**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and facility policy the facility neglected to provide prescribed pain medication to a resident who experienced severe/uncontrolled physical pain and caused mental anguish or emotional distress as evidenced by the resident's verbalization of Just need to die for one (1) of five (5) residents reviewed for pain management. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. The facility neglected to ensure nursing staff had sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room resulting in Resident #25 going without essential pain medication for days. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff neglected to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The neglect by the facility to ensure needed pain medication was available for Resident #25 caused this resident harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and SQC and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation - F600 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 10/24/22, revealed, It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . During an observation on 10/10/23 at 10:15 AM, revealed Resident #25 sitting in his wheelchair in the front hallway area speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but resident was observed to be very distraught and stated, Just need to die. During an observation and interview with Resident #25 on 10/10/23 at 10:45 AM, revealed resident was in his room sitting in his electric wheelchair. His posture was slumped to the side and resident did not sit upright and straight in his chair. He stated he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated that he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain. He stated he had to ration out his pain medicine to be comfortable. He revealed he had an order for one (1) to two (2) pain tablets every six (6) hours as needed for pain and after taking one this morning, he verified he had three tablets remaining. If he took the two for therapy, he would have only one to last him until midnight. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not gotten his medication before he ran out and this should not happen. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. Interview with Registered Nurse #1 on 10/11/23 at 11:00 AM. She stated the automated medication distribution system can be used to obtain medications for the resident if an active prescription is available in the pharmacy. She confirmed there were times when the resident did not have pain medication available and she had tried at times to notify the NP to have a refill sent to pharmacy, but it was not sent timely, and the resident was without pain medication for a longer period of time. Interview with the Director of Nursing (DON) on 10/11/23 at 4:00 PM, confirmed that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain on multiple days. The DON confirmed Resident #25 was sent to the hospital for chest pain when he was out of pain medications on 09/02/23. He received a prescription for pain medications from the ER on [DATE] that was sent to the pharmacy, but it was after hours, and the facility staff did not know the procedure to contact the pharmacy to notify the on-call staff that the prescription was sent, and a code was needed. The resident, therefore, had to endure pain for a long holiday weekend as well as multiple other days. She confirmed that the resident did not receive the pain medication until 5:30 AM on 09/06/23 An interview with Nurse Supervisor/Registered Nurse (RN) #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was still unavailable. She stated she contacted the NP who stated she would come to the facility to evaluate the resident, but before she arrived, the resident called 911 from his personal cell phone and was sent to the emergency room for evaluation. She confirmed the resident was out of his pain medications and he was complaining of severe/uncontrolled pain. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with others also. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the Nurse Practitioner or the Medical Doctor but was not called back. She stated when the provided did not return her call, a prescription was not obtained to receive the medications. On 10/11/23 at 4:15 PM, during an interview ,the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She stated the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a written prescription for the narcotic timely. Therefore, the resident suffered with severe, unrelieved pain for multiple days. An interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23. She stated she relied on the Nurse Practitioner (NP) to follow through with sending the orders to pharmacy as needed. She stated she is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him. A phone interview on 10/12/23 at 10:05 AM, with the Nurse Practitioner revealed she was notified by the facility staff on 9/2/23 that the resident had no pain medication and was in pain and was sent to the emergency room for evaluation of chest pain and she was unaware the resident was requiring as many pain pills as he had needed. She did confirm that she occasionally had a missed call from the facility and when she called the facility, no one knew who needed to speak to her and she did not pursue trying to talk to the administrative staff members to determine who had a concern. She confirmed this could have been some of the times when this resident needed medications. On 10/16/23 at 1:45 PM, an interview with the Administrator revealed the facility staff attempted to notify the Nurse Practitioner multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage pain with as needed (PRN) medications. She confirmed the facility neglected to manage this resident's pain appropriately by the Nurse Practitioner and the Medical Director not responding to the facility's request for a needed resident's care and service which led to severe and uncontrolled pain for a resident. During a phone interview on 10/16/23 at 2:20 PM, with the Medical Director revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he did order short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not a successful option for pain management. He stated he would occasionally order this for a hospice resident, but otherwise he would order PRN pain medicine and not scheduled pain medication. He stated last week, when the facility notified him of the concerns for this resident's pain management, he did order a scheduled every 12 hour long-acting pain medication and a short acting PRN medication. He stated that generally he was only notified when the Nurse Practitioner was unavailable. During a phone interview on 10/17/23 at 11:20 AM, the Medical Director revealed, I am not reluctant about writing for short-acting pain medications, I just do not generally schedule it. He stated he is aware the nurse practitioner wrote prescriptions, but she was not required to notify him each time she wrote a prescription, and she had the right to do this without notifying him each time. He stated, I do not recall being notified that the resident was in extreme pain for days and did not have pain medications available over Labor Day weekend and was sent to the emergency room with chest pain. He stated I do not recall the staff attempting to contact him on 9/10/23 concerning the resident's level of pain and no medication available and the staff being unable to reach the Nurse Practitioner and the resident having to wait until 9/12/23 to receive his medication from pharmacy. He stated he wrote pain medication for short term therapy residents, so they were able to participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medications. He stated he did not recall being notified by the facility of the resident's comment concerning he would be better off dead related to his pain and lack of medication. He stated he does not recall being notified of this, but the staff would only notify him if they could not reach the NP. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated on the pharmacy recommendation dated 8/29/23, it was recommended for a stop date for resident's pain medication, and this was declined with reason of chronic pain syndrome. He stated this was declined since the resident needed the PRN pain medication. The Director of Nursing wrote on the form that the resident frequently complained of pain discomfort. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He confirmed that as of last week, he was aware of the resident's pain and medication availability concerns and put the resident on a long-acting scheduled pain medication and the short acting as needed medication to be used for breakthrough pain. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medication available from the pharmacy was received on 9/6/23 for 14 tablets (10 on one card/form and 4 on another card/form). The prescription was sent on 9/2/23 at 3:40 PM. The first dose of these was administered on 9/6/23 at 5:30 AM. The next prescription for 60 tablets was ordered by the NP on 9/11/23 and was received in pharmacy on 9/11/23 at 10:59 AM. These were delivered to the facility on 9/11/23. The first dose was administered on 9/12/23 at 3:30 AM and the last dose was administered on 9/25/23 at 10:15 PM. The next prescription for 60 tablets was ordered by the NP on 9/26/23 and received in the pharmacy on 9/26/23 at 5:26 PM. These were received in the facility on 9/27/23. The first dose was administered to the resident on 9/27/23 at 6:30 AM. Record review of prescription from the emergency room to the pharmacy dated 9/2/23 for Norco 7.5-325 mg (milligram) tablets with quantity of 14 tablets. Record review of the Controlled Substance Proof of Use form revealed the 14 tablets ordered in the emergency room on 9/2/23 arrived in the facility on 9/6/23, and the first tablet of these was administered to the resident on 9/6/23 at 5:30 AM. The last dose of these 14 tablets was documented as signed out as given on 9/9/23 at 8:01 PM. Record review of text message sent to NP from RN #2 dated 9/10/23 at 10:39 AM, revealed, Hey just double checking you sent those hard copies in yesterday? Pharmacy is saying they don't see them in their fax list. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x (times) 3, message left, MD called x 2, awaiting call back. Record review of the next prescription dated 9/11/23 and was noted as received to the pharmacy on 9/11/23 at 10:59 AM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/11/23 and received in the pharmacy on 9/11/23 at 10:59 AM were delivered to the facility on 9/11/23 (with their routine delivery around midnight). The first of these doses given to the resident was on 9/12/23 at 3:30 AM and the last dose was given on 9/25/23 at 10:15 PM. Record review of progress note dated 9/26/23 at 11:59 AM by Registered Nurse #1 revealed, Resident is upset that his PRN (as needed) pain medication is not in currently however we are awaiting a hard copy from providers so therefore we can not give the specific pain med that he wants at this time. This was explained to resident however he is still upset. Resident is cussing at staff and yelling inappropriately. Resident informed that he can have a different PRN such as Tylenol but he is still upset about being out of his Norco. Again, tried to educate resident on what's going on however resident began to cuss at this writer. Record review of prescription dated 9/26/23 and was noted as received into pharmacy on 9/26/23 at 5:26 PM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of Progress Note dated 9/27/23 by Nurse Practitioner revealed, Charge nurse called to report patient needs refill of hydrocodone acetaminophen. She reports patient is requesting 2 tablets every 6 hours. Order clarified for 2 tablets before therapy for severe pain otherwise one tablet every 6 hours as needed for pain. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/26/23 was noted to have arrived to facility on 9/27/23. The first dose administered of these tablets was 9/27/23 at 6:30 AM and this was the medications being used by resident when the State Agency arrived in facility on 10/10/23 and the resident had 3 tablets left and no other medication prescription waiting. Record review of History and Physical by Medical Director dated 9/6/23. No documentation concerning pain noted. Record review of Progress Note by Nurse Practitioner dated 9/7/23, revealed, History of present illness: 9/2/23 patient was sent to the ER for complaint of chest pain. He returned to facility with discharge diagnoses of Gastroesophageal Reflux Disease (GERD), Osteoarthritis involving multiple joints, Infantile Cerebral Palsy, and Chronic Pain Disorder. No documentation of pain medication not being in facility noted. Record review of Consultation Report dated 8/29/23, revealed the pharmacy recommendation was declined due to the resident's diagnosis of Chronic Pain Syndrome. Record review of Consultation Report dated 10/9/23 revealed the resident's pain medication regimen was not addressed. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE]. His diagnoses included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis and Cerebral Palsy. Record review of Resident #25's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/3/23 revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 th[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for administering pain medications as ordered (Resident #25), applying an anti-contracture device as ordered (Resident #32), and serving a correct therapeutic diet as ordered (Resident #26) for three (3) of 19 residents reviewed. The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to follow the care plan to administer needed pain medication for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR §483.21(b)(1)(i) Comprehensive Care Plans - F656 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Care Plans, dated 2/20/20, revealed, Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Interdisciplinary - all disciplines work together to develop approaches to help residents meet needs or resolve problems. Care Plan - contains resident problems/needs/strengths, resident goals, and interdisciplinary approaches. PROCEDURE: .6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . Resident #25 Record review of the Care Plan with a start date of 8/29/23 revealed a Care Plan Description listed as, Sometimes I have pain, stiffness, and weakness of joints because of my Arthritis . Care Plan Goal Make me comfortable when my Arthritis bothers me .Intervention .Administer pain medication as needed. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medications available from the pharmacy was received on 9/6/23 for 14 tablets (10 on one card/form and 4 on another card/form). The prescription was sent on 9/2/23 at 3:40 PM. The first dose of these was administered on 9/6/23 at 5:30 AM. The next prescription for 60 tablets was ordered by the NP on 9/11/23 and was received in pharmacy on 9/11/23 at 10:59 AM. These were delivered to the facility on 9/11/23. The first dose was administered on 9/12/23 at 3:30 AM and the last dose was administered on 9/25/23 at 10:15 PM. The next prescription for 60 tablets was ordered by the NP on 9/26/23 and received in the pharmacy on 9/26/23 at 5:26 PM. These were received in the facility on 9/27/23. The first dose was administered to the resident on 9/27/23 at 6:30 AM. Resident #25 revealed in an interview on 10/10/23 at 10:45 AM, he had pain and was ordered pain medication, but the facility did not have this available several times since he was admitted on [DATE]. He stated he is not receiving his pain medication as needed and ordered and having frequent pain due to this. During an interview on 10/11/23 at 3:25 PM, the Minimum Data Set (MDS) Coordinator revealed the resident had a care plan for pain management which included administering ordered pain medications as needed. She confirmed the care plan provides a guide for a resident's care and Resident #25's care plan related to pain management was not followed. An interview with the Director of Nursing (DON) on 10/11/23 at 4:00 PM, revealed a care plan is a guide for the resident's needs and care. She confirmed the facility did not provide the resident's pain medication as ordered and needed and therefore, the care plan for the resident's pain management was not followed. Record review of the MDS with Assessment Reference Date (ARD) of 09/03/23 revealed under Section J Pain that the assessment indicated presence of pain and a pain intensity of seven (7). Section C revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis, and Cerebral Palsy. Resident #26 Record review of the Nutrition Care Plan for Resident # 26 revealed, Provide therapeutic diet as ordered. Record review of Resident # 26's Physician Orders List revealed an order dated 3/15/22, Regular Dental/Mechanical Soft Diet, Ground Meat . On 10/10/23 at 11:50 AM, during an observation of the dining room lunch meal, Resident # 26 was observed sitting at a table feeding himself. The resident was provided a whole thin boneless chicken breast (Tuscan Chicken) that had been cut into small pieces, a mix of peas and carrots, rice, and a roll. It was observed that the resident lacked teeth and had only eaten a small portion (approximately 1/3) of the cut-up chicken. The residents lunch meal ticket read, Dental/Mechanical Soft, Ground Meat. During an observation and interview with the Dietary Manager (DM) on 10/10/23 at 11:58 AM, she confirmed that Resident # 26 was served a whole boneless chicken breast that had been cut into small pieces. She revealed that this was an oversight by the dietary server and the resident should have gotten ground chicken. An interview and record review with the MDS Nurse on 10/12/23 at 10:10 AM, confirmed that Resident #26's nutrition care plan was not followed. An interview with the Administrator (ADM) on 10/12/23 at 10:22 AM, confirmed that Resident #26's nutrition care plan was not followed. Record review of Resident # 26's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Rhabdomyolysis, Anxiety Disorder, Depression, Pericardial Effusion (noninflammatory) and Gastro-esophageal Reflux Disease without Esophagitis. Record review of the MDS with an Assessment Reference Date (ARD) of 7/19/23 revealed, under Section K, Resident # 26 received a mechanically altered diet. Also revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 4, which indicated the resident is severely cognitively impaired. Resident #32 Record review of Resident #32's Care Plan with a start date of 6/20/22 revealed, Care Plan Description Sometimes I have pain, stiffness, and weakness of joints because of my Spinocerebellar degeneration, I have an increased risk for development of contractures related to my disease process Category: Pain .Intervention .Remove anticontracture device from left hand at least for 5 minutes every (Q) shift and observe the skin for any impaired integrity . During an observation on 10/10/23 at 10:20 AM, 10:45 AM, 2:20 PM, and 4:10 PM revealed Resident #32 with his left hand contracted closed with his fingertips touching the palm of his hand. No anticontracture device was observed in his left hand. An observation and interview on 10/11/23 at 10:45 AM, with Certified Nurse Aide (CNA) #2, Resident #32 lying in bed, his left hand was contracted, and no anti-contracture device was observed. CNA #2 revealed he used to have a hand roll when he first came here, and it was used to help his hand not contract. CNA #2 looked in the residents' bedside dresser drawers and stated, I don't see it in here now, I'll have to let therapy know. CNA #2 confirmed it had been quite a while since she had seen it in his hand. On 10/11/23 at 11:55 AM, interview with Licensed Practical Nurse (LPN) #1 revealed Resident #32 is supposed to have a hand roll in his left hand. She revealed the nurses are supposed to check it each shift. She confirmed that yesterday and today she had not put a hand roll in his left hand and revealed he is supposed to have something in his hand to prevent further contractures and she should have made sure it was being done. An interview on 10/11/23 at 11:25, the Minimum Data Set (MDS) nurse revealed she is responsible for developing the comprehensive care plans, she revealed the care plans are developed individually for each resident so that each department will know exactly how to take care of the resident. She confirmed Resident #32 had it in his care plan that he was to have an anti-contracture device in his left hand and if it was not being used then the plan of care was not being followed. Record review of the Face Sheet for Resident #32 revealed he was admitted to the facility on [DATE] with diagnoses which included Contracture left wrist, Hereditary ataxia, Epilepsy, Multiple sclerosis, and Chronic pain syndrome. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. The SA validated by record review and interview with ADON the inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. The SA validated by record review and interviews with Medical Director and Pharmacy Consultant one on one education was provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. The pharmacy Consultant also re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident received adequate pain management as evidenced by a resident experiencing excruciating unrelieved pain for one (1) of five (5) residents assessed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility failed to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure needed pain medication was available for Resident #25 caused this resident serious harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR §483.25(k) Pain Management F697 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled, Pain Assessment and Management, dated 1/16/14, revealed, The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being .Recognition: . 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: a. Loss of function; b. Resisting care, striking out; c. Bracing, guarding or rubbing; f. Fidgeting, increased or recurring restlessness; g. Facial expressions: grimacing, frowning, fear, grinding of teeth; h. Change in behavior: depressed mood, decreased participation in usual activities of daily living .Documentation: .c. Notify physician of new pain or pain not relieved by medication or treatment . Record review of facility policy titled, Medication Administration General Guidelines, undated, revealed, POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so . An observation on 10/10/23 at 10:15 AM, revealed Resident #25 sitting in his wheelchair in the front hallway area of facility speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but the resident was observed to be very distraught and stated, I just need to die. An interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine. He stated the staff told him things like Trying to get the Nurse Practitioner (NP) to send a copy to the pharmacy, or They will have to call the doctor or NP to get a new prescription, or We are still waiting for it to come from the pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do, and he felt as if they were not concerned that he was suffering in pain. The resident stated that he did not want to go to therapy today because he would not have enough pain medications left if he took his pain medication prior to therapy and he didn't know when he would be able to get anymore. Resident stated, I feel like I would be better off dead. An interview with Licensed Practical Nurse (LPN) #1 on 10/10/23 at 11:00 AM, revealed Resident #25 requested one tablet at times and requested two tablets at other times for pain, especially on his therapy days, so his supply was used quicker than if only one was taken each time. She stated he had run out of his pain medication before and took an analgesic powder which was one of his ordered as needed (PRN) medications, but it was not as effective as his pain pill. She stated the resident told her he was not going to therapy today since he was concerned with not having enough pain medication since he only has three (3) tablets available for use in the medication cart at this time. She stated he was given a pain pill at 6:43 AM and she could give him two tablets when due so he could have therapy, and he would have another tablet available to use at bedtime, but after that, he did not have another prescription and would not have any more pain pills available to take. She informed him that more medication should be delivered at midnight, but he did not want to risk not having any for his pain. She stated the facility had an automated medication dispensing system that was available if the resident needed additional pain medications if an active prescription was available. LPN #1 revealed she had not called the NP for this resident's pain medications, but she had called for other concerns in the facility, and it was difficult to get in touch with her and would often require calling her several times before she called back. During an interview on 10/10/23 at 1:30 PM, the Physical Therapy Assistant (PTA) revealed the resident was very upset that he did not have pain medication available and did not receive his pain medications as he was ordered to receive, therefore, he would not attend therapy today since he was concerned about being in pain. He stated it was out of character for Resident #25 to get that upset and he had never heard him say anything like He might as well die. He stated that he had reported that statement to the clinical staff for follow up. He stated that they saw the resident in therapy today with the focus on pain control with heat therapy, and he was not able to complete his scheduled therapy session that was normally scheduled. An interview with the facility's Pharmacy Consultant on 10/10/23 at 2:00 PM revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication to be dispensed from the system, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner or the Medical Doctor to have one sent to the pharmacy for staff to receive a code for the medication. She stated Resident #25's ordered pain medication was one of the medications available in the dispensing system and could have been obtained by the staff for this resident on 09/02/23 after his visit to the emergency room (ER). She stated that the staff should know how to retrieve it from the system. During an interview on 10/11/23 at 8:10 AM, Resident #25 revealed he was sent to the ER yesterday and he received a shot of Morphine and that held him over until he received his pain medication at the facility this morning. The resident stated that he had called 911 from his cell phone in his room because he was in so much pain that he was experiencing chest pain. He stated he had received Tylenol, Ibuprofen, and Analgesic Powder when his pain medications were not available and stated, It makes it easier to bear the pain, but it doesn't go away. He also stated he did not understand why his medications continued to be unavailable. An interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1, revealed if a resident had a current prescription in the pharmacy system, a code could be obtained from the pharmacy and the automated medication dispensing system could be used to obtain the medication. When an active prescription was not available, the facility nurse would notify the NP or the Medical Director (MD) for a hard copy to be sent to the pharmacy and it would be filled and delivered to the facility around midnight. She stated Resident #25 took one to two pain pills when needed, so his pill supply did not last long. She revealed the NP, or the MD are notified when the resident had five tablets remaining on his narcotic card and confirmed that this process was not sufficient for this resident since five tablets would only last him a few hours if the maximum was taken. She confirmed she had notified the NP at times for the resident needing refills on medications, but she did not respond timely, or she wouldn't call back at all, which led to the resident being in pain and without medications. She also confirmed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) had been notified of the concerns that the resident did not receive his pain medication as ordered and needed. During an interview on 10/11/23 at 4:00 PM, the DON confirmed that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain on multiple days. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets. The DON confirmed this resident was sent to the hospital for chest pain when he was out of pain medications on 09/02/23. He received a prescription for pain medications from the ER on [DATE] that was sent to the pharmacy, but it was after hours, and the facility staff did not know the procedure to contact the pharmacy to notify the on-call staff that the prescription was sent, and a code was needed. The resident, therefore, had to endure pain for a long holiday weekend as well as multiple other days. She confirmed that the resident did not receive the pain medication until 5:30 AM on 09/06/23 and she was aware of the situation of the resident being sent to the hospital, yet no procedures were changed to prevent the reoccurrence, and the resident was without pain medication several other times after this incident which was unacceptable. She confirmed the staff were not in-service on the procedure of obtaining medications to prevent this from occurring, and therefore it occurred several additional times. She confirmed the facility failed to notify the NP, MD, and pharmacy timely to provide pain medications for the resident and due to this, the resident suffered severe pain multiple days and led to the resident taking less medication than what he needed due to trying to conserve the amount available. She confirmed it was the facility's responsibility to notify the provider and the pharmacy timely when additional medications were needed, and this was not done for this resident. An interview with Nurse Supervisor/Registered Nurse (RN) #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was unavailable. She stated she contacted the NP who stated she would come to the facility to evaluate the resident, but before she arrived, the resident called 911 from his personal cell phone because he was having chest pain. She confirmed the resident was out of his pain medication and was complaining of severe/unrelieved pain and chest pain and was sent to the ER by ambulance for an evaluation. He received pain medication in the ER and a prescription was sent from the ER to the pharmacy and when he returned, he was not in pain. RN #2 stated that she had spoken with the ER doctor because she knew him and told him to give the resident a prescription for his pain medication because he was out of medication at the facility. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the NP or the MD but was not called back. She stated without being able to contact the provider, a prescription could not be obtained, medication could not be given, and the resident suffered with severe and unrelieved pain. RN#2 confirmed that she worked that Saturday 09/02/23 and Sunday 09/03/23 and she assumed that the staff knew how to use and obtain the medication from the automated drug delivery system. During an interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She felt that the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a written prescription of the medication timely. She also confirmed the facility staff failed to be proactive in a timely manner to ensure the NP or MD were notified that a prescription was needed and to give the NP/MD an adequate amount of time to send to pharmacy and pharmacy an adequate amount of time to fill and provide to the facility. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications through the automated system when needed and not available on the medication cart. She confirmed that this drug delivery system was their emergency drug kit (EDK). She confirmed the staff were not adequately trained on the automated medication dispensing system procedure to receive needed medications for the residents for a one-time dose order sent to pharmacy or even when a prescription was in the pharmacy over the long Labor Day weekend, the staff were unaware of what to do and the medication was not obtained. She confirmed the facility neglected the resident's pain management needs and therefore the resident suffered with severe and unrelieved pain for multiple days. She confirmed there were times when pain medication was not available and Tylenol was given and documented that it was ineffective, yet nothing else was done, and there were also times when the resident rated his pain scale level as a 10 and no narcotic pain medication was available to ease this resident's pain and no other interventions were documented. She confirmed the facility staff failed to notify the pharmacy, MD, or the NP when concerns of pain and lack of medications occurred. An interview with LPN #2 on 10/11/23 at 4:20 PM revealed she had worked with Resident #25 several times and on 9/4/23, he was out of his pain pills, and she offered him a Tylenol and he refused since the pain medicine was his preference to ease his pain. She stated she did not notify the provider or the pharmacy since she notified the charge nurse of the resident being out of his pain medications and was told the medication was on its way from the pharmacy. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication on a weekend, holiday, or at night. She stated she failed to meet the resident's pain management needs by not providing the needed service of pain medication for his pain management. An interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23, but she did confirm that the staff had told her that they were unable to reach the NP or the MD over the weekend of 09/02/23-09/04/23. She stated she relied on the NP to follow through with sending the orders to pharmacy as needed and this was not always done timely. She stated she is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him. A phone interview on 10/12/23 at 10:05 AM, with the NP revealed she was notified by the facility staff on 9/2/23 that the resident had no pain medication and was in pain and was sent to the emergency room for evaluation of chest pain. She stated she was unaware the resident was requiring as many pain pills as he had needed. She denied that she did not send in prescriptions when requested by the facility or that she was unavailable when the staff needed to speak to her. She did confirm that at times the facility would call her and when she called the facility back, no one knew who needed to speak to her and she did not pursue trying to talk to the Administrator, DON or the supervisor to see who had a concern. She stated this could have been some of the times when this resident needed medications, but stated there was no way to know for sure. She confirmed the facility failed to meet the pain needs for this resident, but she denied it was her responsibility since she did what she was required to do and was unsure where the breakdown for this resident occurred. During an interview on 10/12/23 at 2:30 PM, the Administrator confirmed the facility failed to provide Resident #25 with adequate pain relief for his well-being. She stated the facility was responsible for meeting these needs and when the NP did not respond timely, the facility failed to initiate contact with the Medical Director for pain management which caused Resident #25 to go without pain medications for multiple days causing him further pain and mental anguish. She confirmed the prescription that was sent to the pharmacy from the emergency room on 9/2/23 was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday 09/05/23 and was delivered to the facility after midnight. She stated that is why the resident did not get a dose until 09/06/23 at 5:30 AM. She confirmed the facility failed to follow up with other options to ensure this resident received the necessary care. She confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication, therefore, the resident suffered unrelieved pain. She also confirmed there were also other days that the facility failed to obtain Resident #25's medication timely and was in pain without medication to ease his pain. During an interview on 10/12/23 at 3:20 PM, the DON confirmed the facility failed to have the resident's pain meds available as ordered and needed, which led to this resident having pain for several days. She confirmed the facility failed to notify the Medical Director or Nurse Practitioner to try to find a pain management solution for this resident. She also confirmed the nursing staff were not adequately trained to know the proper steps to take to obtain residents' pain medications to prevent unrelieved pain. An interview with the Administrator on 10/16/23 at 1:45 PM, revealed the facility staff attempted to notify the NP multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage with as needed (PRN) medications. She stated when the resident went to the emergency room on 9/2/23, he had a prescription for pain meds and this was sent to the pharmacy, but no staff member contacted the pharmacy to get a code for the system to be able to give the resident the medication for pain. She confirmed the facility failed to educate the staff of the steps to obtain pain medications from the automated medication system and because they were not properly trained, this resident suffered days of severe and unrelieved pain. An interview with Nurse Supervisor/RN#2 on 10/16/23 at 2:00 PM, revealed that on 9/2/23, the resident complained of pain and had no pain medication available in the medication cart. She stated the resident called 911 to be taken to the emergency room for evaluation of chest pain and she informed the ER doctor of the situation with the resident not having pain meds available and he sent a prescription for 14 Norco pills to the pharmacy. She stated he received pain medication in the ER so when he returned to the facility, he was not in pain. She revealed the resident had the prescription in the pharmacy, but the staff did not know the procedure for using the medication dispensing system. She stated she assumed the staff knew how to get the meds out of the system when a prescription was available, and she did not inform the other nurses of what to do to get the ordered medication if needed. She confirmed the DON was aware of the resident's pain medication being unavailable and staff not knowing how to obtain it. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with others also. A phone interview on 10/16/23 at 2:20 PM, with the Medical Director (MD) revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he ordered short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not always beneficial for pain management. He stated he would occasionally order this for a hospice resident, but otherwise it was not what he did. He stated last week, he did order this resident a scheduled every 12 hour long-acting pain medication and a short acting PRN medication for breakthrough pain. He stated the facility would notify the NP first and would usually only contact him if the NP was unavailable. He stated that he was called on 10/10/23 to order something different for pain management for the resident and he had not ever been contacted about this resident having pain issues prior to this. He stated, My goal is to manage their pain so they can receive therapy and go home. The MD was informed of the dates that the resident had unrelieved severe pain and was not able to receive therapy and he confirmed that he was not aware of any of this information. During an interview on 10/17/23 at 9:30 AM, the ADON revealed she and the DON were aware the resident did not have his needed pain medication several different occasions. She stated she called the NP and the MD several times and she finally heard back from the NP and informed her the resident needed a prescription for his pain medication. She stated she could not remember the date and time of the conversation with the NP and did not document this in the resident's record. She stated the NP told her that Resident #25 should have enough since he was just getting one every 6 hours except for therapy times, and the ADON informed her that he took two tablets often and the order had been for 1-2 tablets every 6 hours as needed. She stated the NP said she would send a prescription to the pharmacy, but she confirmed that it was not done timely, and they had to call her back again. She confirmed the communication between the providers and staff was part of the problem and that contacting the providers was often difficult. She stated The DON and everyone else were aware the resident had been out of pain medication. She stated the resident became verbally aggressive and was cursing and she felt like this was due to him being in pain. She stated she did not work Labor Day weekend, but she did hear that a prescription was available and had been sent to the pharmacy, but the staff were unaware of the procedure to obtain the ordered medication. She confirmed she felt that many of the facility's nurses were unaware of how the automated medication system worked and how it was available for the staff to obtain residents' medications day and night. She confirmed the facility failed to call the on-call pharmacy to get the resident's ordered medication which led to the resident experiencing unrelieved pain over Labor Day weekend, and failed to get new prescriptions sent to the pharmacy timely. An interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on a weekend, night, or holiday. She stated the pharmacy sent messages when they were off, so she was unsure what to do during these times. An interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system held routine medications, but he was not aware that pain medication was also available. He stated he was unaware of the procedure to obtain pain medication for a resident if none were available in the medication cart and he would have to ask someone if the situation happened. During an interview with the Rehab Director on 10/17/23 at 10:50 AM, it was revealed that Resident #25 had been cooperative and participated in therapy each time except for two times. She stated on 9/26/23 and on 10/10/23, the resident complained of pain and was expressing frustration that his pain medication was not available as needed and he could not understand why his pain medicine was unavailable so often. She stated the nursing staff were notified of the resident's pain and pain medicine concern. She stated on 9/26/23, therapy saw the resident in his room since he was in severe pain and could not get out of bed. Stated on that day, heat wave therapy was used to help relieve his pain and it helped a minimum amount, and the resident was still in pain. She stated on 10/10/23, the resident was upset that he did not have enough pain medicine to be able to participate in therapy without hurting. On that day, he also informed the PTA that he might as well be dead since his pain was uncontrolled. She stated that on that day, therapy placed hot pack to his back and neck, but he did not have relief from his pain. She also stated that on the days he received his pain medicine, he was cooperative and participated in therapy, was a very pleasant man and would also enjoy conversations with the therapy staff. She stated his goal was to get stronger and return to his apartment, so he was very motivated to participate in his therapy. On 10/17/23 at 10:55 AM, a phone interview with the Pharmacy Consultant revealed she did random checks of the medications where she verified the narcotic count, narcotic log, and electronic medication record, but this was not done with each resident on each visit. She stated Resident #25 was a new resident and the initial pharmacy review was completed on 8/29/23 with a recommendation for a stop date for the PRN pain medication which was declined by the MD due to diagnosis of Chronic Pain Syndrome. She stated on 10/9/23, a full pharmacy review was done and no recommendation for his pain medicine was made since he was a new admission with a diagnosis of Chronic Pain Syndrome and was in the facility for therapy. The Pharmacy Consultant confirmed that she was unaware that the resident had taken almost 60 tablets of the PRN pain medication and stated with Chronic Pain, his pain medication should have been scheduled daily instead of a PRN medication if he was taking it that much. She confirmed the DON had been in-serviced on the automated medication system and the directions are also located in the med room in a notebook that is attached to the machine. She stated she did not in-service all the nursing staff, but the DON and nursing management should have in-serviced the staff on the procedure for use. On 10/17/23 at 11:20 AM, during a phone interview, the MD revealed I'm not reluctant about writing for short acting pain medications, I said I wasn't going to, I just don't schedule it, because it is not shown to be affective. The MD confirmed that he was unaware that his NP was writing prescriptions for short acting pain medications and stated, They (NP) don't have to notify me with each prescription that is written. He stated that I do not recall that over Labor Day weekend and several other dates that he was notified of the resident being in extreme pain and pain medications were not available. He stated I do not recall the staff attempting to contact him on 9/10/23 concerning the resident's level of pain and no medication available. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He stated the 8/29/23 pharmacy recommendation was for a stop date, and this was declined with reason of Chronic Pain Syndrome. He stated it was declined because the resident needed the PRN pain medication. The DON wrote on the form that the resident frequently complained of pain discomfort. He stated that he was now aware of the resident's pain and had put the resident on a long-acting scheduled pain medication and the short acting as needed medication used for breakthrough pain and confirmed that he did this on 10/10/23 after the Administrator had contacted him. He stated for short term therapy residents, he wrote for pain medication for the residents to be able to receive and participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medication. He stated he does not recall a call on [DATE] about the need of pain medicine for this resident or for the staff being unable to get in touch with NP. He stated he does not recall being notified by the facility of the resident's comment concerning he would be better off dead. He stated he does not recall being notified of this, but unless the staff could not get in touch with the NP, they would not call him. Record review of the September 2023 Electronic Medication Administration Record (EMAR) revealed other PRN meds administered when Norco was unavailable from 9/2/23 (date of ER visit) until 9/5/23 (when Norco was obtained), the resident requested PRN pain medications including Ibuprofen 200 mg (milligrams) (3 tabs) times 4 doses with a verbalized pain scale of 7-10 and Tylenol 325 mg 1 tablet for pain on a scale of 1 - 3 on 2 days along with the Ibuprofen and Resident #25 had verbalized a pain scale of 10. On 9/10/23 the resident requested Ibuprofen 200 mg 3 tabs along with Tylenol 325 mg 2 tabs for pain scales of 9-10 times 2 doses and BC Arthritis 1000-65 mg 1 packet. On 9/11/23, the resident requested BC Arthritis times 2 doses and Tylenol 325 mg 2 tablets 1 dose and Ibuprofen 200 mg 3 tablets 1 dose for verbalized pain of 7-10. On 9/20/23 he received Tylenol 325 mg 2 tablets for verbalized pain of 10 and Ibuprofen 200 mg 3 tablets for verbalized pain of 5. On 9/26/23 he requested 2 doses of BC Arthritis for verbalized pain of 8. On 9/27/23 he received one dose of BC Arthritis for a pain scale of 6. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medications available fr[TRUNCATED]

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff were competent in medication administration, pain assessment and treatment, notification of providers and pharmacy when medications were needed, and in the procedure for using the automated medication dispensing system for obtaining needed medications for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure nursing staff possessed the knowledge to obtain needed pain medication for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR §483.35(a)(3)(4) Nursing Services - F726 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Competency Evaluation dated 10/17/23, revealed, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents .Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . An observation and interview with Resident #25 on 10/10/23 at 10:45 AM, revealed resident was in his room sitting in his electric wheelchair. His posture was slumped to the side and resident did not sit upright and straight in his chair. He stated he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain and he had to ration out his pain medicine to be comfortable. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not received his medication before he ran out and this should not happen. The facility's Pharmacy Consultant revealed in an interview on 10/10/23 at 2:00 PM, the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated the ordered pain medication for Resident #25 was one of the medications available in the dispensing system and could have been obtained by the staff for this resident if the procedure was followed. An interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1 confirmed there had been times that Resident #25 had to go without his pain medication due to the medication not being available in the facility. The Director of Nursing (DON) confirmed during an interview on 10/11/23 at 4:00 PM, that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain for multiple days. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets. The DON confirmed this resident was sent to the hospital and received a prescription for pain medications from the emergency room that was sent to the pharmacy, but it was after hours, and the facility staff did not know to call the pharmacy to receive a code to obtain the medication from the automated system. She confirmed she was aware of the situation of the resident being sent to the hospital, yet no procedures were changed and no in-services on who to notify and procedure to follow for obtaining medication were given to prevent reoccurrence, and the resident continued to be without pain medication several other times. She confirmed the facility failed to educate the staff on the procedures necessary to obtain needed medications 24 hours a day seven days a week and this led to the resident having severe, unrelieved pain. The Administrator confirmed during an interview on 10/11/23 at 4:15 PM, the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to effectively manage his pain, and due to this failure, the resident suffered multiple days of severe pain. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications when needed but not available on the medication cart, obtaining a prescription, obtaining a one-time dose, obtaining a dose when a prescription was available, or verifying with pharmacy what was needed. She confirmed the staff were not adequately trained on the automated medication dispensing system procedure to receive needed medications for the residents and that this was available 24 hours a day seven days a week. She confirmed the facility staff failed to follow through with notification of the pharmacy, MD, or the NP with concerns of pain and lack of medications available. Interview with LPN #2 on 10/11/23 at 4:20 PM, revealed she did not notify the provider or the pharmacy on 9/4/23 since she notified the charge nurse of the Resident #25 being out of his pain medications and was told the medication was on its way from the pharmacy. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication on a weekend, holiday, or night. An interview on 10/12/23 at 2:30 PM, with the Administrator confirmed the prescription that was sent to the pharmacy from the emergency room on 9/2/23 was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday. She confirmed there were other dates as well that the facility failed to obtain Resident #25's medication timely and he was in pain with no pain medication available. She confirmed the facility's contracted pharmacy had 24 hour a day seven day a week coverage, yet the facility staff were unaware of this and how to proceed to obtain the needed medication, therefore, the resident repeatedly suffered severe and unrelieved pain. In an interview on 10/12/23 at 3:20 PM, the DON confirmed the facility failed to have the resident's pain meds available as ordered and needed, due to the nursing staff not being adequately trained to know the proper steps to take to obtain residents' pain medications to prevent and treat his pain. Interview with the Administrator on 10/16/23 at 1:45 PM, revealed when the resident went to the emergency room on 9/2/23, he had a prescription for pain meds and this was sent to the pharmacy, but no staff member contacted the pharmacy to get a code for the system to be able to give the resident the medication for pain. She confirmed the medication administration skills checklist did not include the procedure for use of the automated medication system. She confirmed the facility failed to educate the staff of the steps to take to obtain pain medications from the automated medication system and because they were not properly trained, this resident suffered days of severe and unrelieved pain. Interview with Nurse Supervisor/Registered Nurse #2 on 10/16/23 at 2:00 PM, revealed on 9/2/23, the resident complained of pain and had no pain medication available in the medication cart. She stated Resident #25 called 911 to be taken to the emergency room for evaluation of chest pain and she informed the emergency room (ER) doctor of the situation with the resident not having pain meds available and he sent a prescription for 14 Norco pills to the pharmacy. She revealed the resident had an active prescription in the pharmacy, but the staff did not know the procedure for using the medication dispensing system. She stated she assumed the staff knew how to get the meds out of the system when a prescription was available, and she did not inform the other nurses of what to do to get the ordered medication after the resident had returned from the ER. An interview on 10/17/23 at 9:30 AM, the Assistant Director of Nursing revealed she was aware that the resident had been out of his pain medication on several occasions. She stated Labor Day weekend she did hear that a prescription was available in the pharmacy, but the staff were unaware of the procedure to obtain the ordered medication. She confirmed the facility failed to call the on-call pharmacy to obtain the resident's ordered medication which led to the resident experiencing unrelieved pain. In an interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on weekends, nights, or holidays. She stated the pharmacy sends messages when they are off, so she was unsure what to do during these times. During an interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system stored routine medications, but he was not aware that pain medication was also available. He stated he was unaware of the procedure to obtain pain medication for a resident if none were available in the medication cart and he would have to ask someone if the situation happened. On 10/17/23 at 10:55 AM, a phone interview with the Pharmacy Consultant revealed the DON had been in-serviced on the automated medication delivery system. She confirmed she did not in-service the nursing staff but felt that the DON and nursing management should have in-serviced the staff on the procedure for use. Record review of Medication Administration Skills Checklist for LPN #1, LPN #2, and LPN #3 revealed there was no instruction on the automated medication dispensing system in the facility documented on the checklist. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medicati[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and facility policy review, the facility failed to acquire and administer the resident's pain medication in a timely manner causing Resident #25 to experience severe/uncontrolled pain multiple times for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure needed pain medication was available for Resident #25 caused this resident harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR §483.45(a)(b)(2) - F755 Pharmacy Services was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Consultant Pharmacist Services, undated, revealed, The consultant pharmacist will ensure that the following services are performed: . 9. Advises facility on policies and procedures for safe and effective delivery, organization, destruction, and use of medications/services in the facility. 11. Conducts in-service education for nursing staff on drug and pharmacy services topics including changes in regulations . Record review of facility policy titled, 1.0 Providing Pharmacy Products and Services dated 1/1/13, revealed, 1. Pharmacy will provide facility with the Facility-Specific Information Sheet . which details how Facility staff can contact Pharmacy twenty-four hours a day, seven (7) day a week (24/7). 3. After the normal business hours set forth in the Facility-Specific Information Sheet, Facility staff should contact Pharmacy by dialing the telephone number provided in the Facility-Specific Information Sheet to page the on-call pharmacist. Resident #25 reported during an interview on 10/10/23 at 10:45 AM, that he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine to be comfortable. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. On 10/10/23 at 2:00 PM, in an interview with the facility's Pharmacy Consultant, revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner (NP) or the Medical Doctor (MD) to have one sent to the pharmacy for staff to receive code. She confirmed that this system is the facilities Emergency Drug Kit (EDK), that the machine houses things that would be needed in an emergency. She stated the pain medication that Resident #25 received was one of the medications available in the dispensing system and could have been obtained by the staff for this resident. The Administrator confirmed during an interview on 10/11/23 at 4:15 PM, the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications when needed and not available on the medication cart. She confirmed the facility staff were not adequately trained on the automated medication dispensing system procedure or how to obtain pain medication from the system to administer to this resident with an active prescription available in the pharmacy or how to obtain a prescription for a one-time dose order sent to the pharmacy. She confirmed the facility staff failed to notify the pharmacy, MD, or the NP when concerns of pain and lack of medications occurred. Licensed Practical Nurse (LPN) #2 revealed in an interview on 10/11/23 at 4:20 PM, that she had worked with Resident #25 several times and on 9/4/23, he was out of his pain medicine, and she offered him a Tylenol and he refused since the pain medicine was his preference to ease his pain. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication of a weekend, holiday, or night when the pharmacy was closed. The Nurse Practitioner stated during a phone interview on 10/12/23 at 10:05 AM, she was notified by the facility staff on 9/2/23 that the resident had no pain medication available and was in pain and was sent to the emergency room for evaluation of chest pain. She denied that she did not send in prescriptions when requested by the facility or that she was unavailable when the staff needed to speak to her. She did confirm that at times the facility would call her and not leave a message and when she called the facility back, no one knew who needed to speak to her and she did not pursue trying to talk to administrative staff to see who had a concern. She stated this could have been some of the times when this resident needed medications. On 10/12/23 at 2:30 PM, during an interview, the Administrator confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication. Therefore, the resident suffered unrelieved pain for multiple days because staff did not realize that they could access the narcotic written prescription and obtain medications from the dispensing machine. The DON confirmed during an interview on 10/12/23 at 3:20 PM, the facility failed to have the resident's pain meds available as ordered and needed, which led to this resident having pain for several days. She also confirmed the nursing staff were not adequately trained to know the proper steps to take to obtain residents' pain medications to prevent unrelieved pain. At 1:45 PM on 10/16/23 , in an interview with the Administrator, revealed the resident was evaluated in the emergency room on 9/2/23 and a prescription for pain medication was sent to the pharmacy, but the facility staff did not contact the pharmacy to get a code for the automated medication system to provide the resident the medication needed for pain relief. She confirmed the facility failed to educate the staff of the steps to take to obtain pain medications from the automated medication system and since they were not properly trained, this resident suffered days of severe and unrelieved pain. The Nurse Supervisor/Registered Nurse #2 reported on 10/16/23 at 2:00 PM, on 9/2/23, the resident complained of pain but had no pain medication available in the medication cart. The resident called 911 to be taken to the emergency room. She stated she informed the emergency room physician that the resident did not have any pain medication available at the facility, so he sent a prescription for 14 Norco pills to the pharmacy. She revealed the resident had the prescription in the pharmacy system, but the staff did not know the procedure for using the automated medication dispensing system to retrieve the medications and stated, I assumed they knew how to get it, and confirmed that she did not provide instruction for the weekend nurses as how to obtain the medication, or that they could get it from the dispensing machine. Interview on 10/17/23 at 9:30 AM, the Assistant Director of Nursing revealed she was aware the resident did not have his needed pain medication several different times and he became verbally aggressive and was cursing and she felt this was due to his pain with no medication for relief. She confirmed that not all the nurses were aware of how to use the automated medication system and how it was available for the staff to obtain residents' medications. She confirmed that after the emergency room visit when a prescription was available in the pharmacy, the facility failed to call the on-call pharmacy to get the resident's ordered medication which led to the resident experiencing unrelieved pain. An interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on weekends, nights, or holidays. She stated the pharmacy sends messages when they are off, so she was unsure what to do during these times. An interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system held routine medications, but he was not aware that pain medications were also available. He stated he was unaware of the procedure to obtain pain medication for a resident if unavailable in the medication cart. During a phone interview on 10/17/23 at 10:55 AM, the Pharmacy Consultant confirmed the DON had been in-serviced on the automated medication dispensing system. She confirmed she did not in-service the nursing staff but that the DON and nursing management should in-service the staff on the procedure for using this system. Record review of prescription from the emergency room to the pharmacy dated 9/2/23 for Norco 7.5-325 mg (milligram) tablets with quantity of 14 tablets. Record review of the Controlled Substance Proof of Use form revealed the 14 tablets ordered in the emergency room on 9/2/23 arrived in the facility on 9/6/23, and the first tablet of these was administered to the resident on 9/6/23 at 5:30 AM. The last dose of these 14 tablets was documented as signed out on 9/9/23 at 8:01 PM. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x 3, message left, MD called x 2, awaiting call back. Record review of the next prescription dated 9/11/23 and was noted as received to the pharmacy on 9/11/23 at 10:59 AM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/11/23 and received in the pharmacy at 10:59 AM were delivered to the facility on 9/11/23 (with their routine delivery around midnight). The first of these doses to be given to the resident was on 9/12/23 at 3:30 AM and the last dose was given on 9/25/23 at 10:15 PM. Record review of prescription dated 9/26/23 and was noted as received into pharmacy on 9/26/23 at 5:26 PM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/26/23 was noted to have arrived to facility on 9/27/23. The first dose administered of these tablets was 9/27/23 at 6:30 AM. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE]. His diagnoses included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis, and Cerebral Palsy. Record review of Resident #25's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/3/23 revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that Resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to Resident #25. On 9/2/23, Resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that Resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for Resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, Resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that Resident #25 was very upset he was he was running low on his pain medication and Resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. [TRUNCATED]

Based on staff and resident interviews, record review, and job description review the facility Administrator failed to ensure care was coordinated between the facility, Nurse Practitioner (NP) and the Medical Director (MD) for pain management for a resident who experienced severe/uncontrolled pain that resulted in the resident being transferred to the emergency room (ER) for pain control for one (1) of 19 sampled residents. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's Administration failed to ensure needed pain medication was available for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR §483.70 Administration was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Job Title: Administrator, signed by the Administrator on 10/18/23, revealed, Duties and Responsibilities - Responsible for planning, organizing, staffing, directing, and coordinating of the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The policy also revealed, Functions: 1. Select personnel to supervise activities of major departments and consult with them regarding problems, .7. Supervise department heads, including office staff; meet with department heads and make rounds . 12. Work with department heads and supervisors to provide staff . in-service training . 13. Maintain personal contact with residents and their families, or guardians . 18. Operate, manage, and maintain facility in accordance with established policies and procedures of the governing body. 19. Act as liaison with the governing body and professional and supervisory staff through meetings and reports . Record review of facility policy titled, Job Title: Director of Nursing, signed by the Director of Nursing on 6/2/23, revealed, Qualifications: . Job Knowledge: Working knowledge of nursing services . administration, supervision, resident care, etc.; .18. Evaluate, plan and organize nursing care according to established policies.20. Supervise nursing activities and promote improvement in nursing care . 32. Be accountable for nursing compliance, excellence, and delivery of resident-care services in adherence with federal, state, and local regulations . In an interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was admitted to the facility for therapy on 8/28/23. He had back and neck pain from a previous injury. He verbalized he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine to be comfortable. The staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. In an interview with the facility's Pharmacy Consultant on 10/10/23 at 2:00 PM, revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner or the Medical Doctor to have one sent to the pharmacy for staff to receive a code. She stated the pain medication that Resident #25 received was one of the medications available in the dispensing system and could have been obtained by the staff for this resident. In interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1 confirmed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) had been notified of the concerns that the resident did not receive his pain medication as ordered and needed. She confirmed there had been times that this resident had to go without his pain medication due to the medication not being available in the facility. In an interview on 10/11/23 at 4:00 PM, the Director of Nursing (DON) confirmed that she was aware that at times, the resident had run out of his pain medicine, and it was not available in a timely manner which led to the resident being in severe pain for multiple days. She confirmed in-services should have been initiated, but the staff were not in-serviced on who to notify and what to do to prevent this from occurring, and therefore it occurred several additional times. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets yet no new plan to prevent this from occurring was initiated. She confirmed the need to address changes in their normal process for this resident was not discussed with administrative staff, therefore no change occurred, and the resident was in pain without appropriate pain management interventions. In an interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She revealed she had not been aware that the resident was without his pain medication on multiple occasions, but as Administrator of the facility, she should have known. She confirmed the administration staff and department heads failed to communicate concern with a resident's pain and no solution was initiated and it continued to occur. In an interview on 10/12/23 at 2:30 PM, the Administrator confirmed the facility failed to provide Resident #25 with adequate pain relief for his well-being. She stated the facility was responsible for meeting these needs and when the NP did not respond timely, the facility failed to initiate contact with the Medical Director for pain management which caused Resident #25 to go without pain medications for multiple days causing him further pain and mental anguish. She confirmed the prescription that was sent to the pharmacy from the emergency room on 9/2/23 was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday 09/05/23 and was delivered to the facility after midnight. She stated that is why the resident did not get a dose until 09/06/23 at 5:30 AM. She confirmed the facility failed to follow up with other options to ensure this resident received the necessary care. She confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication, therefore, the resident suffered unrelieved pain. She also confirmed there were also other days that the facility failed to obtain Resident #25's medication timely and was in pain without medication to ease his pain. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that Resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to Resident #25. On 9/2/23, Resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that Resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for Resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, Resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that Resident #25 was very upset he was he was running low on his pain medication and Resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. The SA validated by record review and interview with ADON the inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. The SA validated by record review and interviews with Medical Director and Pharmacy Consultant one on one education was provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. The pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. The SA validated by record review and interviews with Medical Records Nurse and MDS Nurse that on 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. The SA validated by record review and interview with Pharmacy Consultant that on 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. The SA validated by record review and interview with the Medical Director that on 10/17/23 at 8:00 PM, the Director of Opera[TRUNCATED]

Based on observation, resident and staff interviews, record review, and Medical Director Agreement review, the facility's Medical Director (MD) failed to coordinate medical care and ensure that he or his Nurse Practitioner (NP) responded to the facility for pain control when a resident experienced severe/uncontrolled pain for one (1) of five (5) resident reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure the Medical Director managed and coordinated pain control for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR 483.70(h)(2)(i)(II) Medical Director - F841 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the Medical Director Agreement signed by the Medical Director on 1/1/13, revealed, .3. Services: . ii. Collaborating with the Facility's management staff to help develop, implement, and evaluate resident care policies and procedures that reflect current standards of practice; iii. Working with Facility's leadership in identifying, evaluating, and resolving medical and clinical concerns and issues that affect resident care, medical care, or quality of life or that relate to the provisions of services by physicians and other licensed health care professionals . Record review of the Medical Director Agreement, signed by the Medical Director on 4/28/10, revealed, .The Medical Director is responsible for technical assistance with the implementation of resident care policies and the coordination of medical care in the facility. In order to monitor implementation and provide oversight of medical services, the Medical Director will be present for monthly staff meetings to discuss issues related to resident care and safety. The Medical Director will be accessible by phone, fax, e-mail, or person for resident care issues that arise. The Medical Director will be accessible by person as the needs of the residents dictate, but no less than two visits per month. On 10/10/23 at 10:15 AM, an observation revealed Resident #25 sitting in his wheelchair in the front hallway area speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but resident was observed to be very distraught and stated, Just need to die. Interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain and he had to ration out his pain medicine to be comfortable. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not received his medication before he ran out and this should not happen. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that when the medicine was not available there was nothing they could do, and he felt they were not concerned that he was suffering in pain. Interview with Registered Nurse (RN) #1 on 10/11/23 at 11:00 AM, stated the automated medication distribution system can be used to obtain medications for the resident if an active prescription is available in the pharmacy. She confirmed there were times when the resident did not have pain medication available and she had tried at times to notify the NP to have a refill sent to pharmacy, but it was not sent timely, or she would not return the phone call and the resident was without pain medication for a longer period of time. Interview with Nurse Supervisor/Registered Nurse #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was still unavailable. The resident called 911 from his personal cell phone and was sent to the emergency room (ER) for evaluation. She confirmed the resident was out of his pain medications and he was complaining of severe/uncontrolled pain. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with other residents also. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the Nurse Practitioner or the Medical Director but was not called back by either of them. She stated when the provider did not return her call, a prescription was not obtained to receive the medications. Interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications. She stated the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a hard copy timely. Therefore, the resident suffered with severe, unrelieved pain for multiple days. The Administrator confirmed that she Finally got the Medical Director to order something scheduled for pain for the resident last night. Interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23. She stated she relied on the Nurse Practitioner (NP) to follow through with sending the orders to pharmacy as needed. She is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him and she confirmed that the NP is very difficult to get in touch with at times. Phone interview on 10/12/23 at 10:05 AM, with the Nurse Practitioner confirmed that she occasionally had a missed call from the facility and when she called the facility, no one knew who needed to speak to her and she did not pursue trying to talk to the administrative staff members to determine who had a concern. Interview with the Administrator on 10/16/23 at 1:45 PM, revealed the facility staff attempted to notify the Nurse Practitioner multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage pain with as needed (PRN) medications. But this resident had chronic pain and was taking this medication daily prior to his admission to the facility and he still needed the medication on a scheduled basis, but the Medical Director refused to order it as scheduled until she talked to him last night. Phone interview on 10/16/23 at 2:20 PM, with the Medical Director revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he did order short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not a successful option for pain management. He stated he would occasionally order this for a hospice resident, but otherwise he would order PRN pain medicine and not scheduled pain medication. He stated last week, when the facility notified him of the concerns for Resident #25's pain management, he did order a scheduled every 12 hour long-acting pain medication and a short acting PRN medication. He stated that generally he was only notified when the Nurse Practitioner was unavailable. A phone interview on 10/17/23 at 11:20 AM, the Medical Director revealed, I am not reluctant about writing for short-acting pain medications, I said I wasn't going to write it. I just do not generally schedule it. He stated he is aware the NP wrote prescriptions, but she was not required to notify him each time she wrote a prescription, and she had the right to do this without notifying him each time. He stated, I do not recall being notified that the resident was in extreme pain for days and did not have pain medications available over Labor Day weekend and was sent to the emergency room with chest pain. He stated I do not recall the staff attempting to contact me on 9/10/23 concerning the resident's level of pain and no medication available and the staff being unable to reach the Nurse Practitioner or the resident having to wait until 9/12/23 to receive his medication from pharmacy. He stated he wrote pain medication for short term therapy residents, so they were able to participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medications. He stated he did not recall being notified by the facility of the resident's comment concerning he would be better off dead related to his pain and lack of medication. He stated he does not recall being notified of this, but the staff would only notify him if they could not reach the NP. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He confirmed that as of last week, he was aware of the resident's pain and medication availability concerns and put the resident on a long-acting scheduled pain medication and the short acting as needed medication to be used for breakthrough pain. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x (times) 3, message left, MD called x 2, awaiting call back. Record review of text message sent to NP from RN #2 dated 9/10/23 at 10:39 AM, revealed, Hey just double checking you sent those hard copies in yesterday? Pharmacy is saying they don't see them in their fax list. Record review of progress note dated 9/26/23 at 11:59 AM by Registered Nurse #1 revealed, Resident is upset that his PRN (as needed) pain medication is not in currently however we are awaiting a hard copy from providers so therefore we can not give the specific pain med that he wants at this time . Record review of Resident #25's History and Physical by Medical Director dated 9/6/23. No documentation concerning pain noted. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on 9/6/23 at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on 9/27/23 at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, A[TRUNCATED]