**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 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 3 of 9 residents (Resident #33, #42, and #83) reviewed for pain management. 1. The facility failed to provide effective pain medication for Resident #33 who admitted to the facility on [DATE] and received Hydrocodone-Acetaminophen 1 oral tablet 325 mg. per order, on all three shifts, for 7-15-2025 and 7-16-2025. Resident #33's pain levels remained high without physician notification or effective intervention. 2. The facility failed to provide effective pain medication for Resident #83 who re-admitted to the facility on [DATE] and received Acetaminophen-Codeine 1 300-30 mg. oral tablet on 7-15-2025 three times a day per order. Resident #83's pain levels stayed above a level 5 without effective relief or physician notification or effective intervention. 3. The facility failed to provide effective pain medication for Resident #42 who admitted to the facility on [DATE] and received Norco 1 Oral Tablet 325 mg. from 7-1-2025 through 7-16-2025 every 6 hours per order. Resident #42's pain levels stayed elevated at a level 10 from 7-15-2025 thru 7-16-2025 without physician notification or intervention. An Immediate Jeopardy (IJ) was identified on 7-17-2025 at 12:46 PM. The IJ template was provided to the facility on 7-17-2025 at 12:52 PM. While the IJ was removed on 7-17-2025 at 5:50 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, that was not immediate jeopardy, and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents, who are on controlled pain medication, at risk of not receiving appropriate pain management - resulting in pain. Findings included: 1. Record review of Resident #33's face sheet, dated 7-15-2025 indicated the resident was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter (a surgical wound that has reopened after the initial surgery, and it's being addressed in a follow-up visit), and secondary diagnoses of anemia (blood isn't carrying as much oxygen as it should), type 2 diabetes (a condition where one's body doesn't use insulin properly , a hormone that regulates blood sugar), obstructive and reflux uropathy (a blockage in the body to carry out proper urination), and pain, unspecified. Record review of Resident #33's MDS dated [DATE] revealed Resident #33 was verbal, and had a BIMS score of 13 which indicated Resident #33 was cognitively intact. Resident #33's pain assessment interview indicated she was at a level 10 for pain. Record review of Resident #33's care plan with an initiation date of 6-25-2025 revealed Resident #33 was care planned for acute and chronic pain and required pain management. Resident #33's care planned directed staff to Monitor/record/report to Nurse resident complaints of pain or requests for pain relief and Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #33's physician's orders, initiated on 6-25-2025 indicated the facilities' medical director agreed with Resident #33's care plan. The physician's orders stated for Resident #33 to receive Hydrocodone-Acetaminophen 2 Oral Tablets 10-325 mg. every 4 hours as needed. On 7-15-2025 at 9:15 AM, Resident #33 was heard groaning in her bedroom. Upon entry into Resident #33's bedroom, it was revealed Resident #33 was in pain at a level 10. Resident #33 stated she had been in severe pain for 3 days. Resident #33 said she told the nurse on duty 3 hours ago she was in a high level of pain but only received a muscle relaxer and it did not relieve her pain. In an observation and interview with Resident #33, on 7-15-2025 at 3:00 PM, Resident #33 was lying in bed and said her pain level was at a level 9, and the facility had not provided adequate pain relief. Resident #33 said it made her feel like just giving up. In an observation and interview with Resident #33 on 7-16-2025 at 1:45 PM, it was learned that Resident #33 was at a pain level of 9 and lying in bed. In an observation and interview on 7-16-2025 at 1:49 PM, LVN D was informed that Resident #33 was at a pain level of 9. LVN D was told by Resident #33 that she was at a pain level of 9 at 1:50 PM. LVN D gave Resident #33 PRN pain medication. Record review of Resident #33's Medication Administration Note, dated 7-16-2025 at 1:54 PM, and entered by LVN D, stated Resident #33 received 2 Acetaminophen Oral Tablets 325 mg. Record review of Resident #33's MAR, for 7-15-2025 and 7-16-2025, revealed Resident #33 received her regularly scheduled pain medication of Hydrocodone-Acetaminophen Oral Tablet 10-325 mg. 1 tablet every 4 hours on all three shifts. Record review on 7-16-2025 of the MAR, for Resident #33, revealed the 6:00 AM - 2:00 PM shift (LVN D) had entered a pain rating of 0 in the Pain Assessment Section. In an observation and interview with Resident #33, on 7-16-2025 at 3:21 PM, it was revealed that Resident #33 was lying in bed and was at a pain level of 7-8 since she received the PRN pain medicine at 1:49 PM. Record review on 7-16-2025, of the MAR for Resident #33, for the 2:00 PM-10:00 PM shift, revealed LVN E had entered a pain rating for Resident #33 at a 0. In an interview on 7-16-2025 at 3:40 PM, LVN E said she had worked at the facility for about 1 year, worked the 2:00 PM-10:00 PM shift, and was assigned to Resident #33. LVN E said her process for pain management was, when she comes to work, on her evening shift, she makes rounds with the daytime 6:00AM-2:00 PM nurse and asked the residents if they are in pain. If a resident has been given regular pain medication, and they are still in pain, she will give them their PRN pain medication. LVN E said if the PRN pain medication does not work, she will contact the doctor to get a new order. LVN E said, when she came on her shift today, Resident #33 was at a level 0 for pain. Record review of Resident #33's nurse progress notes and MAR failed to indicate staff contacted the physician because of the facility's ineffective pain management. 2. Record review of Resident #83's face sheet, dated 7-15-2025, indicated a [AGE] year-old female readmitted to the facility, from the hospital, on 7-14-2025, with a primary diagnosis of unspecified dementia without behavioral disturbance (cognitive decline but cannot pinpoint the specific type of dementia or the severity of the condition), and had secondary diagnoses of chronic pain (persistent pain that lasts for three months or longer), end stage renal disease (the final stage of chronic kidney disease, where the kidneys have lost most of their function and can no longer adequately filter waste products from the blood), anemia (a low level of red blood cells carrying oxygen in the blood), and type 2 diabetes (a chronic metabolic disorder where the body either doesn't produce enough insulin or the cells become resistant to its effects, leading to high blood sugar levels). Record review of Resident #83's Quarterly MDS dated [DATE], indicated Resident #83 was verbal, and had a BIMS score of 12, which revealed she had a mild cognitive impairment. In the pain assessment portion, of Resident #83's MDS, indicated she had pain, and the intensity level was a level 7. Record review of Resident #83's care plan initiated on 12-3-2024 and revised on 5-13-2025 stated Resident #83 was care planned for pain r/t osteoarthritis, pressure wound, muscle wasting, and atrophy.staff were to Monitor/record/report to Nurse any signs of non-verbal pain. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment.Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Discuss and record preferences [of pain management options]. Record review of physician orders dated 7-15-2025 indicated the doctor agreed with Resident #83's care plan. Resident #83's care plan stated pain assessments should be done before and after PRN medications are administered using the 0-10 pain scale or Pain AD (Pain Assessment/Documentation area) .and should be done every shift using Pain AD. Resident #83's orders included pain medication of Acetaminophen 2 oral tablets by by mouth every 6 hours and Tramadol 50 mg. 2 oral tablets by mouth every 6 hours as needed for pain. In an observation and interview, on 7-15-2025 at 9:33 AM, it was revealed that Resident #83 was in pain all the time and currently was at a pain level 7 and the facility had done nothing for her pain. Resident #83 stated she tells the staff she is in pain and staff tell her they will see if they can give her another dose of pain medication, but they don't. On 7-15-2025 at 3:13 PM, Resident #83 was observed lying on her bed and stated she was at a pain level of 6. In an observation and interview on 7-16-2025 at 9:50 AM, Resident #83 was observed in her Wheelchair about to leave for her dialysis appointment. Resident #83 stated she was at a pain level 6 and was at a pain level 6 all night long. Resident #83 said rarely was she ever below a level 5 pain level at the facility. Resident #83 was observed yelling out in pain when LVN B attempted to put a sock on Resident #83's right foot. In an interview, on 7-16-2025 at 11:19 AM, it was revealed LVN B had worked at the facility for 1.5 month, worked the 6:00 AM-2:00 PM shift, and was assigned to Resident #83. LVN B said her process for pain management was for the CMAs to give out the regularly scheduled pain medication and if a resident was still in pain, she would give the PRN pain medication. LVN B said she always asked residents for their pain scale rating and documented what level of pain they are at in the MAR. LVN B said if the PRN pain medication did not work and the resident was still at a pain level of 5 or higher, she would contact the doctor. In an interview on 7-16-2025 at 11:26 AM, LVN C said she had worked at the facility for 1.5 years and worked the 6:00 AM - 2:00 PM shift. LVN C said her process for pain management was if a resident was still in pain, after his regular pain medication was given, she would look to see if they had a breakthrough (PRN) pain medication and see if they can give it to the resident. If the resident did not have a PRN medication on file, she would contact the doctor about getting one. LVN C said it was a nursing industry standard to ask a resident what pain level they were at, using the 0-10 pain scale, to determine if a resident was getting the right medication. In an interview, on 7-16-2025 at 1:19 PM, RN F said Resident #83 had been in pain, at a level 8 since 6-9-2025, every time Resident #83 came into the dialysis office for treatment. Record review of Resident #42's face sheet dated 7-16-2025, revealed a [AGE] year-old male who admitted to the facility on [DATE]. His primary diagnosis was sequelae of cerebral infarction (the long-term consequences or complications that arise after the initial brain damage caused by a stroke), and secondary diagnoses were Chronic pain, pain in the right shoulder, and muscle wasting and atrophy (the decrease in muscle mass and strength due to the breakdown or loss of muscle tissue). Record review of Resident #42's Comprehensive MDS, dated [DATE], revealed Resident #42 had a BIMS score of 8, indicating he was mildly cognitively impaired. Record review of Resident #42's care plan dated 5-6-2025 and revised on 5-12-2025 indicated he required pain management d/t chronic pain instructing staff to monitor/record/report to nurse complaints of pain and request for pain treatment.and to notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #42's physician orders dated 5-5-2025 stated Resident #42 was to be assessed for pain before and after PRN pain medication was given using the 0-10 pain scale or PainAD, and document results. The physician agreed with Resident #42's care plan.Physician order date of 5-6-2025 stated Resident #42 receive Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for Pain.Physician order date 5-14-2025 stated Resident #42 receive Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hoursfor Pain related to pain in right shoulder. Record review of Resident #42's MAR revealed he received 1 Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) every 6 hours for the entire month of July through 7-16-2025, received 1 Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) on 7-8-2025 and 7-10-2025. The Pain assessment using the PainAD/Verbal Scale 0-10, for every shift on Resident #42's MAR, indicated he was at a zero-pain rating from 7-1-2025 through 7-16-2025. In an interview and observation on 7-15-2025 at 9:08 AM, it was learned that Resident #42's pain level was at a 10. Resident #42 was observed to be swollen, and he wanted to know if his pain medication could be increased pain in his left hand. Resident #42 said his pain levels were high at night, and it was keeping him from sleeping. Resident #42 said he had to keep his left hand elevated to prevent throbbing pain. In an observation and interview, on 7-15-2025 at 2:51 PM, Resident #42 said his pain was at a level 10. In an observation and interview on 7-16-2025 at 9:16 AM, Resident #42 said his pain level was at a level 10 and has stayed at a level 10 for days. In an observation and interview on 7-16-2025 at 1:21 PM, LVN B was observed attending to Resident #42. LVN B stated Resident #42 was in pain all the time. LVN B said Resident #42 had a diagnosis which caused pain but did not know what it was. LVN B said she was not aware of Resident #42 being in pain at a level 10. LVN B said she asked Resident #42 his pain level every time she gives him pain medication, and Resident #42 has never told her he was in pain at a level 10. LVN B said she did not know what pain level Resident #42 was on 7-15-2025, even though she was working and assigned to Resident #42. In an interview on 7-16-2025 at 1:30 PM, the Medical Director revealed the facility had not contacted him about high pain levels in the last two days. The Medical Director said the facility should contact him if a resident has received their PRN pain medication, are still at a level 5 pain or higher, and the PRN pain medication did not bring the pain level below a level 5. The Medical Director said the facility did not have a pain management doctor, but it might be a good alternative to non-narcotic pain management. Record review of the facility's policy titled Pain Management, dated 6-2020 stated: To ensure accurate assessment and management of the resident's pain. A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain.if the Licensed Nurse is unable to determine if the resident's facial expression is related to pain, the nurse will advise the attending physician and Interdisciplinary Team committee, so that the attending physician can consider ordering a pain medication.A Licensed Nurse will reassess the resident for pain quarterly and eventfully.If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for review of medications.Nursing staff will implement timely interventions to reduce the increase in severity of pain. An Immediate Jeopardy (IJ) was identified on 7-17-2025, at 12:46 PM. The Administrator and ADON were notified. The IJ template was provided to the Administrator via email on 7-17-2025 at 12:46 PM and a Plan of Removal (POR) was requested. The following POR was submitted by the facility and accepted on 7-17-2025 at 3:31 PM. Summary of Details which lead to outcomes.F697 - Pain Management On 7/17/2025 during annual survey at [Nursing Facility]. [State] surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to ensure that 3 residents' chronic pain were managed to bearable levels. The notification of the alleged immediate jeopardy states as follows: The facility failed to ensure residents 83, #33 and #42's chronic pain were managed to bearable levels. Residents remained at pain levels of 6 or higher consistently even when pian medication was administered. Identify residents who could be affected. All residents with chronic pain have the potential to be affected. Identify responsible staff and what action taken. 1. Resident # 83, #33, and # 42, new pain assessment completed. MD (Medical Director) notification to clarify orders and any changes in pain management/interventions. Completed by assistant director of nursing on 7/17/25. 2. All residents with chronic pain will have a new pain assessment completed, any assessment with pain level of 4 or greater, MD will be notified to clarify orders and any changes in pain management/interventions. Completed by Nurse managers on 7/17/25. 3. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 4. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 5. Regional MDS/MDS Nurse: All residents with chronic pain care plans audited to ensure appropriate pain interventions in place. Completion of 7/17/25. 6. All patients with chronic pain, assessments will be monitored daily to ensure patients' pain is managed to comfortable levels and the residents are not experiencing adverse outcome. DON/ADON Nurse managers. Ongoing daily. 7. Pain levels documented 4 or above in pain assessment by licensed Nurse will be placed in pain monitoring log to be reviewed daily by DON/ADON/Nurse manager to ensure follow up and interventions in place. In-Service conducted. 1. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. 2. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Implementation of Changes Resident # 83, #33, and # 42, new pain assessment completed. MD notification to clarify orders and any changes in pain management/interventions. Completed by assistant director of nursing on 7/17/25. All residents with chronic pain will have a new pain assessment completed, any assessment with pain level of 4 or greater, MD will be notified to clarify orders and any changes in pain management/interventions. Completed by Nurse managers on 7/17/25. All nurse managers educated by regional nurse consultant on pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Director of Nursing/assistant director of nursing/nurse managers in-serviced all licensed staff pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. Completion of 7/17/25. Regional MDS/MDS Nurse: All residents with chronic pain care plans audited to ensure appropriate pain interventions in place. Completion of 7/17/25. All patients with chronic pain, assessments will be monitored daily to ensure patients' pain is managed to comfortable levels and the residents are not experiencing adverse outcome. DON/ADON Nurse managers. Ongoing daily.Pain levels documented 4 or above in pain assessment by licensed Nurse will be placed in pain monitoring log to be reviewed daily by DON/ADON/Nurse manager to ensure follow up and interventions in place. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 7/17/2025 and training was completed on 7/17/2025. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated pain management/pain assessments, change in condition/MD notification, PRN pain medication administration. The Director of Nursing/Assistant director of nursing will ensure competency through signing of Inservice, and verbalization. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 7/17/25. The Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review abnormal pain assessments daily in stand-up. Weekend supervisor will review on Saturday/Sunday, x 4 weeks to ensure residents' pain is managed at comfortable levels and the residents are not experiencing adverse outcomes. Any adverse findings will be reviewed during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/17/2025 and conducted an Ad HOC QAPI regarding ensuring chronic pain is managed to bearable levels and that residents are comfortable and not experiencing adverse outcomes. The Medical Director was notified about the immediate Jeopardy on 7/17/2025, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 7/17/2025. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Processes. The New Process/ system was started on 7/17/2025. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 7/17/2025. The facility was monitored for compliance with the POR (Plan of Removal) on 7-17-2025 as follows: In an interview on 7-17-2025 at 3:24 PM, LVN G stated he was in-serviced on pain management today and informed that the facility received an IJ for not providing effective pain management. LVN G said a new policy that had been implemented was to complete a change in condition on a resident if they were at a pain level of 4 or higher. The facility can give Tylenol if the resident has a PRN pain medication, and their pain level is from 1-5. If the resident's pain level is above a level 5, they will give them something stronger. If the resident does not have anything stronger on their chart and they are above a pain level of 5, they notify the doctor. LVN G said in the in-service for pain, he was instructed to put a pain level number in the MAR, in (PCC) and there are not prompts to put the number in. LVN G said the nurse assigned to the resident on shift, was responsible to monitor the resident's pain levels. In an interview on 7-17-2025 at 3:45 AM, LVN E said she had been in-serviced on pain management after the IJ was called. LVN E said she was instructed when a resident's pain level is a 4 or above, call the doctor for a stronger pain medication. She was told to put in the progress notes the level of pain the resident was at and what was given to them to relief it. LVN E said the changes the facility implemented was to complete a change of condition when the resident reaches a pain level of 4 or higher. Record review on 7-17-2025 at 4:20 PM, confirmed the facility had completed in-service training, by the ADON, on Medication Administration and PRN Medication Administration to ensure residents were assessed for pain after PRN medication has been given, Pain Management to ensure residents don't rise higher than a level 5, and Change in Condition and Physician notification. In an interview on 7-17-2025, at 4:25 PM, the ADON stated the DON was on vacation and she was the ADON for the entire facility. The ADON said this IJ occurred because the State identified the nurse's documentation on pain management was inconsistent. The ADON said she will complete all in-services on how to monitor, document, and perform effective pain management. The ADON said she will make sure the managers are trained on this as well as the weekend supervisors. The ADON said the nurses on duty will notify management (ADON/DON) whenever the pain levels are greater than a 4, and they will have a discussion as to what needs to be done next. The ADON said the physician will also be called when pain levels rise above a 4. After that, the ADON said a follow-up with the patient will occur and a review of proper documentation by the nursing staff. The ADON said a new process was the facility now has a Pain Management Log, where pain levels that are greater than 4 are entered into it. In an interview, on 7-17-2025 at 4:42 PM, LVN C revealed that she was provided an in-service on 07/17/2025. LVN C said the in-service stated there will be a pink binder at the nurse's station containing pain assessment forms on each resident. The nurses were to document pain findings in the binder. LVN C stated that when a resident was in pain, we were to document the pain level, give them their routine pain medication, wait for a while, then note what their pain level was after the medication was given. If pain was at a level 4, we were to call the physician for possible additional medication. LVN C said we then continue to monitor resident's pain level, and if pain continues, contact the physician to send the resident to hospital.In an interview, on 7-17-2025 at 4:45 PM, LVN D revealed that she was provided an in-service regarding pain management on 07/17/2025. LVN D said that nurses are to monitor resident's pain levels regularly and provide residents with routine pain medication. If a resident's pain level rose to a level 4, nurses are to call the physician to see if the physician will order another pain medication. If the resident's pain level is still high, contact the Physician, with change in condition filled out, and the physician will send the resident out to hospital for uncontrollable pain. In an interview, on 7-17-2025 at 4:59 PM, LVN B revealed that she was provided an in-service on pain management on 07/17/2025. LVN B said that the in-service training stated we were to document resident's pain levels, on the Pain Assessment form, when a resident asked for pain medication. LVN B said after a resident has received their regularly scheduled pain medication, wait a while, check their pain level again, and document the pain level. LVN B said if a resident's pain level was at a level 4 or above, the nurse was to call the physician for another medication. The nurse was to continue to assess the resident for pain. If a resident's pain continues to be at a level 4 or greater, contact the physician so the resident can be sent out to the hospital to be treated. In an interview, on 7-17-2025 at 5:00 PM, LVN H stated that he was not in-serviced on pain management, as of today, but was in-serviced on pain management on 7-14-2025. LVN H said he was trained to document the pain medication given to the resident that was prescribed by the doctor. LVN H said the facility has narcotics in stock. LVN H stated that he will follow-up with the resident and document the resident's pain level. LVN H said he will let the doctor know if a resident's pain persists. LVN H said if the doctor has initiated a narcotic, and he has given the resident the narcotic, he will follow up with the doctor to let him know how the resident is doing. The ADON and nurses are responsible for managing resident's pain levels and monitoring what the nurses are doing. On 7-17-2025, at 6:02 PM, LVN H said he was in-serviced on pain management, pain levels, and when to notify the doctor. LVN H said he was told to notify the doctor if a resident's pain level reached a level 5. LVN H said the in-service stated once a nurse gives a resident pain medication, the nurse was to follow up with the resident to see how effective the pain medication was. The nurses were to document, in the progress notes, what level the resident's pain was. If the pain level has not dropped, contact the doctor. In an observation, on 7-17-2025 at 5:20 PM, Resident #83 was observed to be sleeping peacefully. In an interview, on 7-17-2025 at 5:45 PM, the Medical Director stated the risk to residents not receiving proper pain management could be it could cause other problems. The Medical Director said pain management can be tricky, and everyone is different. The Medical Director said the nursing staff need to make sure they document pain management correctly in the electronic medical records. In an observation, on 7-17-2025 at 5:50 PM, Resident #42 and Resident #33 were observed being transported to the hospital due to high pain levels. On 7-22-2025 at 12:20 PM, the Administrator said the IJ occurred because the State found a concern with the way the facility was handling pain management. The Administrator said the way the facility will monitor the ensure compliance with the POR was to have daily management meetings with the nursing department and for management to stay in communication with the weekend shift with residents who have pain concerns. The facility will bring those concerns to the QAPI monthly meetings. The Administrator said the DON and the Administrator were responsible to monitor and oversee the processes of pain management. An Immediate Jeopardy (IJ) was identified on 7-17-2025 at 12:46 PM. The IJ template was provided to the facility on 7-17-2025 at 12:52 PM. While the IJ was removed on 7-17-2025 at 5:50 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, that was not immediate jeopardy, and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.