F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide pain management for one of three residents (R3)
reviewed for pain in the sample of 5. This failure resulted in R3 not receiving pain management for a fall
with serious injury for 24 hours. This past non-compliance occurred from 11/16 until 11/18/24.
Residents Affected - Few
Finding Include:
R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired, and R3
requires substantial to maximum assistance. R3's MDS dated [DATE] documents R3 is moderately
cognitively impaired. R3 needs partial assistance from another person for any activities.
R3's Electronic Health Record documents R3 has diagnoses of FX (Fracture) of Unspecified Part of Neck
of Left Femur and Traumatic FX.
R3's Pain Care Plan 11/13/24 documents R3 has potential for pain related to unstable angina and COPD
(Chronic Obstructive Pulmonary Disease) Interventions: anticipate the residents need for pain relief and
respond immediately to any complaint of pain. Observe report to nurse any S/SX (signs and symptoms) of
nonverbal pain.
R3's Fall Investigation dated 11/17/24 documents resident (R3) noted to have witnessed fall (CNA)
(certified nursing assistant) V9 resident noted to fall on her left side of body, head, shoulder hip, and leg. No
obvious signs of trauma to left hip, left shoulder, and left leg PERRLA (pupils are equal round and reactive
to light and accommodation) within normal limits for this resident. Pupils equal and brisk. No c/o (complaint
of) headache or discomfort, able to move all extremities as prior. Adduction and abduction without issues
and WNL (within normal issues) for this resident. Bruising to left upper lip and posterior facial cheek. No gait
alterations noted, no difficulties ambulating, no indication of further emergent medical need at this time. MD
(Medical Doctor) updated, POA (Power of Attorney) updated and nurse. Intervention: place pressure pad
alarm in bed.
R3's Left Femur Left Hip X-ray dated 11/18/24 at 5:32 PM documents slightly impacted subcapital FX of
femoral neck. Impression impacted subcapital FX.
R3's Medication Administration Record (MAR) for the month of November documents Pain assessment not
completed for November 16-21.
R3's November 2024 MAR documents Pain record highest level of pain Q (every) shift, 11/16 on days R3's
pain was a 10 on day shift. R3 was not given pain medications on 11/16/24. On 11/17 pain was not
evaluated, and pain medications were not given on 11/17/24. On 11/18/24, R3's pain was rated a 6 on
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145508
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145508
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Health Care Center
1450 26th Street
Highland, IL 62249
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
days and evenings; however, R3 was not given pain medications on this day. On 11/19 R3's pain was a 6 on
days and evenings, on 11/20/24 R3's pain was a 6 on days and evening; however, R3 was at the hospital
and not residing at the facility.
R3's MAR also documents R3 was given Tylenol 325 milligrams (mg) two tablets Q (every) 6 hours PRN (as
needed) and was given on 11/22 for a pain level of 2 and it was effective. R3 was not given any pain
medication on 11/18 although her pain was rated at a 6.
R3's MAR documents Tramadol 50mg Q 8 hours PRN for chronic pain was last given on the 10th of
November.
R3's Physician Order Sheet (POS) dated 5/14/24 documents Norco 5/325mg (milligrams) give one tablet by
mouth every 6 hours as needed for pain. Do not exceed 4 GM (grams) daily.
R3's POS dated 11/20/23 documents Tramadol 50mg 1 tablet every 6 hours as needed for pain.
R3s POS dated 11/22/24 documents Acetaminophen 325mg give 2 tablets by mouth every 4 hours as
needed for pain fever.
R3's After Visit Summary from a local hospital documents R3 was discharged on 11/22/24.
On 12/3/24 at 3:50 PM, V2 Director of Nursing stated, I recognized there was a problem, and I did a plan of
correction right away. Everyone was in serviced on Pain Management.
On 12/5/24 at 9:36 AM, V12 Physician stated, absolutely I expect her (R3) pain to be treated, if she (R3)
complained.
The facility policy Management of Pain dated 5/16/22 documents promptly and accurately assessing and
diagnosing pain. Encourage the resident to self-report pain.
Prior to the survey date, the Facility took the following actions to correct the noncompliance on 11/18/24.
Immediate Actions:
1.The facility in serviced all nurses regarding pain management and the administration of pain medications
on 11/18/24. This was completed by V2.
2. The facility added pain management as an action plan to quality assurance as well as monitoring
compliance beginning on 11/18/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145508
If continuation sheet
Page 2 of 2
