Suring Health And Rehab Center

jeopardy to resident health or safety

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.

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