**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 1 of 5 sampled residents (R1) received care and treatment in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) and failed to ensure a change of condition was recognized and acted upon timely.On 8/26/25, R1 complained of increased pain and difficulty breathing. The Nurse Practitioner (NP) was notified and indicated R1 could have additional acetaminophen up to 4000 milligrams (mg) in a 24 hour period in addition to tramadol and could use diclofenac or stock pain reliever for back/shoulder pain. The NP also gave an order to try to wean R1 off oxygen which the NP presumed was used for anxiety/pain and indicated if R1 continued to require oxygen, staff should notify the NP. The orders were not transcribed in R1's medical record at that time. According to staff interviews, R1 was tearful, reported ongoing pain and difficulty breathing, and cried out in pain during the evening hours. R1's medical record did not contain evidence of assessments of R1's condition or documentation that R1 required oxygen throughout the evening. There were no additional updates to the NP or Medical Doctor (MD) until R1 requested to go to the emergency room (ER). At the ER, R1 was diagnosed with sepsis, right pleural effusion, and acute renal failure and was subsequently transferred to another hospital and admitted to the Intensive Care Unit (ICU). The facility's failure to recognize a change of condition, complete thorough assessments, and provide timely care for a resident with increased pain and difficulty breathing despite the use of oxygen led to a finding of immediate jeopardy that began on 8/26/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 9/5/25 at 9:57 AM. The immediate jeopardy was removed on 9/5/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action planFindings include:The facility's Pain Management policy, dated 2/5/25, indicates the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Facility staff should use a systematic approach for recognition, assessment, treatment, and monitoring of pain. The facility's Notification of Changes policy, dated 3/2025, indicates the facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change in condition such as a significant change in the resident's physical, mental, or psychosocial condition and circumstances that require a need to alter treatment. According to the Wisconsin Nurse Practice Act, N6.03(1): A Registered Nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.On 9/3/25, Surveyor reviewed R1's medical record. R1 had diagnoses including heart failure, diabetes, anxiety, and lymphedema. R1's Minimum Data Set (MDS) assessment, dated 6/28/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.A care plan, dated 7/23/25, indicated R1 had altered respiratory status/difficulty breathing related to heart failure with a goal to maintain a normal breathing pattern. The care plan contained interventions to use oxygen per nasal cannula 1 to 4 liters per minute (LPM) as needed for shortness of breath (SOB), respiratory distress, or comfort; and monitor for signs/symptoms of respiratory distress and report to physician as needed, including increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, cough, pleuritic pain, accessory muscle usage, and skin color changes to blue/grey.R1's Medication Administration Record (MAR) indicated R1 received scheduled acetaminophen (a non-opioid anlagesic medication used to treat mild to moderate pain) 1000 mg three times daily for pain (up to 4000 mg total per day) (start date 6/21/25); tramadol (an opioid medication used to treat pain) 50-100 mg every 6 hours as needed for pain related to lymphedema (start date 6/3/25); and acetaminophen 650 mg every 4 hours as needed for fever/pain (start date 4/22/25). R1 also had an order in pending status on 8/27/25 for diclofenac sodium gel (a pain relieving medication) apply to back/shoulder topically every 6 hours as needed for pain.R1's medical record indicated R1 complained of right shoulder and back pain at a level 5 out of 10 (based on a numeric scale of 10 being the worst pain) and difficulty breathing on 8/26/25 at 2:00 AM. Tramadol 100 mg was administered and supplemental oxygen was provided via nasal cannula at 2 LPM. R1 attributed the pain to a pulled shoulder muscle from using the sit-to-stand lift. Unit Manager (UM)-E documented at 4:33 AM that the pain medication was effective and R1 had a pain level of 0 out of 10.On 8/26/25 at 8:04 AM, UM-E notified R1's physician that R1 had increased shoulder and back pain during the night that R1 attributed to using a sit-to-stand lift and complaints of SOB while lying in bed. R1's vital signs were assessed. R1 had a pulse rate of 93 and an oxygen saturation level of 94% on room air. R1 was placed on supplemental oxygen which helped R1's SOB so R1 was able to sleep. R1's MAR indicated R1 received tramadol 100 mg for pain at a level 7 out of 10 on 8/26/25 at 8:38 AM.On 8/26/25 at 9:35 AM, an NP responded to the 8:04 AM update and indicated R1 could have additional acetaminophen up to 4000 mg in a 24 hour period in addition to tramadol and could use diclofenac or stock pain reliever for back/shoulder pain. An order indicated to try to wean R1 off oxygen which the NP presumed was used for anxiety/pain and indicated if R1 continued to require oxygen, staff should notify the NP. On 9/3/25 at 1:11 PM and at 3:31 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who gave R1 a shower on 8/26/25. CNA-F indicated CNA-F usually provides R1's shower right away in the morning because it is an extensive process due to R1's edema wraps and routine. CNA-F stated R1 was using oxygen when CNA-F entered the room and R1 stated staff thought oxygen would help R1's pain. R1 indicated the pain was all over and not anywhere specific. CNA-F indicated CNA-F usually asks the nurse to administer pain medication prior R1's shower because R1 is usually in pain and cries at the start of the shower, however, CNA-F can get R1 to relax and calm down as the shower proceeds. CNA-F indicated it takes time to complete R1s shower but R1 usually enjoys it CNA-F indicated when R1 received a shower on 8/26/25 between 10:00 and 11:00 AM, R1's pain was different than usual. R1 cried throughout the shower and screamed out in pain when CNA-F reached out to R1 without making contact. CNA-F rushed through R1's shower due to R1's discomfort. CNA-F did not observe R1 struggling to breathe though and indicated R1 was still crying when CNA-F took R1 back to R1's room. After the shower, CNA-F informed the nurse who indicated they would check on R1. CNA-F stated that at approximately 2:00 PM, CNA-F went back to check on R1 because CNA-F was concerned about R1's condition in the shower. CNA-F indicated R1 looked worn out and was sitting in bed bent over a bedside table with R1's head down. CNA-F put a blanket over R1 and told R1 to tell the nurse if R1 felt worse.R1's medical record indicated R1's pain was at a level 0 out of 10 on 8/26/25 at 11:07 AM and was also at a level 0 out of 10 when R1's scheduled acetaminophen was administered at 11:36 AM.On 9/3/25 at 10:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who worked the 8/26/25 AM shift. LPN-H was notified during report that R1 had increased pain during the night and UM-E sent a message to the NP. UM-E informed LPN-H that UM-E administered oxygen to R1 during the night. LPN-H checked on R1 between 6:00 and 7:00 AM and indicated R1 was sleeping. LPN-H stated the next time LPN-H heard something was at approximately 9:00 AM when CNA-F asked for something for pain for R1. LPN-H administered R1 PRN tramadol and checked R1's vitals signs. LPN-H spoke to R1 and indicated everything seemed okay. LPN-H stated R1 later received a shower and LPN-H didn't hear from R1 for the remainder of the shift. LPN-H approached the NP who was in the building that day. The NP indicated the NP was not planning to see R1 but had gotten an update through the system. LPN-H stated R1 did not complain of pain or breathing issues. In a subsequent interview at 12:39 PM, LPN-H did not recall if R1 used oxygen during the shift. LPN-H indicated the last time LPN-H saw R1 was at approximately1:00 PM when LPN-H administered R1's scheduled acetaminophen. When asked if LPN-H saw the NP's response and orders at 9:35 AM, LPN-H indicated LPN-H did not see either at that time but processed the orders during LPN-H's next shift which started on 8/26/25 at 10:00 PM and went through 6:00 AM on 8/27/25.R1's MAR indicated R1 was only administered scheduled acetaminophen on 8/26/25 at 9:07 PM and R1's pain was at a level 0 out of 10. The MAR did not indicate any PRN pain medication was administered to R1 after 8:38 AM on 8/26/25. Surveyor also noted NP's orders received by the facility at 9:35 AM on 8/26/25 after UM-E notified the physician were not transcribed into R1's medical record until 8/27/25 at 3:32 AM. On 9/3/25 at 10:24 AM, Surveyor interviewed CNA-G who worked the 8/26/25 PM shift. CNA-G started at approximately 2:00 PM and was told in report that R1 was lethargic and not feeling well and wasn't R1's usual self. CNA-G indicated there was no mention of pain, nausea, or breathing difficulties. When CNA-G entered R1's room at approximately 3:00 PM, R1 complained of pain on the right side around the rib cage and arm and asked to be transferred to the commode. CNA-G indicated R1 would only let CNA-G raise R1 so far in the EZ Stand (a mechanical lift) during the transfer because it hurt too much. CNA-G stated R1 provided no energy or help during the lifting process and stated it hurt around R1's rib change and to move R1's arm up. CNA-G positioned R1 on the commode and notified RN-D that R1 would like pain medication. RN-D stated RN-D would check with R1. R1 then activated the call light, told CNA-G that R1 could not breathe, and asked to be transferred to the recliner. CNA-G transferred R1 into the recliner and put oxygen on R1 until RN-D could assess R1. When R1 activated the call light again after dinner trays were passed, CNA-G told R1 that CNA-G would ask RN-D for pain medication. R1 told CNA-G that RN-D had already been in R1's room and R1 wanted something stronger. CNA-G retrieved the pulse oximeter, walked into the hallway, and told RN-D that R1 was having dificulty breathing. RN-D said RN-D would get there as soon as RN-D could. CNA-G answered other residents' call lights and then heard moaning from R1's room between 6:30 and 7:00 PM. CNA-G entered R1's room and asked what CNA-G could do. R1 said R1 just hurt. CNA-G notified RN-D. CNA-G stated staff tried to make R1 comfortable by offering repositioning, pillows under R1's back, and heat/ice. CNA-G was in the process of putting other residents to bed and heard R1 call out, Help me. Help me. It hurts. It hurts. CNA-G and RN-D immediately entered R1's room. RN-D said the only thing RN-D could do was send R1 out to be evaluated. CNA-G indicated R1 usually had pain but didn't usually yell like that during transfers. CNA-G did not know what RN-D gave R1 for pain or what else RN-D had done. On 9/4/25 at 2:36 PM, Surveyor interviewed RN-D via phone who indicated RN-D was not updated on any concerns for R1 during shift report. RN-D indicated RN-D administered metformin to R1 prior to 6:30 PM and R1 did not report any pain. RN-D did not recall being told by staff that R1 complained of pain between 3:00 and 4:00 PM. RN-D also didn't recall being told by a CNA that R1 was still in pain, had difficulty breathing, and needed oxygen after 4:00 PM. RN-D indicated R1 always used oxygen and RN-D did not expect to be updated that R1 needed oxygen. (Of note: R1's medical record did not indicate R1 always used oxygen.) RN-D also didn't recall being informed by staff that R1 was in pain after dinner trays were passed. RN-D indicated RN-D heard R1 cying in pain across the hall at approximately 6:30 PM. RN-D checked on R1 who indicated R1 was in pain which could have been due to therapy. RN-D checked R1's vital signs which RN-D indicated were fine, however, RN-D didn't document the vital signs and could not recall what they were. RN-D stated RN-D focused on a musculoskeletal assessment but did not document the assessment or inform Surveyor of the results. RN-D indicated R1 complained of pain in the shoulder and thorax and RN-D provided scheduled acetaminophen at that time. R1 refused tramadol and Biofreeze (a topical pain reliever) because R1 wanted something later if the pain got worse. RN-D did not complete a pain assessment at that time but asked R1 the location of the pain. RN-D was going to contact the physician for a different pain reliever but didn't do so because R1 wanted to go to the hospital. RN-D then focused on calling the physician so R1 could be transferred. When Surveyor indicated R1's scheduled acetaminophen was administered at 9:07 PM and R1's pain was rated at a level 0 out of 10, RN-D indicated R1 did not indicate R1 had pain until approximatey 20 minutes later. Between 9:00 and 10:00 PM, R1 told RN-D that R1 had difficulty breathing and wanted to go to the hospital. RN-D did not complete a respiratory assessment because RN-D called the physician and 911 and R1 did not want RN-D to touch R1. RN-D notified Director of Nursing (DON)-B between 9:00 and 10:00 PM that R1 was transferred to the hospital but had not spoken to DON-B prior. A progress note, dated 8/26/25 at 9:25 PM, indicated the physician was notified that R1 had increased pain on the right side of the chest and difficulty breathing and wanted to go to the ER. At approximately 10:30 PM, R1 left the facility with 911 transport to the hospital. A progress note at 11:52 PM indicated R1 refused tramadol and acetaminophen when offered. Hospital documentation indicated R1 arrived at the hospital on 8/26/25 at 10:42 PM and had diagnoses including sepsis, right pleural effusion, and acute renal failure. At 11:17 PM, R1 received fentanyl (an opioid medication used to treat pain) 100 micrograms (mcg). At 11:32 PM, R1 had a fever of 102.5 degrees Fahrenheit (F) and was placed on oxygen at 5 LPM. At midnight, R1 received acetaminophen 1000 mg and ketorolac tromethamine (a nonsteroidal anti-inflammatory medication used to treat pain) 15 mg. On 8/27/25 at 1:40 PM, R1 was transferred to the ICU at another hospital. On 9/3/25 at 6:59 PM, Surveyor interviewed R1 who was in the hospital. R1 indicated R1 was tired all day on 8/26/25 and it hurt to breathe. R1's pain and breathing got progressively worse throughout the day. R1 indicated sometime after supper between 7:00 and 9:00 PM, R1 told RN-D that something needed to be done and asked to go to the hospital. R1 was transferred to the ER and diagnosed with sepsis and a bacterial infection and told that R1's lungs were filled with fluid. R1 could not recall if R1 was offered tramadol or received pain medication at the facility that day but stated if R1 did receive pain mediation, it didn't work because R1 was in a lot of pain and it was hard to breathe. R1 stated R1 was fuzzy on the details of the day. R1 stated staff knew R1 was hurting and having difficulty breathing and at approximately 9:00, R1 couldn't take it any longer. RN-D entered R1's room close to 7:00 PM. R1 thought RN-D was going to give R1 Tylenol, however, R1 wasn't sure if R1 received it and told RN-D that R1 needed something stronger. R1 did not recall if R1 received a stronger medication. R1 recalled telling a CNA that R1 needed to see a nurse. R1 stated R1's pain was at a level 10 out of 10 that evening and was like nothing R1 had felt before. R1 stated staff did not send R1 to the ER until R1 requested to go. R1 stated staff offered ice and heat and indicated it was easier for R1 to sit up than lay down. R1 did not recall using oxygen during the day but stated R1 used oxygen toward the evening and the night prior.On 9/3/25 at 3:44 PM, Surveyor interviewed R1's primary MD ((MD)-C) from the facility who indicated when R1 complained of a different type of pain in the shower, staff should've notified MD-C about R1's change in condition. MD-C also indicated if anything is off or if a resident isn't acting like themself, staff should notify MD-C. MD-C indicated if R1 had increased SOB despite the use of oxygen, did not get better with oxygen, or needed increased oxygen, staff should've notified MD-C. On 9/3/25 at 4:13 PM, Surveyor interviewed DON-B who indicated the orders received from the NP at 9:35 AM on 8/26/25 for increased acetaminophen, diclofenac cream, and to wean R1 from oxygen should have been transcribed in R1's medical record within 2 hours of receipt of the orders. DON-B indicated the nurse who provided care for R1 should have completed a full assessment, including vital signs and a range of motion assessment, and updated the physician with the results. DON-B also indicated staff should have administered as needed diclofenac gel, acetaminophen, and/or tramadol and should have documented the actions taken to alleviate R1's pain in real time. DON-B indicated if a resident has pain, staff should complete a pain assessment, provide non-pharmacological interventions, and/or administer and document medications. DON-B spoke with RN-D who cared for R1 from 6:00 PM until R1 was transferred to the ER regarding the steps to take to provide care for R1. DON-B indicated RN-D did not complete the steps DON-B had provided. DON-B discussed with staff the importance of visualizing a resident to ensure pain medication is effective and confirmed oxygen use should be documented in the resident's medical record. DON-B indicated staff discussed implementing a triple carbon copy system so if staff have a concern, they can fill out a copy and give it to the nurse, DON-B, and NHA-A to ensure follow-up.The failure to recognize and act upon a change in condition in a timely manner led to serious harm for R1 who was still hospitalized on [DATE] and created a finding of immediate jeopardy. The immediate jeopardy was removed on 9/5/25, however, the deficient practice conitnues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:Completed a head-to-toe assessment for all in-house residents.Implemented an eInteract Point Click Care (PCC) Evaluation for Change in Condition and use of internet tools and resources.Reviewed in-house residents in daily Interdisciplinary Team (IDT) meetings for completion, documention, and identification of a change in condition, assessments (including vital signs), and provider notification.Educated staff on the facility's policies regarding notification, pain management, identifying a change in condition, and transcription and documentation of orders.Implemented audits and reviewed progress notes for change of condition response.