daily and times it was horrible or excruciating. The Pain Assessment indicated Resident #1 rated her pain as very severe. Record review of the nursing progress noted dated 7/06/23 at 3:06 p.m. indicated, The skilled nurse contacted [the physician] in regards for the need of ordered controlled medications. [The physician] reports ordered medications have been sent to the pharmacy at this time, awaiting arrival . Record review of pain level summary dated 7/06/23 at 7:30 p.m. indicated Resident #1 had a pain level of 9 out of 10. Record review of the pain level summary dated 7/06/23 at 9:24 p.m. indicated Resident #1 had a pain level of 7 out of 10. Record review of pharmacy packing slips dated 7/06/23 indicated Resident #1's morphine sulfate and hydrocodone had been delivered. During an interview on 7/07/23 at 1:20 p.m. Resident #1 said she had been in pain when she admitted to the facility on [DATE]. Resident #1 said did not receive any pain medication until 7/06/23 at 10:50 p.m. During an interview on 7/12/23 at 1:32 p.m. LVN B said she had worked at the facility 2 weeks. LVN B said she worked the 6:00 a.m.-6:00 p.m. shift. LVN B said Resident #1 in pain when she came in for her shift on 7/06/23. LVN B she was told in report about Resident #1' pain medications not being at the facility. LVN B said the order for Resident #1's pain medications had not been sent to the pharmacy. LVN B said she contacted the physician regarding Resident #1's pain medications. LVN B said she had text the physician regarding Resident #1's pain medication on 7/06/23 at 10:02 a.m. but did not chart that she had contacted him at that time. LVN B said she told Resident #1 that she could administer her some Tylenol. LVN B said Resident #1 refused the Tylenol. LVN B said without documentation there was no way to prove medications were given, communication with the physician had taken place, or that Resident #1 had refused Tylenol. During an interview on 7/12/23 at 1:43 p.m. the pharmacy staff said there was not time of delivery for Resident #1's medication on 7/06/23 documented. The pharmacy staff said they did not have the time the controlled medication order was received from the physician. During an interview on 7/12/23 at 2:26 p.m. the DON said when a new admit was coming from the hospital she expected staff to ask the hospital nurse during report to have the hospital doctor send a triplicate with the resident if they have an order for narcotics. The DON said she expected staff to ask the hospital nurse to administer pain medications to a resident with pain prior to them transferring to the facility. The DON said if a resident was admitted with pain 9 out of 10 she expected the nurse to reach out to the physician regarding sending in a controlled medication order if needed and get an order for an as needed pain medication until the pain medication requiring a controlled medication order was available. The DON said if it was after hours the nurses had access to on-call physicians to request an order for pain medication. The DON said the facility's Medical Director had standing ordered for all residents for Tylenol for pain. The DON said when she came into work on 7/06/23 Resident #1 was complaining of pain. The DON said she was called to the Resident #1's room. The DON said Resident #1 complained that she had not yet received any pain medication since she had admitted to the facility on [DATE] and was in pain. The DON said the nurse had been working on getting Resident #1's pain medication all day on 7/06/23. The DON said it was important to manage resident's pain so the residents were pain free. The DON said if something was not charted the only way to prove it had been done would be ask the physician. During an interview on 7/12/23 at 3:41 p.m. the Medical Director said he was familiar with Resident #1. The Medical Director said he had not seen Resident #1 in person yet. The Medical Director said the facility had notified him on 7/06/23 regarding Resident #1's pain. The Medical Director said he could not verify what time he was notified of Resident #1's pain. The Medical Director said he sent the controlled medication order to the pharmacy for Resident #1's morphine sulfate and hydrocodone on 7/06/23. The Medical Director said he could not verify the time the controlled medication orders for these medications was sent to the pharmacy. The Medical Director said the facility had standing orders from him for residents to receive Tylenol for pain. During an observation and interview on 7/13/23 beginning at 12:15 p.m. Resident #1 was lying in the hospital bed resting. Resident #1 said she did not feel good at all. Resident #1 said she did not remember speaking to the surveyor last week or her admission to the facility. During an interview on 7/13/23 at 2:32 p.m. LVN G said she was the nurse who admitted Resident #1 on 7/05/23. LVN G said Resident #1 complained of pain of 9 out of 10. LVN G she had 3 admissions the night that Resident #1 was admitted to the facility. LVN G said the ADON had assisted with inputting orders on 7/05/23. LVN G said her admission assessments for Resident #1 were not completed until 7/6/23, but she had dated them for the night Resident #1 admitted on [DATE]. LVN G said she gave Resident #1 pain medication on 7/06/23. LVN G said the night that she admitted Resident #1 had said she was in pain around midnight and asked for her pain medicine. LVN G said Resident #1 said she was always in pain. LVN G said on 7/05/23 she offered Resident #1 Tylenol and that Resident #1 accepted the Tylenol, but that she did not document giving her Tylenol. LVN G said LVN B gave her report on 7/06/23. LVN G said the LVN B told her in report that she had to contact the pharmacy after the first pharmacy run regarding Resident #1's pain medication and reached out to the physician regarding sending the controlled medication order to the pharmacy. LVN G said that she assumed in the facility's EMR it could be seen when the assessments had been completed. LVN G said she actually never completed the admission evaluation and locked it due to not having Resident #1's height and weight. LVN G said there was no way to prove she had administered Tylenol to Resident #1 due to it not being charted. LVN G said when she came on shift 7/05/23 at 6:00 p.m. the day shift nurse had already taken report from the hospital on Resident #1. LVN G said the report sheet it indicated Resident #1's narcotics order had already been sent to the pharmacy. LVN G said she did not contact the physician regarding Resident #1's pain medication due to being told in report it had been sent to the pharmacy. LVN G said she did not call the pharmacy to verify the narcotics orders were there because she had 3 admissions (3 new residents transferred to the facility from home, the hospital, or another nursing facility) and did not have the time. LVN G said it was important to administer scheduled pain medication to help keep their pain under control and not let it get to an excruciating level. Record review of the facility's Pain Management Policy dated 10/24/2022 indicated, The facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences .The facility will utilize a systemic approach for recognition, evaluation, treatment, and monitoring of pain. Pain evaluation are completed on admission, quarterly, with a significant change of condition, and as needed .Based on professional standards of practice, an assessment or evaluation by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate the following information, as applicable to the resident: History of pain and its treatment .Asking the patient to rate the intensity of his/her pain using a numeric scale, a verbal or visual indicator that is appropriate and preferred by the resident .Reviewing the resident's current medical conditions .Impact of pain on quality of life .Current prescribed pain medications .Based on the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission . The Administrator was notified on 7/13/2023 at 11:55 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/13/2023 at 11:57 a.m. The facility's Plan of Removal was accepted on 7/14/2023 at 7:35 a.m. and included: 1. Immediately Resident # 1 discharged to hospital on 7/11/23. A Pain User defined assessment will be completed on 100% of all residents in center by the DON/designee to identify if any other residents are experiencing pain. This will be completed today 7/13/23 at 6:00 pm. DON or designee will notify the physician of any resident experiencing unrelieved pain with current pain regimen. This will be completed 7/13/2023 at 6:00 pm if applicable DON or designee will provide all license nurses education on Pain Management Policy this will be completed 7/13/23 at 6:00 pm. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Notification of Change in Condition Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. DON or designee will provide all license nurses education on Medication Administration Policy. This will be completed by 7/13/23 at 6:00 pm. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. Licensed nurses who have not had the in-service by the completion date, will be in-serviced prior to start of their shift. 2. Identification of Residents Affected or Likely to be Affected: DON/Designee will complete a Pain assessment on 100% of all residents in center to identify if any other residents experiencing pain. This will be completed 7/13/2023 at 6:00 pm, and Physician notification will be completed by charge nurse of resident, for any resident identified with pain. 3. Actions to Prevent Occurrence/Recurrence: DON/Designee will Provide all nurses with education on Pain Management Policy. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance for recognition of pain (verbal and non-verbal,) pain evaluation, pain management and treatment as well as monitoring and reevaluation. DON/Designee will Provide all nurses with education on Notification on Change of Condition. This will be completed by 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. The education provides guidance on when to communicate acute change in a resident's status to the Physician, NP, and responsible party. DON/Designee will Provide all nurses with education on Medication Administration Guidelines. This will be completed by 7/13/2023 at 6:00 pm. No nurse will be allowed to work until this education has been completed. The education provides guidance on the process for accurate, timely administration, documentation, monitoring, and reevaluation of medication administration. DON/Designee completed 100% audit on 7/13/2023 at 4:00 pm and validated that all residents who receive pain medication, have medication available. DON/Designee started education with all license nurses on Control Substance Prescriptions Guidelines (which includes back up procedures for new admissions, including notifying physician and telehealth physician after hours for orders.). This education will be completed on 7/14/2023 at 6:00 am. No nurse will be allowed to work until this education has been completed. 4. Monitoring: DON or designee will monitor daily the 24hr sheets to identify any residents with unrelieved pain with physician notified of any identified. DON or designee will complete the QAPI pain monitor tool daily x 30 days, to validate no resident are experiencing unrelieved pain. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 7/13/2023 The facility's Medical Director was notified of the immediate jeopardy at 1:41pm on 7/13/23 by the administrator. On 7/13/23 4:00 pm an ad hoc QAPI meeting was conducted including medical director to discuss findings and sustained compliance. On 7/14/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 7/14/23 between 10:53 a.m. and 11:25 am (LVN A, LVN B, RN C, LVN D, LVN E, LVN F) were performed. All staff interviewed were able to name types of non-verbal pain indicators, non-pharmacological pain interventions, when to notify the physician, how to obtain pain medication for newly admitted residents, what information should be documented in the resident EMR, and proper medication administration and documentation. A random sample of resident EMR's were reviewed to ensure pain assessments had been completed on 7/13/23. Record review of QAPI meeting sign-in sheet dated 7/13/23 indicated appropriate staff in attendance. Record review of the DON's signed statement indicated pain medication audit and verification had been completed on all residents receiving pain medication. While the IJ was removed on 7/14/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.