**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 (Resident #195) residents reviewed for pain. The facility failed to provide scheduled Morphine and Tramadol for Resident #195 from 02/07/2025-02/09/2025 which resulted in mental anguish and untreated pain. An IJ was identified on 02/11/2025. The IJ template was provided to the facility on [DATE] at 04:56 PM. While the IJ was removed on 02/14/2025, the facility remained out of compliance at a scope of isolated and a severity level of 1 because all nursing staff had not been trained on pain assessments and the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Record review of Resident #195's admission record, dated 02/14/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection in lungs), dementia (a condition that affects thought processes), insomnia (difficulty sleeping), chronic pain syndrome, hypertension (high blood pressure), osteoarthritis (a condition that affects the cartilage that cushions the ends of the bones), scoliosis (a sideways curvature of the spine), and spinal stenosis (narrowing of the spinal canal in the low back). Record review of Resident #195's care plan, dated 02/12/2025, revealed Resident #195 had pain with relevant interventions that included administer analgesia and evaluate effectiveness of pain interventions. Record review of Resident #195's hospital discharge physician orders dated 02/07/2025 revealed the following order: Morphine SR 30mg oral three times a day last administered at 02/07/2025 at 08:19 AM. The physician progress note reflected, chronic backache continue home regime. Record review of Resident #195's physician's orders, dated 02/10/2024, revealed: Morphine Sulfate Oral Tablet 30mg Give 1 tablet three times a day for pain with a start date of 02/07/2025 07:00PM Tylenol Tablet 325mg Give 2 tablet by mouth every 4 hours as needed for mild pain with a start date of 02/08/2025 12:30AM Tramadol 100mg Give 1 tablet by mouth every 8 hours as needed for pain. Give medication until he gets Morphine Sulfate 30mg TID with a start date of 02/09/2025 02:00AM and an end date of 02/09/2025 02:10AM Tylenol Extra strength 500mg Give 2 tablet by mouth every 8 hours for pain with a start date 02/09/2025 07:00AM and an end date of 02/09/2025 03:42PM Tramadol 100mg Give 1 tablet by mouth every 8 hours for pain to be given until Morphine is available with a start date of 02/09/2025 07:00AM and end date of 02/09/2025 03:41PM. Record review of Resident #195's medication administration record for 02/07/2025-02/10/2025 revealed: Morphine Sulfate Oral Tablet 30mg Give 1 tablet by mouth three times a day for pain with start date of 02/07/2025. Missed doses with documented awaiting arrival from pharmacy noted were: 02/07/2025 07:00 PM 02/08/2025 07:00 AM 02/08/2025 01:00PM 02/08/2025 07:00PM 02/09/2025 07:00 AM 02/09/2025 01:00PM First dose of medication documented for 02/09/2025 at 08:54 PM. Tylenol 325mg Give 2 tablet by mouth every 4 hours as needed for mild pain. Medication documented as given: 02/08/2025 12:40 AM 02/08/2025 03:25 PM 02/10/2025 01:48 AM Tramadol oral tablet 100mg Give 1 tablet by mouth every 8 hours as needed for pain start date 02/09/2025 02:00 AM and end date 02/09/2025 02:10AM. No signature noted on medication administration record for this medication. Tramadol oral tablet 100mg Give 1 tablet by mouth every 8 hours for pain start date 02/09/2025 07:00 AM and stop date 02/09/2025 03:41 PM. Medication documented as not given 02/09/2025 07:00AM with notation waiting for the pharmacy to deliver, the nurse was notified. Medication documented as not given 02/09/2025 03:00 PM with notation Hold medication per nurse's request. Tylenol Extra strength 500 mg Give 2 tablet by mouth every 8 hours for pain start date 02/09/2025 07:00 AM and stop date 02/09/2025 03:42 PM. Medication documented as not given 02/09/2025 03:00 PM with notation Hold medication per nurse's request. Record review of Resident #195's progress note, dated 02/08/2025 at 10:09 PM and documented by LVN A, revealed the following: Resident has not received his Morphine 30 mg po tablet. He is really frustrated over this issue. Faxed another triplicate to [MD] and awaiting delivery. Tylenol 650mg and not enough. Record review of Resident #195's progress note, dated 02/09/2025 at 02:44 AM and documented by LVN A, revealed the following: Resident continue to call for his Morphine 30mg. Called on call NP for [MD] temporarily orders Tramadol 100mg q 8 hrs to be given together with Tylenol ES 1000 mg po q 8 until Morphine comes. First dose already given. Discussed about the Morphine with resident and stated that he has the medication at home. Encouraged resident to communicate with his [family member] to bring the medication today. Record review of Resident #195's progress note, dated 02/09/2025 at 02:58 AM and documented by LVN A, revealed the following: No pain noted or expressed. Pain level is currently at 10. Record review of Resident #195's progress note, dated 02/09/2025 at 08:54 PM and documented by LVN A, revealed the following: Received 10 tablets of Morphine 30mg and given to resident. Tramadol and Tylenol d/c as Morphine received. Record review of Resident #195's progress note, dated 02/09/2025 at 08:56 PM and documented by LVN A, revealed the following: Resident verbalizes or expresses presence of pain. Pain level is currently at 10. Resident demonstrates non-verbal signs of pain. Record review of Resident #195's progress note, dated 02/10/2025 at 01:44 AM and documented by LVN A, revealed the following: Resident awake and alert in bed. Called several times asking for his Morphine medication. Explained to him that the medication is to be given 3 x a day at 7am, 1pm, and 7pm .Tylenol 650 mg po given prn at 1:40am. During an interview and observation on 02/10/2025 at 10:06 AM, Resident #195 revealed he had concerns about his morphine not being administered since he was admitted . The resident stated he had been taking Morphine three times a day for a long time. He stated his primary care physician had him set up on the medication to control his pain and it had worked in the past. Resident #195 stated he hadn't been below a level 7 of 10 pain(Scale 0=no pain and 10=the worst possible pain), and he hurt in his lungs and lower back. When asked to describe the pain he rated at 10, the resident stated hell and sharp. The resident exhibited facial grimacing and appeared in pain during the interview. During an interview on 02/10/2025 at 03:01 PM, LVN D stated she was the nurse on duty when Resident #195 was admitted to the facility on [DATE] around 03:30 PM. She stated she faxed a request for a triplicate (specialized prescription for controlled medications) for the Morphine to the MD per protocol, but she wasn't sure what time. The Morphine didn't come in before she left her shift on 02/08/2025 at 06:00 AM. She stated she passed it on in report and documented it on the 24-hour report. She stated there had been some communication errors with the pharmacy getting prescriptions. She stated they needed to continue to attempt to obtain the medication needed. LVN D stated not getting pain medication that was ordered could cause discomfort for the resident. During a telephone interview on 02/10/2025 at 03:23 PM, LVN E stated he worked the next morning after Resident #195 was admitted . He stated he was not aware that Resident #195 was missing his Morphine on that day. LVN E stated if he had been aware of the need for pain medication, he would have contacted the on-call NP to get an order for something stronger than Tylenol until the Morphine arrived and the DON to expedite getting the medication. During a telephone interview on 02/10/2025 at 04:11 PM, NP L stated if a resident needed a triplicate, then the nurse needed to fax a completed request form to the MD. She stated the MD received the faxes on the weekend too and addressed the requests as they were received. She stated Tylenol 650mg is not a comparable pain medication to Morphine Sulfate 30mg. During a telephone interview on 02/10/2025 at 04:17 PM, the MD stated he received the request for a triplicate prescription for Resident #195 on 02/07/2025. He stated he sent the prescription to the wrong pharmacy. The MD stated he wasn't sure how the lack of pain medication could affect the resident since he had not assessed the resident yet. During an interview on 02/11/2025 at 10:42 AM, the DON stated the facility preferred to get the orders prior to the residents' admission to ensure a triplicate could be requested prior to the resident's arrival. She stated the policy was for the nurse to fax a request form to the MD. The MD then would send the prescription to the pharmacy, and the facility should have received the medication on the next delivery. The DON stated if there were issues with obtaining the medication then that medication needed to be put on hold and an order should have been obtained for a substitute that could have been pulled from the E-kit or the nurse should have administered Tylenol from the standing orders. She stated she did not consider Morphine and Tylenol to be equivalent. The DON stated Resident #195 arrived at the facility around 3:30PM on 02/07/2025. She stated the nurse requested a triplicate when the resident arrived. The DON stated Resident #195's Morphine wasn't received on 02/07/2025 or 02/08/2025. She stated Morphine should have been placed on hold after the first delivery without it. She stated the nurse and medication aide just documented the medication was unavailable. The DON stated the nurse that worked 02/09/2025 at 02:20AM pulled the Tramadol from the emergency kit and administered it. She stated Resident #195 received Tylenol an additional 3 times prior to his Morphine arriving on 02/09/2025 around 09:00 PM. She stated that uncontrolled pain might affect each resident differently. During a phone interview on 02/11/2025 at 11:54 AM, LVN A stated he worked with the resident the nights of 02/09/2025 and 02/10/2025. He stated he called the pharmacy on 02/09/2025 to locate the Morphine. They had not received a triplicate. He stated the only orders Resident #195 had for pain was Tylenol 650mg, so he contacted the NP and received an order for Tramadol and Tylenol together. He stated the NP was going to follow up with the MD for the triplicate for Morphine. LVN A stated he then pulled the Tramadol from the E-kit and gave the initial dose. He stated the resident was rating the pain a 10 before the Tramadol and between a 6 and 8 after the Tramadol. During a phone interview on 02/11/2025 at 01:16 PM, MA N stated she worked with Resident #195 on 02/08/2025 and 02/09/2025. She stated she notified the nurses that were working that the Morphine was unavailable. MA N stated, I was told to just document it as unavailable by them[the nurses]. She stated [Resident #195] was in a lot of pain and stuff. During an interview on 02/11/2025 at 01:26 PM, CNA I stated he worked with the Resident #195 on 02/08/2025 and 02/09/2025. He stated Resident #195 complained of pain on those days. CNA I stated he gave Resident #195 a bed bath on 02/09/2025 because Resident #195 was in too much pain to get up. He stated he notified LVN M about Resident #195's pain. During an interview on 02/11/2025 at 01:40 PM, the FM stated Resident #195 had been taking Morphine Sulfate 30mg three times a day for more than a decade. The FM stated during a visit on 02/08/2025, Resident #195 had facial grimacing worse than ever before. During an interview on 02/11/2025 at 02:36 PM, the DON stated she didn't have an answer for why the nurse didn't pull the second dose of Tramadol from the E-Kit. She stated there was Tramadol in the E-kit at that time and the nurse should have pulled the medication to administer it to the Resident #195. Record review of facility policy titled Pain-Clinical Protocol, dated 2001 and revised October 2022, revealed: Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain . 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. . Monitoring 1. The staff will assess the individual's pain and related consequences at regular interval, at least each shift for acute pain or significant changes in levels of chronic pain. Record review of facility policy titled admission Assessment and Follow Up: Role of the Nurse, dated 2001 and revised in September 2012, revealed Purpose-The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan and completing required assessment instruments, including the MDS. . Steps in the Procedure . 7. Conduct an admission assessment (history and physical), including: . d. Current medications and treatments . 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Record review of undated facility policy titled Delivery, Receipt and storage of medication revealed: 6.1 Delivery schedules .Orders requiring more urgent delivery will be communicated by the facility to the pharmacy either by fax or verbally. The pharmacy will expedite delivery of those medications within a 4-hour window. The ADM and DON were notified on 02/11/2025 at 04:56 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/12/2025 at 03:29 PM and included: On 02/10/25 an abbreviated survey was initiated at [facility name]. On 02/11/2025 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of the alleged immediate jeopardy states as follows: The facility failed to provide effective pain interventions for Resident #195 for 2 days. Action: Upon learning of the deficient practice, the Director of Nursing and Nursing Admin began a review of resident's charts for pain assessment orders, reviewed current PRN pain medication usage for all residents, and reviewed all residents who are flagging for increased pain to assure effective pain management regimens. A total of 12 residents were identified. The 12 identified residents have received an evaluation by the provider (NP or Hospice RN) to evaluate the effectiveness of the current pain regimens. All new orders have been transcribed and confirmed. Monitoring: This will be monitored for completion through the morning clinical meeting process. The DON or designee will oversee this until this is completed. This task has been completed and does not require further oversight due to completion. Responsible: Director of Nursing and Nursing Administration Start Date: 02/11/2025 Completion Date: 02/12/2025 Action: Regional Director of Clinical Services contacted Pharmacy to aid in a MAR to Cart Medication Audit to assure all ordered medications are available. The results from the MAR to Cart Medication Audit are available in a report sent by the consultant pharmacist. Monitoring: DON/Designee to complete MAR to Cart Audit on all narcotic pain medications once monthly for three months to ensure compliance. The Administrator will provide oversight of the monitoring. Responsible: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: Regional Director of Clinical Services provided in-service education to Director of Nursing and Nursing Administration regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place, how to conduct a pain assessment properly and proper action when ordered pain medication is not available. ADON and Nursing Administration provided verbal summary of educational material to ensure comprehension. Responsible: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: DON began in-service education for all nurses currently on shift regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place, how to conduct a pain assessment properly and proper action when ordered pain medication is not available. Nursing Administration will complete a second pain assessment on 5 residents twice weekly for 3 months to ensure proper assessment of resident pain and level of nurse proficiency. Comprehension was verified through return demonstration and verbal summary. Monitoring: Ongoing education will be provided to all new hires, PRN, leave of absence prior to first shift worked. Responsible: Director of Nursing or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Regional Director of Clinical Services initiated and completed an audit of pain evaluation assessments on 100% of residents on 02/11/25. No residents were identified as having a pain rating score of greater than 5. The pain evaluation assessment is available for review in the resident's individual chart. Responsible Party: Regional Director of Clinical Services Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: All CNAs and MAs will be educated on how to enter a pain alert in PCC (the electronic health record) and to verbally notify charge nurse of resident complaints of pain. All CNAs and MAs currently working have been educated on the process. Comprehension was verified through return demonstration and verbal summary. PRN and/or new staff will be educated prior the start of their next shift. Comprehension will be verified through return demonstration and verbal summary. Facility does not currently utilize agency staff. Monitoring: Alerts will be reviewed in morning and afternoon meeting process to ensure they have been addressed. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: All licensed nursing staff will be provided with in-service education regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen and proper action when medication is not available prior to next shift worked, including new hires, PRN, Vacation, and Leave of Absence staff. Validation of triplicate receipt will be completed by the assigned nurse upon admission. If a resident is admitted with a new controlled medication that a triplicate has not been received for, they will immediately contact the primary care physician. Comprehension was verified through return demonstration and verbal summary. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions during clinical morning meeting process to ensure compliance with plan. Monitoring: The DON/ADON or designee will follow the morning meeting process to ensure compliance. This will be documented on the morning clinical follow-up sheet. During weekend hours, the on-call nurse will verify that a pain assessment order has been entered for all admissions and/or readmissions. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Confirm Pain medications are available for all new Admissions, Readmissions, or newly received orders for pain medication during clinical morning and afternoon meeting process to ensure pain medication availability. If the medication is unavailable, the medication will be removed from the Med Bank. During weekend hours the on-call nurse system will be utilized if a medication is unavailable. Monitoring: Follow the morning meeting process to ensure compliance Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: Review all residents currently identified for increased or change in pain weekly during WE CARE clinical meeting to confirm ongoing interventions and physician notification. Monitoring: Follow WE CARE meeting process to ensure compliance. This will be documented on the We Care form. The Administrator will provide oversight for the ongoing monitoring. Responsible Party: DON/ADON or Designee Start Date: 02/11/2025 Completion Date: Ongoing Action: AD HOC (as needed) QAPI meeting conducted to discuss plan of removal for compliance Monitoring: Review any compliance issues in QAPI meeting for 3 months. Responsible Party: Administrator Start Date: 02/11/2025 Completion Date: 02/11/2025 Action: Medical Director notified of alleged deficient practice. Monitoring: Will update Medical Director of any compliance issues during QAPI meeting for 3 months. Responsible Party: Administrator Start Date: 02/11/2025 Completion Date: 02/11/2025 The Surveyor monitored the POR on 02/13/2025 and 02/14/2025 as followed: During interviews and observations on 02/13/2024 from 11:40 AM - 12:04 PM and 02/14/2025 at 12:31 PM, CNA K, CNA Q, and MA R, from different shifts, stated they were in-serviced on pain management before working their shift. The CNA K and CNA Q stated any time a resident verbalized pain they were to notify the nurse immediately and put an alert in the EHR. CNA K, CNA Q and MA R stated if a resident could not verbalize pain, then they monitored for non-verbal signs of pain including facial grimacing or behaviors out of the ordinary. If they were to notice any of the non-verbal signs of pain, then they were to notify the nurse immediately and put it in the EHR. All staff then demonstrated how to enter the alert in the EHR. During an interview on 02/14/2025 at 10:44 AM with the RDCS, revealed that she did in-service the DON and the ADM regarding pain assessments, acute pain, change in level of pain and who to notify. During interviews on 02/14/2025 from 01:18 PM - 01:41 PM, LVN S, LVN T, and LVN U from different shifts stated they had been in-serviced on pain management before their shifts. All three LVNs verbalized how to assess for pain in residents, which included non-verbal pain indicators. All stated for new residents with orders for pain medication that required a triplicate, they needed to contact the pharmacy and physician to ensure a triplicate was received. All staff stated they would follow up to ensure the triplicate was received by the pharmacy. The nurses stated they would give the pain medication and follow up a short time later to ensure the medication was effective. If the medication was ineffective, then the provider would be contacted for something else. Observation of 4 medication carts 02/13/2025 at 11:23am revealed that pain medications were available for all residents on the list of residents that had orders for pain medication provided by the pharmacy. Record review of Pain Assessments for 16 of 16 residents reviewed revealed they all had a Pain Assessment done on 2/11/2025. Record Review revealed that the RDCS used a Census Sheet to verify all pain assessments were completed on 02/11/2025. She also wrote a statement of completion. Record review of 11 of 11 residents' charts revealed pain level was entered for every shift. Record review revealed the pharmacy conducted a medication/nursing cart audit on 02/11/2025. Record review revealed in-service training with the DON and Nursing Administration was completed on 2/11/2025 related to pain assessments, acute pain, change in level of pain and who to notify. Record Review revealed 37 of 45 nursing staff were in-serviced for pain management from 02/11/2025-02/14/2024. Record review of morning clinical follow-up sheets revealed they were filled out for follow up items on 2/12/2025, 2/13/2025 and 2/14/2025. Record review revealed that the facility had already scheduled a We Care Meeting for 2/17/2025 to 2/20/2025. Record Review of QAPI held on 2/11/2025 over Plan of Removal revealed that all required members attended the meeting and signed off, including the MD. The ADM and DON were notified on 02/14/225 at 03:08 PM that the IJ had been removed. While the IJ was removed on 02/14/2025, the facility remained out of compliance at a scope of isolated and a severity level of 1 because all nursing staff had not been trained on pain assessments and the facility's need to evaluate the effectiveness of the corrective systems.