Health inspection·July 10, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assess a resident with new onset pain, failed to document the new onset pain, and the facility failed to ensure the resident's provider received notification of new onset pain. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin in the sample of 4. Residents Affected - Few The findings include: R1's admission Record (Face Sheet) showed an original admission date of 10/9/24 with diagnoses including, but not limited to, generalized osteoarthritis, overweight, dementia, and a fracture of the lower end femur (thigh bone, onset date 6/24/25). R1's 4/10/25 Quarterly Minimum Data Set (MDS) showed severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. R1's MDS showed she was dependent upon staff for toilet hygiene, bathing, lower body dressing, and all types of transfers. R1's MDS showed she received scheduled pain medication; however, she denied pain for the previous six days and she did not receive as-needed pain medication during the review period. R1's June 2025 Medication Administration Record (MAR)/Treatment Administration Record (TAR) showed twice-daily pain assessments. The pain assessments showed no documented pain until the PM documentation on June 22, 2025, (Sunday) at a rating of 3 out of 10. The MAR showed an order for Acetaminophen (an over-the-counter pain medication), two 650-milligram tablets to be given every 8 hours as-needed for pain. The MAR showed this medication was not given for the month of June 2025 until June 21, 2025, (Saturday) at 11:38 PM. The acetaminophen was documented as being given by V12 Nurse for a pain rating of 9 out of 10. R1's Progress Notes showed no entry for 6/21/25. R1's 6/22/25 Health Status Note (Nurse's Note) from 12:56 PM showed, CNAs (Certified Nursing Assistant) alerted this nurse that resident seemed to be having some right leg pain and is not tolerating bearing on that side. This nurse assessed resident, resident not tolerating range of motion well, winces and says 'no' .CNAs used [mechanical lift, crane type] for transferring resident from bed to chair. No fall or event noted that would indicate cause of increased pain. Message left for provider, DON (Director of Nursing, V2) notified, POA (Power of Attorney) notified of increased pain in right leg. (Authored by V5 Registered Nurse) The next chronological note from 6/23/25 (Monday) at 9:09 AM showed the nurse practitioner assessed R1 and ordered an X-ray of R1's right knee. Page 1 of 2 145789 145789 07/10/2025 Allure of Geneseo 704 South Illinois Street Geneseo, IL 61254

F 0697 Level of Harm - Minimal harm or potential for actual harm R1's 6/24/25 progress note from 12:06 PM, showed the nurse practitioner was notified of the X-Ray results and R1 was sent out via 911. R1's 6/26/25 Health Status Note from 11:37 AM showed R1 returned from the hospital with a right lower femur fracture. The note showed family declined surgical intervention and placed R1 in hospice care. Residents Affected - Few On 7/9/25 at 2:20 PM, V12 Nurse stated she was notified by a CNA that R1 was having pain the evening of 6/21/25. V12 stated R1 does not typically have pain. V12 stated she prepared two acetaminophen tablets and then entered R1's room. V12 stated R1 was crying, which was not unusual behavior for R1. V12 stated she asked R1 if she was having pain and R1 nodded her head yes. V12 stated she asked R1 where she was having pain, and due to R1's dementia, she was unable to state where her pain was. V12 stated she did not assess R1 for this new onset pain. V12 stated after she gave R1 the acetaminophen, R1 fell asleep and showed no signs or symptoms during the remainder of her shift, which ended on 6/22/25 at 7:00 AM. On 7/9/25 at 9:50 AM, V5 Registered Nurse stated she was notified by a CNA that R1 was having pain the morning of 6/22/25. V5 stated she assessed R1 and was able to identify her pain to her right leg with movement, which was not normal for R1. V5 stated there was no bruising or cuts to the leg. V5 stated R1 had not fallen and there was no indication regarding the cause of R1's pain. V5 stated R1 was normally a stand-and-pivot transfer or a mechanically assisted sit-to-stand lift. V5 stated due to R1's pain, she was changed to a crane-type mechanical lift transfer. V5 stated she notified R1's provider, however, the provider did not respond. V5 stated R1 was seen by the provider the following day (6/23/25). On 7/9/25 at 2:35 PM, V2 Director of Nursing (DON) stated V12 should have assessed and documented the assessment regarding R1's pain the evening of 6/21/25. V12 stated if a resident, like R1, is unable to verbalize their pain location due to cognitive deficits, there are alternative methods such as range of motion, skin assessments, or palpation (pressing and feeling the patient's body.) V2 said the purpose of the nursing assessment is to determine the cause of the resident's change in condition and gather information. V2 stated she was aware R1's provider had not returned V5's notification on 6/22/25; however, V2 stated she was aware R1's provider would be at the facility on 6/23/25. V2 stated she was not aware R1 had stated pain the evening of 6/21/25. V2 said, given that R1 had new onset pain with range of motion and R1's method of transfer needed to be altered to accommodate the new pain; V5 should have ensured R1's provider received the notification prior to the end of her shift. The facility's Notification of Change policy (August 2024) showed, Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial conditions .Circumstances that require a need to alter treatment . On 7/9/25 at 10:34 AM, V4 R1's Physician stated there was no indication R1 suffered a fall, and it is possible she received the fracture during a normal, safe transfer and that staff may not have been aware of the fracture when it occurred. V4 stated R1 has weakening of the bones (osteopenia), she has arthritis, she has had a right knee replacement, she is female, she is overweight, and she is elderly. V4 stated these are all risk factors contributing to R1's fracture. V4 stated a delay in R1 being sent to the hospital would not have altered her outcome. 145789 Page 2 of 2