Ignite Medical Mchenry

timely manner which applies to 1 of 3 residents (R1) reviewed for Pain Management in a sample of

female resident admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery and presence of left artificial hip joint.R1's Brief Interview for Mental Status assessment dated [DATE] showed R1 was cognitively intact.R1's Physician Order Summary Report printed 2/23/26 showed R1's pain medication ordered upon admission was Oxycodone-Acetaminophen oral tablet 10-325 milligrams (Percocet) to be given every 4 hours as needed for pain.On 2/23/26 at 12:25 PM, R1 stated they were taking their pain pills every 4-5 hours.

R1 stated if they went longer than that the pain would get bad. R1 stated on 2/14/26 they told V15 Certified Nursing Assistant (which fits the description given by R1) around 7 PM they needed some pain medication. R1 stated they were told it was shift change, and it may be a little bit before the nurse was in. R1 stated the next person she saw was V11 Licensed Practical Nurse at 8:30 PM. R1 stated their pain had gotten pretty bad (7/10) by the time V11 came to the room. R1 stated V17 (R1's family) was on speaker phone at that time. R1 stated V11 stated they were not told R1 had asked for pain medication.On 2/23/26 at 2:15 PM, V17 stated they were on the phone with R1 at 8:30 PM on 2/14/26. V17 stated R1 sounded upset, told them R1 request medication at 7:00 PM, and had not seen anyone since. V17 stated V11 came into the room to see R1. V17 stated V11 said she was not informed R1 had asked for pain medication. V17 stated they heard R1 tell V11 their pain was 7/10.On 2/23/26 at 6:10 PM, V11 stated they rounded on R1 for evening medication rounds. R1 was grimacing, agitated, and said she was in pain (7/10). V11 stated they were not told in report or by a CNA R1 had requested pain medication prior to V11 entering the room. V11's shift started at 7 PM. V11 stated they entered R1's room around 8:30 PM on 2/14/26. V11 stated if they were told R1 needed pain medication they would have administered it sooner.R1's Vital Summary (pain) printed on 2/23/26 showed R1's pain level was a 7/10 at 8:30 PM on 2/14/26.R1's Medication Administration Record printed 2/23/26 showed R1 received a doses of Oxycodone on 2/14/26 just before 2:00 PM and the next dose at 8:30 PM (6.5 hours between doses).On 2/23/26 at 12:40 PM, V3 Director of Nursing stated a resident's pain level is what they say it is. If a CNA is told by a resident they need pain medication the CNA needs to let the nurse know so the nurse can do something about it.R1's Initial Care Plan dated 2/12/26 showed R1 is having pain in the left hip and lower back. An intervention for pain is to respond immediately to any complaint of pain.The facility's Pain Management Policy dated 1/1/26 showed the facility must ensure that 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.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE