**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management to one resident (Resident#1), of five residents reviewed for pain management, that was consistent with professional standards of practice, her comprehensive person-centered care plan, and her goals and preferences.On 07/14/2025 the facility staff failed to recognize and address Resident #1's pain while providing incontinent care to Resident #1. On 07/14/2025 CNA A failed to alert RN A of Resident #1's expression and exhibition of pain. CNA A continued to provide incontinent care on 07/14/2025 even when Resident #1 exhibited signs and symptoms of pain. This failure could place residents at risk from receiving prompt pain management.The findings include:1. Record review of Resident #1's admission Record, dated 07/19/2025, revealed a [AGE] year-old-female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses which included cerebral infarction (stroke), altered mental status, muscle wasting and atrophy (tissue wasting), cognitive communication deficit, and thrombocytopenia (blood clotting irregularity). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11, which meant moderate cognitive impairment. Resident #1 was partial/moderately reliant on staff for ADLs. Record review of Resident #1's care plan, date initiated 04/20/25, documented [Resident #1] has had an actual fall 4/20/25 related to: unsteady gait Actual fall 4/22/25 Actual fall 5/9/25 Actual fall 7/13/25 Goal: Will resume usual activities without further fall incident 4/20/25: grip strips to area in front of toilet. 4/22/25: Visual cues, Call don't fall signs in room. 5/9/25: therapy to assess for therapeutic modifications to wheelchair. 7/13/25: Dycem to wheelchair, pulmar cushion to wheelchair.Record review of Resident #1's progress note documented by RN B effective date 07/13/2025 20:50 (8:50PM) revealed Resident was watching TV in wheelchair in sitting area in front of nurses station. Resident was then observed on floor next to wheelchair on her right side. Resident did not cry out or request any help. Resident was alone in sitting area, no other employees or residents in residents' vicinity. This RN rushed to resident side, assessed for injuries, range of motion, obvious disfigurements, none observed. Resident offered prn pain medication and resident refused. Denies pain to any other areas. Resident assisted up to wheelchair by staff and taken to room, placed in bed. Brief changed and peri-care performed. Resident again observed for injury or deformities. None noted. Resident offered prn pain medication and denied again. Resident further assessed for any other injuries, Resident denies hitting her head or losing consciousness. [Provider] contacted and resident [family member] contacted. [Resident #1] and [family member] refused ER evaluation.Record review of Resident #1's progress note documented by RN A, effective date 07/14/2025 at 03:51 (3:51AM), revealed F/U Fall Day 1/3. No c/o pain/discomfort. No distress noted. No latent injuries noted. Sleeping with eyes closed. RRR, even and unlabored. VS WNL. Record review of Resident #1's progress note documented by RN A, effective date 07/14/2025 at 0:500 (5:00AM) at 0420 (4:20AM) CNA came to alert this nurse that resident was crying out in pain when CNA had to turn her to change her bed. Slight deformity noted to outer right hip area w/ bruising noted. Bruise noted to inside aspect of right knee. Resident is unable to pick up her right leg and screams out in pain every time she is moved or turned. VS - 125/78, 82, 16, 98.9. @ 0434 Called 911; @ 0437 Called [family member] LMOM. EMS arrives to transport resident. Assisted them w/ transfer to stretcher for resident's comfort. @ 0450 Called report to [ER]. Called [family member] back and spoke with her to let her know which hospital EMS was transporting [Resident #1] to. @ 0457 [physician] (notified). @ 0458 Notified DON. Record review of Resident #1's ER record dated 07/15/2025 revealed [AGE] year-old female fall out of wheelchair and sustained a right greater trochanter fracture. MRI completed and confirmed fracture does not show extension into the intertrochanteric area. Ortho deemed her non-operative and she is to follow up in their clinic in 2 weeks with x-rays. Mobilize/ambulate using assistive device. Due to this being an isolated orthopedic injury and is non-op, there are no further interventions or surgeries planned by our service. Tertiary survey was completed and was negative for any new issues, pains, or concerns. 2. Record review of Resident #2's admission Record, dated 07/20/2025, revealed a [AGE] year-old- female who was admitted to the facility on [DATE]. Resident #2 was admitted with diagnoses which included muscle wasting and atrophy (partial or complete wasting away or a part of the body), and lack of coordination. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15, which meant Resident #2 was cognitively aware. Resident #2 was substantially/maximally reliant on staff for ADLs. Resident #2 was not coded for any neurological deficit that would indicate deficit in cognition. Record review of Resident #2's care plan, date initiated 05/02/2025, documented The resident has an ADL self-care performance deficit r/t left hand Arthritis with contracted fingers, weakness post hospital stay. Goal: The resident will improve current level of function in through the review date. Interventions: Provide the level of assistance resident requires in ADL care as follows: Bed Mobility: Assist X 1 Staff toileting: assist x 1 Staff transfers: assist x 1 Staff dressing/ grooming: assist x 1 staff Eating: limited assist X 1 Staff bathing: assist X 1 Staff M-W-F 6/2. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. PT/OT evaluation and treatment as per MD orders. Resident #2 was not care-planned for any cognition impairments. During an interview on 07/19/2025 at 4:47 PM and 07/20/2025 at 3:48 PM, Resident #2 stated she was Resident #1's roommate. Resident #2 stated she recalled the event on Sunday, 07/13/2025. Resident #2 stated, she recalled Resident #1 being transferred by wheelchair into the room and heard Resident #1 emoting an emotional response. Resident #2 stated the emotional response sounded like an outburst of moaning which indicated to her, Resident #1 was in pain. Resident #2 recalled on 07/13/2025, overhearing RN B (dayshift) on the phone with Resident #1's family member, telling the family member Resident #1 had fallen, but both the family member and Resident #1 voiced no desire for ER transfer. Resident #2 stated she recalled the night shift (10PM-6AM) CNA A enter the room on three separate occasions throughout the night. Resident #2 stated during CNA A's second round, CNA A entered the room, notified Resident #1 she was going to provide care, and overheard Resident #1 verbalizing moans and ow which indicated pain. Resident #2 stated she told CNA A Resident #1 was moaning throughout the night. Resident #2 stated after she notified CNA A, CNA A vacated the room. Resident #2 stated CNA A entered the room for a third round, and again Resident #1 verbalized an exhibition of pain, and Resident #2 stated to CNA A she believed Resident #1 may have broken something after her fall on 07/13/2025, to which CNA A vacated the room, and returned with a nurse. Resident #2 stated after the nurse entered the room, she overheard the nurse instruct CNA A to not move Resident #1, and Resident #1 needed to be sent to the emergency room as something might be broken. Resident #2 stated she recalled roughly around 5AM, EMS arrived and removed Resident #1 from the room. Resident #2 reiterated she saw CNA A enter the room on three separate occasions. Resident #2 stated the first occasion was roughly around 11PM on 07/13/2025, the second around 2-3AM and third around 4-5AM on 07/14/2025. Resident #2 stated on the second and third occasion she smelled bowel movement and stated that was her confirmation CNA A was providing incontinent care. Resident #2 stated Resident #1 was consistently and intermittently moaning throughout the night and voiced to the CNA on the second and third round, Resident #1 was verbally exhibiting pain of moaning. Resident #2 stated on the second occasion when CNA A entered the room and provided care, she overheard Resident #2 scream and complain about her leg hurting. Resident #2 stated it wasn't until the third round around roughly 4AM that she saw a nurse enter the room. During a phone interview on 07/19/2025 at 5:00 PM, CNA A stated when she arrived for her shift around 10:00 PM on 07/13/2025, she did not recall being notified of Resident #1's fall. CNA A stated she rounded on Resident #1 on three occasions. CNA A stated she rounded on Resident #1 around 10:20 PM on 07/13/2025, secondly around 2:30 AM and thirdly around 4:30 AM both on 07/14/2025. CNA A stated during her first round, she provided care to Resident #1, Resident #1 did not seem like herself, as she was quiet and not as talkative, but at the time she did not exhibit any signs or symptom of pain, and when she asked Resident #1 if anything was wrong, Resident #1 verbalized she was okay. CNA A stated during her second round, she provided incontinent care to Resident #1, and during the care Resident #1 was exhibiting signs and symptoms of pain and was moaning throughout incontinent care yet continued to gently complete the incontinent care. CNA A stated during the second round Resident #1 verbalized pain in her right hip. CNA A stated she did not report the pain to charge nurse because as soon as she completed the incontinent care and desisted with moving Resident #1, Resident #1 no longer exhibited pain, and therefore CNA A continued to care for other residents. CNA A stated while she attempted to recall the second and third round on 07/14/2025, Resident #1's pain appeared to get worse while she provided perineal and bowel movement care, and furthermore became difficult to turn Resident #1 as she was exhibiting pain and saying ow when CNA A attempted to turn Resident #1. CNA A stated during her third round, roughly around 4:30 AM, Resident #1 was exhibiting more pain during incontinent care. CNA A stated she was trying to clean Resident #1 without moving her, as an effort to minimize pain, but when she asked Resident #1 what hurt, Resident #1 stated her leg was hurting. CNA A reiterated round two consisted of Resident #1's complaint of pain of the hip area, and on the third round, the pain was of Resident #1's leg. CNA A stated she did not desist with attempting to provide care, as her reasoning was, she could not leave Resident #1 in bowel movement and urine. CNA A stated she was educated to notify the charge nurse when she notices anything irregular. CNA A stated had she had more information about Resident #1's fall, her actions would have been to notify the charge nurse during her second round. CNA A stated she had taken care of Resident #1 before, and Resident #1 was known to lightly moan when she was turned during incontinent care, and did not believe anything was irregular during her first round. CNA A stated she notified RN A on her third round when Resident #1 was exhibiting pain, but did not notify RN A during her second round because Resident #1, after completion of incontinent care, no longer exhibited signs of pain. CNA A stated during her third round, Resident #1 was attempting to assist with movement, as CNA A asked for Resident #1 to lift her buttock but was exhibiting severe pain, therefore could not assist CNA A with incontinent care. CNA A stated she did not desist with providing care on the third round because she needed to get the job done. CNA A stated after she completed Resident #1's incontinent care, she exited the room and went to notify RN A around 4-5AM timeframe. CNA A stated she notified RN A of Resident #1's exhibition of pain, to which she verbalized to RN A she believed something may have been broken. CNA A stated when RN A entered the room, RN A directed her not to move Resident #1, as an intervention to decrease any chance of an injury worsening. CNA A stated RN A stated Resident #1 was going to be transferred to the emergency room, and the paramedics would be transferring her shortly. CNA A stated after her shift was completed on 07/14/2025, she learned Resident #1 had a fall on 07/13/2025. CNA A stated she believed her actions were just and would not have changed the choices she made. CNA A reiterated she did not notify RN A regarding her second round, as Resident #1 discontinued signs and symptoms of pain after incontinent care was completed. CNA gave no definitive answer when asked, what could potentially occur if the charge nurses were not notified when residents exhibit signs and symptoms of pain. CNA A stated during her three rounds, while she was consistently within Resident #1's hallway, and throughout her shift, Resident #1's door was ajar, and never heard any loud outward expression of pain coming from Resident #1's room. During a phone interview on 07/19/2025 at 7:42 PM, RN A stated she worked on Sunday night (10PM-6AM), 07/13/2025. RN A stated on 07/13/2025, during bedside shift report, she was notified of Resident #1's fall, and that RN B (2PM-10PM) stated sometime around 9PM, the Resident #1 fell to the floor and never cried out, nor had any skin irregularities or noticeable contusions that warranted emergent interventions. RN A stated Resident #1 was scheduled for x-rays on 07/14/2025. RN A was told the mobile x-ray company did not have technicians after hours and would need to be completed in the morning on 07/14/2025. RN A stated she rounded on Resident #1 around 11PM and Resident #1 was not exhibiting any signs nor symptoms of pain. RN A stated she rounded on Resident #1 roughly 2-3 times between the hours of 11PM-1AM while assessing Resident #1's Neuro checks. RN A stated additionally she was quietly observing Resident #1 and without turning the light on, observed Resident #1 with her eyes closed, and was not exhibiting any signs nor symptoms of pain. RN A stated as part of the fall protocol neuro checks must be completed. RN A stated she checked vital signs and Neuro checks throughout the night from roughly 11:00PM (07/13/2025) thru 1:00AM (07/14/2025) and completed an assessment roughly around 3:00AM on 07/14/2025, however Resident #1 never verbalized any complaint of pain, or exhibited any signs of pain. RN A stated during her first initial round Resident #1 was not exhibiting any signs nor symptoms of pain. RN A stated it was not until 4-5AM timeframe when CNA A notified her Resident #1 was really hurting. RN A stated once she was notified, she commenced a head-to-toe assessment on Resident #1 and noticed not only a slight deformity to right hip but also exhibiting pain. RN A stated she noticed swelling on the outside of the right end of the femur that met the pelvis and had a purple/red discoloration. RN A stated she immediately called 9-1-1 because her findings were abnormal. RN A stated between the hours of 11:00PM on 07/13/2025 thru 4:00AM on 07/14/2025 she was not notified of any pain concerns for Resident #1. RN A reiterated she was in Resident #1's room consistently throughout the night completing neuro checks, vital signs, and additionally was in the hallway consistently to attend other residents, and never heard any loud outward expression of pain from Resident #1's open door room. RN A stated the protocol for all aides was if they noticed any irregularities including pain, they must notify the nurse. RN A stated the reason aides were mandated to notify the charge nurses of any irregularities was so the nurses could complete an assessment and if warranted would implement interventions to mitigate the issues. RN A stated additionally with every concern, especially pain, the physician must be notified, and the physician's directives would be executed. RN A stated she followed her protocol when she was notified of Resident #1's pain, she immediately called 9-1-1, then notified her managerial staff, physician, and responsible person. RN A stated if CNA A witnessed Resident #1 in pain, she should have been notified immediately and continued to state she directed Resident #1 not to be moved to minimize any further injury exacerbations, which potentially would prevent any negative outcome. RN A stated as a preventative measure she did not want to cause a potential dislodgement of Resident #1's lower extremity, and immediately called 9-1-1. RN A stated she was never notified of CNA A's second round findings regarding Resident #1. RN A stated the scheduled facility x-rays were not completed at the facility due to Resident #1 being transferred to the ER. During an interview at 07/20/2025 at 3:50 PM, the DON stated she was notified on 07/14/2025 by RN A that roughly around the 4-5AM timeframe, Resident #1 was exhibiting signs and symptoms of pain. The DON stated she was notified on 07/14/2025 by the night nurse RN A, via text, that during CNA A's last round roughly around the 4-5AM timeframe, when CNA A completed her last round of incontinent care, Resident #1 was exhibiting signs and symptoms of severe pain. The DON stated CNA A notified RN A she could not turn Resident #1 and was exhibiting pain during care. The DON stated when RN A completed her assessment, RN A observed bruising which warranted further evaluation and called 9-1-1 as the situated necessitated emergent services. The DON stated it was not until the 4-5AM timeframe on 07/14/2025, that she was notified of any additional concerns after Resident #1 fell around 9PM on 07/13/2025. The DON stated if CNA A witnessed any concerns regarding pain or any irregularity, she should have notified RN A immediately to advocate for Resident #1's safety. The DON stated aides were mandated to notify the clinical nurse so the nurses could complete a head-to-toe assessment and should their findings warrant an immediate intervention, the nurse could act swiftly to ensure the well-being of all residents. The DON stated she was unaware of CNA A's second round pain findings regarding Resident #1. The DON stated if RN A implemented a directive to not move Resident #1, it may have been due to precautionary measure to minimize further injury exacerbations. The DON stated potentially if CNA A did not notify RN A when she first witnessed Resident #1 exhibiting pain, there would be a potential for a negative outcome. The DON reiterated she was not notified of any additional pain concerns from when Resident #1 fell on [DATE] around 9PM, to when she was notified by RN A of the pain concern on 07/14/2025 around 4-5AM. The DON stated the physician was notified when Resident #1 had the fall on 07/13/2025 around 8:50PM and additionally when RN A was made aware of Resident #1's pain around 4-5AM on 07/14/2025. Record review of the facility's Acute Condition Changes-Clinical Protocol policy and procedure, date revised December 2015, revealed, .3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. A. Nursing assistant are encouraged to use the Stop and Watch Early Warning Tools to communicate subtle changes in the resident to the Nurse. Record review of Pain Assessment and Management policy and procedure revise dated March 2015, revealed Pain management is a multidisciplinary care process that includes the following b. Effectively recognizing the present of pain;.5.conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is on set of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes.