**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of abuse for 3 of 5 residents (Residents #6, #7 and #8) reviewed for abuse. The facility failed to ensure Residents #7 and #8 had the right to be free from abuse when Resident #6 hit Resident #7 in the face on 06/26/25 and put his hands around Resident #8's neck on 07/02/25. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm . The failure placed residents at risk for abuse. Findings included:Record review of Resident #6's admission MDS, dated [DATE] and signed as complete by the DON on 06/25/25, reflected the resident was a [AGE] year-old male. The resident admitted from home to the facility on [DATE], and his diagnoses included Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and depression. The resident had severe cognitive impairment with a BIMS score of zero, and he displayed disorganized thinking and intention continuously. The resident was assessed to have physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, disruptive sounds), and wandering, which all occurred 1 to 3 days during the assessment period. These behaviors were assessed to significantly intrude on the privacy or activity of others. The MDS also reflected the resident rejected evaluation or care that was necessary to achieve the resident's goals for health and well-being, which occurred 1 to 3 days during the assessment period. The MDS further reflected the resident was able to transfer and walk independently. Record review of Resident #6's Care Plan, initiated on 06/13/25, reflected Resident #6 had the potential to be verbally and physically aggressive related to poor impulse control. The Care Plan included the following: Problem: 6/12/25 angry look in his face, threw coloring book across the table Problem: 6/14/25 climbed into bed with peer combative, hitting/swinging at staff during redirection. Intervention: 6/14/25 attempted to remove from peer's bed, left alone [due to] agitation Date Initiated: 06/16/2025 Problem: 6/21/25 entered female peer's room and began hitting and grabbing at the CNA's clothes when she attempted to redirect him out of room, attempted to hit female peer Intervention: 6/21/25 attempted to redirect from room, CNA used her body to shield female resident from both men, [Resident #6] left room [status post] incident with male peer, refused skin assessment and VS, NP notified with N.O. anxiolytic topically Q 6hrs, RP/DON/ADON/weekend supervisor notified, placed on 1:1 supervision; 6/22/25.NP N.O. anxiolytic PO Q6hrs PRN, RP notified - Date Initiated: 06/23/2025. Problem: 6/24/25 agitated, striking out at staff. Intervention: 6/24/25 PRN anxiolytic administered - Date Initiated: 06/25/2025. Problem: 6/26/25 hit peer in the face with closed fist. Intervention: 6/26/25 separated from peer and escorted to room, encouraged to sit on bed and provided with books to color, MD/NP/RP/DON/ADON/Administrator notified, unable to obtain VS d/t agitation, SW completed updated BIMS assessment with BIMS 1. Date Initiated: 06/27/2025 Problem: 6/27/25 combative with sitter and peers. Intervention: 6/27/25 staff attempted to redirect, once calmed down he walked to his room, PRN medication administered, DON notified, taken out on patio x approximately 15 minutes. Date Initiated: 06/30/2025. Problem: 6/30/25 verbal/physical aggression towards staff: swinging/kicking/hitting, throwing items in room, swinging pencil. Intervention: 6/29/25 verbally redirected, assisted to bed, covered with blanket, assessed as able without waking [Resident #6] up, continued monitoring. Date Initiated: 06/30/2025. Intervention: 6/30/25 topical anxiolytic applied with assistance, pencils removed and placed in med room, NP witnessed episode, continues 1:1 monitoring. Date Initiated: 07/01/2025 Problem: 7/1/25 threw chair at sitter, then charged sitter and fell, stood up and charged at sitter again, pacing. Intervention: 7/1/25 assessed, area treated, DON/ADON/MD/RP notified with N.O. transfer to hospital r/t injury, unable to obtain VS, patio door opened, and [Resident #1] came in facility, RP arrived at facility, transferred to.hospital Problem: 7/2/25 kicked the table, entered peer's room and placed his hands around peer's neck. Intervention: 7/2/25 kicked table: assessed with trauma noted to R great toe, area cleansed and treated. 7/2/25 placed hands around peer's neck: separated from peer immediately, [head-to-toe assessment] completed, VS obtained, redirected, MD/RP notified; SWA sending clinicals to [Behavioral Health Hospitals]. Date Initiated:07/02/2025. The Care Plan also reflected the following additional interventions to address Resident #6's verbal and physical behavioral symptoms: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/13/2025Analyze times of day, places, circumstances, triggers, and what de-escalatesbehavior and document. Date Initiated: 06/13/2025Assess and address for contributing sensory deficits. Date Initiated: 06/13/2025. Assess [Resident #6's] needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 06/13/2025COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 06/13/2025 Give [Resident #6] as many choices as possible about care and activities. Date Initiated: 06/13/2025 Modify environment adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed, etc. Record review of Resident #6's progress notes, dated 06/26/25, documented by LVN E reflected the following: This resident was observed standing in dining area talking with another resident who was sitting in a wheelchair. This resident hit the other resident in his face/cheek with his fist causing a reddened area to the other resident's cheek. The residents were separated and this resident was escorted to his room by the nurse and encouraged to sit on his bed and was given his crayon box and coloring book which he pushed away and then laid down on the bed.Review of Resident #6's progress notes dated 07/01/25, reflected the following: Resident on patio with 1/1 pacing and suddenly he picked up a chair and threw it and started running at Sitter and he fell on rt shoulder. Resident quickly got off ground charging at sitter. This nurse was passing window and saw resident chasing sitter. Resident pacing and holding rt arm, small skin tear noted to rt wrist Orders to transfer resident to hospital for injury Record review of Resident #6's progress notes, dated 07/02/25, documented by LVN F reflected the following: Resident observed going into another resident's room and placed his hands around his neck. Staff immediately separated [Resident #6] and was re-directed. Record review of the facility's Provider Investigation Report, completed by the DON on 07/03/25, reflected the following: The facility initiated an investigation on 06/26/2025 after two residents were involved in an altercation. [Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of 0.[Resident #7] is a [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, hypothyroidism, HLD, depression, HTN, DM, AFIB, CHF, COPD, cellulitis and anxiety. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 1.On 06/26/2025 both residents were in the common area in front of the nurse's station. Both residents were calm and suddenly [Resident #6] struck [Resident #7] on the left cheek. The residents were separated immediately and assessed by the nurse. [Resident #7] had a reddened area to the cheek, v/s 106/64,76,97.8,18. The reddened area dissipated without bruising although there is discoloration to both cheeks that is permanent. [Resident #6] refused vital signs at the time due to his agitation. There have been no further incidents between these two residents. Neither resident could recall the incident when interviewed by the DON. There was no root cause identified as the event was unprovoked.Both families were notified. [Psychological Services], MD, Regional support team and HHSC were all notified. Both residents were seen by the Social [NAME] and [Psychiatric] N.P. [Resident #6] continues to have behaviors during one-on-one observation and remains on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors. After through [sic] investigation, the incident did occur but due to the residents' lack of cognition, it was not an intentional act of abuse. Both residents have be monitored by administrative staff frequently. [Resident #7] remains in the facility with no distress or concerns noted. We are seeking a more appropriate placement for [Resident #6]. Record review of the facility's Provider Investigation Report, completed by the DON on 07/09/25, reflected the following: The facility initiated an investigation on 07/02/2025 after two residents were involved in an incident.[Resident #6] is a [AGE] year-old male who resides on the dementia unit. He was admitted on [DATE] with the diagnosis of Alzheimer's, HLD, depression, anxiety, hearing loss, HTN, and TIA's. He can walk ad lib and is dependent on staff for assistance with ADL's. He has a BIMS score of o.[Resident #8] is an [AGE] year-old male who resides on the dementia unit. He admitted on [DATE] with the diagnosis of dementia, dysphagia, CKD, COPD, DM, dysphagia, depression, HTN, and behavior disturbance with dementia. He uses a wheelchair for mobility and is dependent on staff for ADL's. He has a BIMS score of 01.On 07/02/2025 [Resident #6] entered [Resident #8['s room and placed his hands around his neck. The CNA was directly behind him and redirected him away from the resident immediately. [Resident #8[ was assessed and there was no redness, irritation, or bruising noted. He denied feeling anything. There was no injury.[Resident #8] was interviewed by Social Services and could not recall the incident. Neither resident could recall the incident when interviewed by the DON.Both families were notified. The police, [Psychological Services], MD, Regional support team and HHSC were all notified.Both residents were seen by the Social Services and [Resident #6] continues to be seen by the [Psychiatric] N.P. [Resident #6] continued to have behaviors during one-on-one observation and remained on one-on-one with the facility seeking alternate placement. His medications were reviewed and adjusted without being effective in modifying his behaviors. He was sent to [Hospital] on 07/06/2025 due to his agitation and aggression. He remains there currently.Incident reports were completed, skin assessments and pain assessments were completed. Care plans were updated. Education was initiated on Abuse and Neglect and managing difficult behaviors.Based on the investigation, there is no evidence of abuse.Both residents have be monitored by administrative staff frequently. [Resident #8[ remains in the facility with no distress or concerns noted. [Resident #6] is still at [Hospital], but we continue to look for a more appropriate placement for him. 2. Record review of Resident #7's quarterly MDS, dated [DATE], reflected the a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included stroke, non-Alzheimer's dementia and depression. Resident #7's BIM's was a 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #7 used a wheelchair for mobility. 3. Record review of Resident #8's significant change MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, depression and vascular dementia, mild with other behavioral disturbance. The resident had a BIM's of 1, which indicated his cognition was severely impaired. The MDS further reflected Resident #8 used a wheelchair for mobility. Observation and interview on 07/10/25 at 9:39 AM revealed Resident #7 was in the secure unit television/dining room area across from the nurses' station sitting in his wheelchair pleasantly talking to other residents. He was alert and oriented and able to answer simple/basic questions. The resident was asked about the incident where he was struck by Resident #6, but he was not able to recall the incident. Observation on 07/10/25 at 9:44 AM revealed Resident #8 was in a high back wheelchair in the television/dining area. The resident was able to answer simple basic questions but was not able to recall the incident between him and Resident #6. Interview on 07/10/25 at 10:26 AM with LVN E revealed she was at the nurse's station getting a weight on another resident and Resident #7 was sitting at the doorway of where the other resident's weight was being obtained. At that time Resident #6 approached Resident #7 and both residents began to have a normal conversation and there was not aggression when all of sudden Resident #6 struck Resident #7 on the cheek with a closed fist and Resident #7 yelled out he hit me. Both residents were separated immediately, and Resident #7 was assessed, and he denied any pain but his check was slightly reddened from where he had been struck and the following day the redness was gone. LVN F said Resident #6 was admitted with extreme behaviors and wandered in and out of other resident rooms and would become very physical throwing things and trying to hit at staff as they redirected. LVN F stated Resident #6 was unpredictable and at first the resident was easily redirected to his coloring books. LVN F further stated Resident #6 was put on 1:1 supervision due to his unpredictable physical behaviors but did not recall date. Interview on 07/10/25 at 10:37 AM with CNA G revealed she had just taken Resident #7 to the bathroom and pushed him into the TV area and Resident #6 was standing in front of the nurse's station and both residents began to talk to each other in a normal tone and then, suddenly, Resident #6 struck Resident #7 in the face with a closed fist. CNA G said she immediately removed Resident #7 from the area and LVN F assisted in separating the residents. CNA G said Resident #7 had some redness to his check where he was struck but said it had not lasted very long. CNA G stated she believed Resident #6 was put on 1:1 after the incident and she described Resident #6 as very unpredictable with his mood swings. They were told if they noticed Resident #6 becoming upset, they were to remove the other residents away from him and let him calm down because Resident #6 would become very physical when he was redirected. Interview on 07/10/25 with CNA H revealed Resident #6 was very quiet but they had to pay very close attention to him because the resident would quickly strike out at anyone that was around him including the staff who were watching him 1:1. CNA H said Resident #6 would become very physical when they tried to redirect him, and the behavior would come out of nowhere and described him as very unpredictable. Interview on 07/10/25 at 11:12 AM with CNA I revealed Resident #6 appeared to be relaxed and then, all of a sudden, he would throw things around his room and became physical with others. CNA I said the staff were instructed to keep other residents away from Resident #6 and kept their distance until the resident calmed down. Interview on 07/10/25 at 1:40 PM with CNA J revealed the night of the incident with Resident #8, 07/02/25, Resident #6 had been out to the hospital and his family had taken him out AMA and took him back to the facility around 2:00 AM or 3:00 AM. She said Resident #6 was already on 1:1 supervision and when he arrived, he appeared agitated and soon after the resident's family left. CNA J said Resident #6 left his room and he was trying to go into other resident's rooms and she kept redirecting him out. During one of times, she was redirecting the resident out of a room, as she was shutting the other resident's door, Resident #6 immediately ran into the room across the hall (Resident #8's room) and CNA J said she followed him and before she could redirect him, Resident #6 was seen bending over Resident #8 and put his hands around his neck. CNA J said she immediately got to Resident #6 before he could squeeze his neck and yelled for LVN F to assist. CNA J stated Resident #8 woke up at that time and yelled at the staff to get Resident #6 out of his room. She said as they were trying to redirect Resident #6, he kept trying to swing at them and they finally got the resident back to his room where he finally laid down. CNA J further stated that was the first time she experienced Resident #6's aggression during the night shift and the incident was all unprovoked. Attempts to interview LVN F on 07/10/25 were unsuccessful. Interview on 07/16/25 at 10:53 AM with the ADON revealed she was told about the incidents with Residents #6, #7, and #8. The ADON said Resident #6 was transferred from another facility and there was no documentation of his aggressive behaviors but once he got to their facility, the resident was very unpredictable with his physical behaviors. The ADON stated Resident #6 was put on 1:1 supervision after the first incident with Resident #7 and never came off that supervision. Interview on 07/10/25 at 2:13 PM with the DON revealed Resident #6 was admitted from another facility and they were not aware of any of his physical behaviors, or he would never have been accepted. The DON said as soon as Resident #6 was admitted he began to have aggressive behaviors, and they tried to adjust his medications and also tried diversional activities, but nothing seemed to work. The resident was immediately put on 1:1 when he began to show aggression towards staff. Resident #6 was on 1:1 supervision from 06/21/25 to 06/24/25 and had been taken off for a while due to some decreasing behaviors and was put back on 1:1 after the incident with Resident #7 on 06/26/25 and was on it until the remainder of his stay. The DON stated there was nothing that triggered his behavior and it was difficult to tell when he was about to escalate and that was why they decided to keep him on 1:1 until they could find alternate placement. The DON said the resident had been sent to the hospital (07/01/25) after he became physically aggressive with the 1:1 sitter and he had fallen back. The resident was sent to the hospital for an evaluation because he had fallen on his arm from his physical behaviors and the Resident's Family had taken him out of the hospital AMA stating she had gotten tired of waiting for Resident #6 to be seen. Finally Resident #6 was sent to the hospital again (07/06/25) because she wanted them to do a psychological evaluation where he remained as they had Resident #6 on a 4- point restraint due to his aggressive behaviors and would not be accepted back due to his aggressive behaviors. Monitoring for compliance included the following: Observation on 07/10/25 of Resident #9, who was on 1:1 supervision, revealed staff were providing the resident with 1:1 supervision. The resident was on 1:1 supervision due to behaviors exhibited towards staff and for exit-seeking. Record review of the incident/accident log reflected there were no resident-to-resident incidents/altercations in the facility following Resident #6's last incident on 07/02/25. Record review of in-services, dated 06/26/25 and 07/02/25, reflected staff were in-serviced on the types of abuse/neglect prior to the HHSC investigation. The staff were also in-serviced on what to do when resident behaviors escalated, notify the abuse prevention coordinator of the behaviors, and who to notify of any behavior/incidents. The staff were also in-serviced on tips of dealing with aggressive behaviors in residents with dementia,. 81 staff members participated in the in-service on 06/26/25 and 74 staff participated in the in-service on 07/02/25. The staff were from various titles and shifts. Interview with staff on 07/10/25 from 10:26 AM to 3:52 PM from various shifts (6:00 AM-2:00 PM; 2:00 PM-10:00 PM; and 10:00 PM-6:00 AM) included LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, CNA M, CNA N, LVN O, CNA P and the ADON. All the staff were able identify the different types of abuse, identify when a resident was escalating, try to identify a trigger, use gently tone or try to calm the resident, move them to a calm environment, shift their attention to a different activity, remove themselves from the room or leave the resident for a while until they calm down and make sure other residents were safe from aggressive residents , and notify upper management if a resident behavior escalated for further instruction. Observation of the residents on the secured unit on 07/10/25 from 9:39 AM to 11:24 PM revealed none displayed verbal or physical aggression towards other residents. Facility staff on the secured unit were observed to provide adequate supervision, assistance, and redirection as needed to meet the residents' needs. Interview on 07/10/25 at 2:13 PM with the DON revealed they screened residents prior to admission, and they did not accept any residents with aggressive behaviors. Record review of the facility's Abuse, Neglect, and Exploitation policy, implemented on 08/15/22, reflected the following: PolicyIt is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures and prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #3, #4, and #5) residents reviewed for use of assistance devices for positioning and transfers. 1. On 01/13/25 Hospice Aide K failed to use a drawsheet when repositioning Resident #3 in bed and instead raised her up underneath her armpits hard to pull her up in bed and heard a loud crack or pop. The facility ordered x-rays, and it was determined the resident had sustained a displaced humeral neck fracture (shoulder/upper arm fracture) due to the improper transfer and failure to use a drawsheet to position her in bed. 2. The facility failed to ensure Hospice LVN BB and Hospice Aide CC used a transfer belt when transferring Resident #4 and Resident #5. An IJ was identified on 01/29/25. The IJ template was provided to the facility on [DATE] at 4:03 PM. While the IJ was removed on 01/31/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures placed residents at risk of serious harm. Findings included: Record review of Resident #3's face sheet, dated 01/16/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #3's MDS Quarterly Assessment, dated 10/28/24, reflected Resident #3 had a BIMs score of 02, indicating severe cognitive impairment. Resident #3 was dependent on staff for toileting and showering, toilet transfers, tub/shower transfers, chair bed to chair transfers, lying to sitting on side of the bed, and sit to lying. Resident #3 required substantial/maximum assistance with upper and lower body dressing, rolling left and right. Her diagnosis included High Blood Pressure, Alzheimer's Disease, Anxiety, Depression, and bipolar disorder and Dysphagia (difficulty swallowing). Resident #3 received hospice care. Record review of Resident #3's Care Plan, reviewed on 01/17/25, reflected: Focus: [Resident #3] has an Activity of Daily Living self-care performance deficit related to muscle wasting, lack of coordination and impaired mobility. Goal: Resident will maintain current level of function Intervention: [Resident #3] was dependent on staff for toileting and showering, toilet transfers, tub/shower transfers, chair bed to chair transfers, lying to sitting on side of the bed, and sit to lying. [Resident #3] required substantial/maximum assistance with upper and lower body dressing, rolling left and right. Bath/Showering: Provide sponge bath when showering was not tolerated, with assistance by 1 staff, Bed Mobility: Resident required extensive assistance by 1 staff to turn and reposition in bed, Dressing: Extensive assistance by 1 staff. Transfers: Limited to extensive assistance by 1 staff to move between surfaces. [Resident #3] has an alteration in musculoskeletal status related to acute Left humeral neck fracture, moderate to severe glenohumeral osteoarthritis. 1/13/25 complaint of pain L shoulder during shower with hospice CNA. Goal: [Resident #3] will remain free from pain or at a level of discomfort acceptable to her. Interventions:1/13/25 assessed, Nurse Practitioner notified with new order STAT X-Ray Left shoulder, Representative notified. X-Ray results: Acute humeral neck fracture. Moderate to severe glenohumeral osteoarthritis. Nurse Practitioner /Responsible Party/hospice/DON notified; routine pain medication administered. Record review of the facility's Provider Investigation Report, dated 01/21/25, reflected: Incident date: 01/13/25, Time of Incident 7:15 AM. Person(s) or Resident (s) involved: [Resident #3] Alleged Perpetrator(s)(AP): [Hospice Aide K] Description of the Allegation: [Resident #3] complained of pain in her left shoulder after having a bath with the hospice aide, [Hospice Aide K]. Assessment: Date 1/13/25 Time: 8:43AM by [RN I] -Resident c/o pain to the left shoulder when she was given her a shower. Assessment performed ablet to squeeze my fingers c/o pain when lifting the arm. NP in the facility notified and ordered x-ray. Facility Investigation Findings: Confirmed. Provider Action taken post-investigation: [Resident #3] [is] being monitored for pain and medicated as indicated. Education continues with staff on abuse and neglect and turning and repositioning. Hospice aides are being re-educated also. Facility initiated an investigation on 01/14/2025 after [Resident #3] made a complaint of pain in her shoulder and an x-ray that was ordered, returned with an Internal and external rotation views of the shoulder were obtained. There [is] a minimally displaced humeral neck fracture (a fracture in the neck of the upper arm bone where the broken bone pieces are only slightly out of alignment). Gleno-humeral joint space loss and spurring are noted (a space withing the shoulder joint is narrowed, and there are visible bone growths present, indicating the development of degeneration of joint cartilage and the underlying bone in the shoulder). There is no shoulder separation. There is no calcific tendinopathy (the formation of calcium deposits in tendons, leading to inflammation and pain). Diffuse osteopenia (generalized decrease in bone mineral density) is demonstrated. IMPRESSION: Acute humeral neck fracture. Moderate to severe gleno-humeral osteoarthritis. .[Hospice Aide K] came in for the interview and stated that he was repositioning [Resident #3] in the bed and did not use the draw sheet. He was informed of the injury and Hospice [Name] nurse was informed that he would need to removed from our building pending the investigation. Other residents who were under Hospice [Name] care were evaluated for pain, distress or injury with none noted. Staff were re-educated on our abuse-neglect policy and turning and repositioning when in bed and bathing. Hospice Aide K statement dated 01/14/25: On 01/13/20[24] I came to provide care for [Resident #3], [I] have been her aide since 12/21/2023. [I] usually give her bed bath but yesterday she had stool on her, so I took her to the shower. After showering her [I] dried her off and dressed her and assisted her back to the bed. She [is] a one-person transfer. After [I] put her back in bed, [I] adjusted her legs, but [I] noticed that she was still too far down in the bed. [I] went behind the headboard and lifted her under her arms to pull her up. [I] usually use the draw sheet but this time I just grabbed her under her arms. [I] did hear a pop at this time, and she said that her arm hurt. [I] reported to the nurse that she was complaining of pain, and he went to assess her. [I] reported it to my supervisor at Hospice [Name]. [Today], [I] was informed that there is a fracture. It was a complete accident. [I] didn't use the draw sheet like [I] was supposed to and was trained to do so by my company. [I] take pride in the work [I] do and always try to always ensure safety. [I] care so much for my patients and made a mistake that will never happen again. 1/14/25 hospice nurse in and assessed with pain medication adjustments, increase anxiolytic (medications to treat anxiety disorders), hold anticoagulant x 3-day, Blood Pressure medication, as needed anticholinergic (drugs that block the action of the neurotransmitter) related to secretions, Representative notified, 2 Person Assist provided with turning and repositioning, call light in reach. 1/15/25 hospice new order antibiotic therapy twice a day x 7day prophylactically (actions taken to prevent or guard against a disease or infection). 1/16/25 Left arm elevated on pillow for comfort, assisted with repositioning. Assist Resident #3 to change positions. Alternate periods of rest with activity out of bed as tolerated/allowed in order to prevent respiratory complications, dependent edema (swelling that occurs in the lower extremities), flexion deformity (joint is permanently bent in a flexed position) and skin pressure areas. Be sure call light is within reach and respond promptly to all requests for assistance. Educate resident /family/caregivers on joint conservation techniques. Give analgesics (pain reliever) as ordered by the physician. Monitor and document for side effects and effectiveness. Monitor for any side effects to NSAIDS such as GI bleeding or renal impairment. Monitor/document for risk of falls. Educate resident/family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Monitor/document/report as needed signs and symptoms or complications related to arthritis: Joint pain. Joint stiffness, usually worse on wakening; Swelling; Decline in mobility; Decline in self-care ability; Contracture formation/joint shape changes; Crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Record review of Resident #3's x-ray results dated 01/13/25 reflected x-rays of the resident's left shoulder showed the following findings: .Findings: Internal and external rotation views of the should were obtained. There is a minimally displaced humeral neck fracture. Gleno-humeral joint space loss and spurring (bony growths that form in your joints) are noted. There is no shoulder separation. There is no calcific tendinopathy. Diffuse osteopenia is demonstrated. Impression: Acute humeral neck fracture. Moderate to severe gleno-humeral osteoarthritis. Record review of Resident #3's progress notes reflected the following entries: - 01/13/25 10:32 AM written by RN L: Hospice aide reported to the RN L that resident complained of pain to the left shoulder when he was giving her a shower. Assessment performed able to squeeze my fingers complained of pain when lifting the arm. Nurse Practitioner in the facility notified and ordered x-ray. Called .mobile x-ray and an order was placed family notified and will continue to monitor. - 01/13/25 11:34 AM written by RN L : left shoulder pain, started 01/13/25, since started it has gotten worse. Things that make the condition worse: movement. Things that make the condition better: calm. - 01/13/25 6:30 PM: Left shoulder X-ray results received with the following findings: Acute humeral neck fracture and moderate to severe gleno-humeral osteoarthritis. Nurse Practitioner notified pending new orders, call placed to family and Hospice awaiting call back from Hospice. DON notified. Routine pain medications administered as per orders. - 01/14/25 8:42 AM written ADON B: Resident complained of left arm pain 1/13/25. Nurse Practitioner was in the building and notified. X-ray positive for fracture. Pain controlled by Tylenol #3. - 01/14/25 2:13 PM written by ADON B: Hospice nurse in the facility to examine resident. She gave the following orders: 1. Discontinue Routine Tylenol #3 2. Start Tylenol #3 2 tabs every 6 hours as needed for pain. 3. Start Hydrocodone 10/325 1 by mouth every 6 hours routine. 4. Discontinue Tylenol #3 when hydrocodone arrives. 5. Morphine 20 mg/ml give 0.25 - 0.5 ml under the tongue every hour as needed for severe pain/short of breath. 6. Tylenol 650 mg suppository give one recetally every 4 hours as needed for fever greater than 100.5 Do not exceed 3gm Tylenol in 24 hours. 7. Give Tylenol #3 2 tabs now for severe pain. - 01/14/25 2:30 PM written by ADON B: Resident's family member was contacted via phone regarding change of condition/arm fracture. Explained to her how resident obtained injury and the plan moving forward to provide comfort care. New orders from hospice reviewed with family member. Family member in agreement with not pursuing aggressive measure and is ok with comfort measures. - 01/14/25 10:02 PM: Resident was stared on Norco 10/325 mg routine, medication administered this as per orders for left shoulder pain. Resident stable and able to voice needs. Incontinent care provided by staff. Call light in reach. Observation of Resident #3 on 01/15/25 at 2:00 PM revealed the resident was in bed resting. The resident responded that she felt okay and closed her eyes. Observation and interview on 01/16/25 at 2:00 PM with Resident #3 revealed her in bed. Resident #3 revealed she did not have any pain and did not display any signs or symptoms of distress. Resident #3 was not able to effectively communicate about her arm injury. Interview on 01/16/25 at 2:05 PM with CNA J revealed Resident #3 was currently on hospice, she was informed there had been an injury with Resident #3's left arm. CNA J stated Resident #3 allowed incontinent care however was very protective of her left arm. CNA J stated Resident #3 had a great relationship with Hospice Aide K and looked forward to his visits. According CNA J stated she was aware to use a draw sheet to reposition residents and never to pull on their body parts. CNA J stated Resident #3 had been asking for Hospice Aide K because it had been a couple of days since he had returned. Interview on 01/16/25 at 3:12 PM with RN L revealed Resident #3 received bed baths and showers from hospice, RN L stated on 1/13/25 Resident #3 received a shower from Hospice Aide K after placing her back in bed, Hospice Aide K alerted me that Resident #3 complained of pain to the right shoulder. RN L stated he went in room to complete assessment and Resident #3 stated that when Hospice Aide K pulled her up in bed, she heard a pop and had pain soon after. RN L stated the Nurse Practitioner was in the building and after alerting her she ordered x-ray. RN L stated Hospice Aide K revealed that he showered Resident #3 and placed her back in bed, she was low in bed, so he stepped behind the bed lifting her placing his arms underneath her shoulders and lifted her up in bed, heard a pop, then she complained of pain. Interview on 01/16/25 at 3:25 PM with Hospice Aide K revealed he has been working with Resident #3 for over a year coming to the facility Monday, Wednesday and Friday to provide mostly bed baths. He stated on 01/13/25 Resident #3 was heavily soiled and required a shower. Hospice Aide K stated after transferring Resident #3 to her bed she was still too low in bed. Hospice Aide K stated In order to get her pulled up I always raise the bed and feet up with the controller to allow gravity to assist me. I put my arms under her arm pits. I usually grab the sheet. This time I did not grab the sheet. I put my weight against the headboard. This time when I lifted her, I did so hard there was this loud cracking sound. I can not say why I repositioned her this way, without the use of a draw sheet He stated when he pulled her up there was a loud cracking, popping noise from the left shoulder. Hospice Aide K stated, When I heard that, I ran to alert the nurse. During the assessment Resident #3 reported her left shoulder was hurting, an x-ray was ordered, and the following day it was reported Resident #3 had a fracture. Interview on 01/16/25 at 4:10 PM with DON revealed she was informed Resident #3 complained of pain of the left shoulder. The DON stated the Nurse Practitioner had ordered an x-ray that revealed findings of a fracture. The DON stated she went to speak with Resident #3 when she expressed Hospice Aide K was bathing her and she heard a loud pop. The DON stated she called Hospice Aide K; he confirmed the there was a loud pop to the shoulder which resulted in Resident #3 having pain. Interview on 01/16/25 at 4:27 PM with ADON B revealed he had been informed by RN L that Resident #3 had received a shower from Hospice Aide K, he attempted repositioning her in bed by pulling Resident #3 up by placing his arms underneath her shoulders and not using the draw sheet. ADON B stated x-ray results came revealing a fracture leading us to make all the notifications to the DON, physician, hospice and Family Member. ADON B stated Resident #3 was kept comfortable and orders for Tylenol 3, Norco and Morphine was administered. ADON B stated inservices were started to train staff to always have help with repositioning, use draw sheet, do not pull-on resident body parts. ADON B stated all aides including hospice staff were responsible for asking for assistance from other aides, charge nurses or ADONs to reposition residents, not doing so placed residents at risk of injury or fall. Interview on 01/16/25 at 4:45 PM with the DON revealed she was currently completing the investigation and inservices for Resident #3. The DON stated staff were being inserviced on repositing residents, using draw sheet, asking for assistance when repositioning residents. Record review of Inservice Training Report dated 01/14/25 Abuse and Neglect; also 01/14/25 Turning and Repositioning/lift extremities/monitor for discomfort reflected the following: Each resident should have a draw sheet placed under them when in bed. When turning and repositions a resident in bed, [you] should never pull them by their arms or legs. Use the draw sheet for all turning, repositioning, and pulling them in the bed. GENTLY, lift the arm and legs when off loading or moving for comfort. If a patient shows signs of discomfort during any aspect of care, STOP what [you[ are doing and get your nurse. (Make sure the resident is safe). Remember, pain is not always expressed verbally. Monitor facial expressions. At no time should we refer to a resident as being dead weight. 2. Record review of Resident #4's face sheet, dated 01/29/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #4's quarterly MDS assessment, dated 01/08/25, reflected a BIMS score of 06, which indicated severe cognitive impairment. Her diagnoses included unspecified dementia, dysphagia, hypertension (high blood pressure). The MDS further revealed Section GG - Functional Abilities indicated Resident #4 needed substantial/maximal assistance (helper does more than half the effort lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to- chair transfer. Record review of Resident #4's care plan revised date 01/13/25 reflected: Problem: [Resident #4] has an ADL self-care performance deficit r/t impaired mobility. Goal: [Resident #4] will maintain current level of function in ADLs through the review date. Interventions: FUNCTIONAL PERFORMANCE: CHAIR/BED-TO-CHAIR TRANSFER: [Resident #4] requires substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). BATHING/SHOWERING: [Resident #4] requires total assistance by 1 staff with bathing/showering. Observation on 01/29/25 at 10:23 AM revealed Hospice LVN BB performed a transfer for Resident #4 from the wheelchair to the bed to provide the resident a bed bath. Hospice LVN BB explained the procedure to Resident #4. Hospice LVN BB then locked the resident's wheelchair and told Resident #4 to hug her. Hospice LVN BB was observed to put her arms around Resident #4 underneath the resident's arms and lifted the resident up. She then turned the resident and sat her on the bed. Resident #4 was not able to stand her own and depended on the hospice nurse to do the transfer. Hospice LVN BB did not use a transfer belt when performimg the transfer. Record review of Resident #5's face sheet, dated 01/29/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #5's significant change in status MDS assessment, dated 12/27/24, reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her diagnoses included old myocardial infarctio n (previous heart attack that's no longer active), malnutrition, dysphagia, hypertension (high blood pressure). The MDS further revealed Section GG - Functional Abilities indicated Resident #5 needed substantial/maximal assistance (helper does more than half the effort lifts or holds trunk or limbs and provides more than half the effort) for chair/bed-to- chair transfer. Record review of Resident #5's care plan revised date 01/16/25 reflected: Problem: [Resident #5] has an ADL self-care performance deficit r/t impaired mobility, declining health. Goal: [Resident #5] will maintain current level of function in ADLs through the review date. Interventions: FUNCTIONAL PERFORMANCE: CHAIR/BED-TO-CHAIR TRANSFER: [Resident #5] requires substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair). BATHING/SHOWERING: [Resident #5] requires total assistance by 1 staff with bathing/showering. Observation on 01/29/25 at 10:30 AM revealed Hospice Aide CC performed a transfer for Resident #5 from the bed to the wheelchair, so she could take the resident to the shower room. Hospice Aide CC explained the procedure to Resident #5. Hospice Aide CC then helped Resident #5 sit on the side of the bed. Hospice Aide CC lifted the resident by holding onto the resident's waistband, and the resident stood up. Hospice Aide CC next told the resident to hold onto her like she was hugging her. Hospice Aide CC held the Resident #5 by the waist with both hands, lifted her, and placed the resident to the wheelchair. Hospice Aide CC did not use a transfer belt, and Resident #5 was not able to stand her own and depended on the hospice Aide to do the transfer. Interview on 01/29/25 at 11:03 AM with Hospice LVN BB revealed she was the aide and the nurse assigned to Resident #4. She stated today 01/29/25 was the first-time meeting Resident #4. She stated she was covering for another hospice staff. She stated when she came in, she told the facility who she was visiting and obtained report from the charge nurse. She stated she was told about Resident #4's transfer. She stated Resident #4 was a one person assist. She stated she also got report last week from the resident's Case Manager, and she was told the resident was a one-person transfer. She stated she had access to Resident #4's hospice care plan, and the care plan only stated Resident #4 could transfer to the bed and the chair with assist, but she could not see by how many people and with what device. She stated she could get more information from her office. Hospice LVN BB stated when she was told Resident #4 was a one person transfer it was not specified whether to use a gait belt or not. She stated she only followed what the resident's care plan stated which was one person transfer. Hospice LVN BB stated if more information was required, the hospice company needed to be contacted to obtain the information. Interview on 01/29/25 at 11:51 AM with Hospice Aide CC revealed she was the hospice aide for Resident #5. She stated she visited Resident #5 five days a week. She stated when transferring Resident #5 from the bed to the wheelchair or the wheelchair to the bed, Resident #5 was able to hold onto her and able to stand. She stated Resident #5 was a one person assist for transfer. She stated it was unknown if any devices were needed to complete the transfer. Hospice Aide CC stated the charting system provided a summary of the patient's care. She stated for a transfer it did not specify if a gait belt was needed. She stated the facility had not provided any information if a gait belt was needed to transfer Resident #5. She stated any transfer training she had received was from her hospice company. Interview on 01/29/25 at 12:03 PM with RN I revealed when hospice came in to visit residents, the Hospice staff sometimes communicated with the nurse on duty; however, sometimes they did not because Hospice staff already knew the resident care. He stated he did not provide hospice staff any oversight on care or transfers. He stated the hospice aides should get the details of the care plan and any information regarding transfers and positioning from their hospice nurse. Interview on 01/29/25 at 12:20 PN with the Nurse Practitioner revealed Resident #3 was on hospice services and her orders and care were managed by hospice. She stated the day of the incident she was in the facility, and she gave orders for x-rays since Resident #3 needed one urgently but when results were back, she told staff to report to the hospice nurse. Interview on 01/29/25 at 12:24 PM with LVN Z revealed she had residents on her hall who were seen by hospice. LVN Z stated when the hospice staff visited, she provided them with report and gave them any updated information on the resident. She stated if the resident was two person assist, she would notify the hospice staff and would let them know to come get her when they were ready to transfer. She stated the only information she would provide the hospice staff would be any change of condition updates and if the resident was a one person or two persons assist. She stated she could not recall if they used any devices when transferring but they should use a draw sheet when repositioning or turning the resident. Interview on 01/29/25 at 1:33 PM with ADON B revealed when a hospice staff came to the facility, the charge nurse was responsible to provide report or any change of condition to the hospice staff. ADON B stated he was not sure if the facility staff provided any information regarding transfers or if they required the use of a gait belt when transferring a resident. He stated it was the responsibility of the hospice staff to ensure they knew the resident's care plan and if the resident was a one person or two person assist. ADON B stated it was the responsibility of the hospice company to in-service all hospice staff. He stated facility staff were in-serviced on repositioning and transfers after Resident #3's incident. He stated today (01/29/25) he contacted all hospice companies to let them know of the incident regarding repositioning and they expected for all hospice staff to be trained. ADON B stated he could not answer the question of who was responsible or who provided hospice staff of any oversight on care or transfer. Interview on 01/29/25 at 1:46 PM with ADON A revealed she had 9 residents on the secure unit. She stated when a hospice staff came in, they provided the hospice staff with any information regarding the resident. She stated the hospice staff reviewed the care plan on their own system and they knew if the resident was a one person, or two persons assist. ADON A stated if the hospice staff needed assistance with transfer they would assist. She stated it was unknown who provided training to the hospice staff. Interview on 01/29/25 at 2:05 PM with the DON revealed after Resident #3's incident, the facility had implemented education of facility staff regarding turning and repositioning/lifting extremities, monitoring for discomfort, abuse and neglect, and use of a draw sheet. She stated Hospice Aide K was removed from the facility. She stated Resident #3 was assessed, pain medication provided, a conference with the family and skin assessments were completed on all other hospice residents. She stated they also completed a QAPI meeting on 01/14/25. The DON stated the hospice companies were responsible for their own staff and checked for competencies and training. She stated she had not in-serviced any hospice staff and only completed a 1:1 with Hospice Aide K after the incident. She stated her expectations were for hospice companies to train their own staff, and when hospice staff visited, they must check in with the charge nurse to make sure the resident did not have any changes in their care plans. She stated prior to signing any contract with a hospice company the facility provided them with the facility expectations and their responsibilities. She stated one of the responsibilities was for them to train their staff. The DON stated her expectations were for staff to use a draw sheet when turning and repositioning a resident. She stated if a resident was not able to 100 percent transfer own their own, staff were expected to use a gait belt. She stated staff should know how to transfer a resident with the use of a [NAME] belt, it was part of their competencies. She stated the resident Kardex (a medical-patient information system) stated whether the resident was a one- or two-person transfer. She stated staff and residents should not be bear hugging each other when transferring. She stated hospice staff should follow their care plans and gait belts were part of their uniforms. She stated when a resident was a one-person transfer staff should use a gait belt for safety. The potential risk would be the resident falling or staff falling on top of the resident. A policy regarding Positioning and Transfers was requested; however, the DON stated the facility did not have a policy regarding Positioning and Transfers. Interview on 01/30/25 at 10:16 AM with the Assistant Rehabilitation Director revealed for a resident who needed assistance with transferring from a wheelchair to the bed or the bed to a wheelchair staff were recommended to use a gait belt. She stated when transferring a resident, if the staff must touch the resident to complete the transfer, they should use a gait belt. She stated the potential risk would be injury, or the resident falling. She stated if a resident needed to be repositioned on the bed staff should use a draw sheet. She stated it was not okay to use their arms to pull on them as it could cause injuries. She stated Resident #4 and Resident #5 were able to transfer but with the assistance of staff they could not transfer own their own. She stated it was recommended for staff to use a gait belt when transferring Resident #4 and Resident #5. This was determined to be an Immediate Jeopardy (IJ) on 01/29/24 at 3:40 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 01/29/25 at 4:03 PM. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/30/25 at 12:13 PM and reflected the following: Actions Taken: For those Identified: Skin and pain evaluations were completed for Resident # 1 [4] & 2 [5] by the Licensed Nurse on 1/29/25. No skin alterations or pain was observed. To Identify Other Residents: Eighteen (18) residents were identified as being in Hospice Services in the center on 1/29/25. All were evaluated for skin alterations and pain by the licensed nurse on 1/29/25. All were evaluated for assistive devices to prevent accidents and harm to residents by the Licensed Nurse on 1/29/25. Education/ System Change: The center will ensure the necessary devices are available for positioning and transferring for Hospice Staff. On 1/29/25, the Director of Nursing/designee educated the Director of Nursing at the eight (8) Hospice Companies that are contracted to provide hospice services at the center that the Hospice Company will: o Have current clinical positioning and transferring competencies for their staff providing services in the center will be provided to the facility on 1/30/25. o That their staff are to meet with the center's Licensed Nurse prior to providing care to discuss coordination of care per the resident's care plan including having and using the necessary assistive devices for positioning and transferring residents. All Hospice Staff will be educated by the Director of Nursing and/ or designee prior to working with the Hospice resident. Education will continue until all Hospice Staff have completed the required education. Beginning 1/29/25, and ongoing, new Hospice Staff will receive this training prior to providing care to the Hospice residents and transfer from bed to wheelchair competency will be completed. Education topics include: o Incidents[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and records 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 4 residents (Resident #1) reviewed for pain management. The facility failed to obtain physician orders for the intrathecal pain pump from the Pain Physician for Resident #1 upon admission on [DATE] for immediate care and needs. After the orders were obtained, the facility failed to assist Resident #1 with a patient controlled bolus as needed for breakthrough pain via a surgically implanted pain pump per the Pain Medicine Physician Orders dated 09/10/24 at 2:25 PM. The facility failed to assist Resident #1 with a patient controlled bolus (a single dose of a drug or other medicinal preparation given all at once) of a combination pain medication infusion (Baclofen 15.0 mcg [skeletal muscle relaxant]; Hydromorphone 2.73 mcg [treats moderate to severe pain]; Clonidine 0.511 mcg [for post-spinal cord injury related pain]; and Droperidol 0.273 mcg [to prevent nausea and vomiting]), every 6 hours as needed for breakthrough pain via an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord) on 09/07/24 - 09/13/24. Resident #1 could self-administer the bolus dose by pressing the button on a personal therapy manager device but the device was kept out of the resident's reach . The facility failed to assess and evaluate Resident #1 for pain. Upon admission on [DATE], Resident #1 verbalized pain and requested assistance with the patient controlled bolus via the pain pump. Resident #1 verbalized pain and requested assistance with the pain medication for 7 days (09/07/24 - 09/13/24). Resident #1 received her first patient controlled dose of pain medication for breakthrough pain on 09/14/24 at 9:27 PM. Resident #1's pain level ranged between a 6 to an 8 out of 10 from 09/07/24 to 09/14/24. An IJ was identified on 09/15/24. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 09/17/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents on pain medications to experience unnecessary pain, an abnormal response to pain, or serious harm. Findings included: Record review of Resident #1's admission MDS assessment, dated 09/11/24, reflected a [AGE] year-old female who admitted from an inpatient rehabilitation hospital to the facility on [DATE] with diagnoses: Neuromuscular Dysfunction of Bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem); Osteoporosis (a bone disease that causes bones to become brittle and break easily); Quadriplegia, incomplete (weakness or paralysis of all four limbs); Pressure ulcer of sacral region, stage 4; Pressure ulcer of unspecified buttock, stage 4; and Anxiety. A BIMS score of 15 suggested Resident #1 was cognitively intact. Resident #1 required maximum assistance to total dependence for ADLs. Section J - Health Conditions of the admission MDS assessment reflected Resident #1 received scheduled pain medication. Response(s) in the pain assessment interview revealed No to pain presence. All other questions related to pain were skipped based on the answer No if [Resident #1] had pain or hurting at any time in the last 5 days? A response was not selected if the Staff Assessment for Pain be Conducted? Record review of Resident #1's Order Summary Report, dated 09/14/24 at 2:06 PM, reflected: - Order date 09/07/24: Vital signs every shift. [BP, Temp, Pulse, Resp, O2 Sats, Pain Level] - Order date 09/07/24: Monitor for pain every shift. Use 0 - 10 scale for alert residents. - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 2 capsules by mouth two times a day for Neuropathy (nerve damage condition). - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 4 capsules by mouth at bedtime for Neuropathy. - Order date 09/07/24: Myrbetriq extended release 24-hour tablet [NO DOSE]. Give 1 tablet by mouth two times a day for Bladder Spasms. - Order date 09/07/24: Pyridium 100 mg tablet. Give 2 tablets by mouth as needed for urinary discomfort TID. - Order date 09/10/24 (The DON discontinued this order after surveyor intercession on 09/14/24): DO NOT give bolus on resident's Pain Pump. - Order date: 09/14/24 (The DON discontinued this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen, hydromorphone, clonidine and Droperidol. Staff is not to access pump. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen 285.1 mcg, hydromorphone 51.83 mcg, clonidine 9.719 mcg and Droperidol 5.183 mcg/24 hours. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Baclofen Solution 15 mcg via implant every 6 hours as needed for Pain related to Quadriplegia. Supervised self-administration bolus includes Hydromorphone 2.73 mcg, clonidine 0.511 mcg and Droperidol 0.273 mcg. Place personal therapy manager device on implanted device to RLQ so she [Resident #1] can self-administer medication bolus. Record review of the Pain Medicine Physician Orders faxed to the facility on [DATE] at 2:24 PM, effective 04/15/24, reflected: - A simple continuous 24-hour pain medication infusion (Baclofen 2,200.0 mcg/mL; Hydromorphone 400.0 mcg/mL; Clonidine 75.0 mcg/mL; and Droperidol 40.0 mcg/mL) in a 39.0 mL reservoir. - The 24 hour dose infused Baclofen 10.8 mcg/hr (259.8 mcg/day); Hydromorphone 1.97 mcg/hr (47.25 mcg/day); Clonidine 0.369 mcg/hr (8.859 mcg/day); and Droperidol 0.197 mcg/hr (4.725 mcg/day). - The bolus dose infused Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg, 1 bolus every 6 hours as needed for breakthrough pain. The bolus duration was for 1 minute. There was a 6-hour bolus restriction window (lockout duration 6 hours). Record review of Resident #1's Baseline care plan, printed 09/14/24 at 3:24 PM, reflected: - [Resident #1] was on pain medication therapy (Date initiated: 09/07/24; Revised on 09/14/24). Interventions initiated on 09/07/24 included, Ask physician to review medication if side effects persist; For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications; Monitor/document/report PRN adverse reactions to analgesic therapy .; and Review for pain medication efficacy . The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through the review date. - Interventions added (revised) by the DON on 09/14/24 after surveyor intercession: Administer po Analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Facility Dr. offered to switch to PO medications; Resident has pain pump. Staff is not to access must go see pain mgmt. doctor when needed if pump not functioning or dislodged contact MD and pain management doctor. Pump delivers: Baclofen, hydromorphone, clonidine and Droperidol. Needs refill prior to 12/07/24. Record review of Resident #1's September 2024 MAR reflected nurse initials that attested to medication/treatment administration as ordered on 09/07/24 - 09/14/24. The Baclofen Solution bolus was initiated on 09/14/24 at 9:27 PM. Pain monitoring every shift revealed zeros each shift (2:00 PM-10:00 PM and 10:00 PM-6:00 AM) on 09/07/24; three times a day (6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM) on 09/08/24 - 09/14/24. The pain level entered 09/14/24 10:00 PM-6:00 AM shift revealed 5 out of 10. The vital signs reflected zeros for the pain level on 09/07/24 - 09/13/24. Vital signs were not entered on 09/14/24 (6:00 AM-2:00 PM). The pain level was a 4 out of 10 on 09/14/24 (2:00 PM-10:00 PM). Record review of the Medication Reconciliation Report for discharge date d 09/03/24 at 4:49 PM, sent from the rehabilitation hospital, reflected an incomplete order for a Baclofen Pump. The order did not list the medications infused via the Baclofen pump, doses, or frequency. Record review of the Discharge Orders dated 09/07/24 did not reflect the Baclofen Pump. During an interview on 09/14/24 at 2:14 PM, LVN A said that she worked weekend doubles (6:00 AM-2:00 PM and 2:00 PM-10:00 PM) and was the admission nurse for Resident #1 on 09/07/24. LVN A said that she did not know about the pain pump until she performed the head-to-toe skin assessment. LVN A said the pain pump was located at the right lower quadrant of [Resident #1] abdomen. LVN A said that she brought it to the other nurse (RN B) she worked alongside. LVN A said that she had heard of a pain pump but did not have experience with hands-on medication administration via the pump. LVN A said that Resident #1 indicated she needed the bolus dose via the pain pump for pain. LVN A said she did not recall the pain level. LVN A could not explain why the admission pain assessment reflected Resident #1 did not have pain. During an interview on 09/14/24 at 4:28 PM, ADON C stated on 09/09/24, the 6:00 AM-2:00 PM nurse (LVN D) reported that Resident #1 asked for assistance with a bolus dose from the pain pump. ADON C said that he was unaware of the pain pump. ADON C said during the morning clinical meeting, the Medical Director (the facility PCP) stated that the nurses should not access the pain pump to administer a bolus dose. ADON C indicated that the facility was concerned about the amount of pain medication Resident #1 received and if the bolus was administered, Resident #1 could overdose. ADON C said that he completed the pain assessment on 09/09/24 and entered no pain because [Resident #1] had a pain pump and received medicine for pain. ADON C said that he did not ask Resident #1 her pain level. During an observation and interview on 09/14/24 at 4:59 PM, Resident #1 was observed in bed lying on her back, head of bed raised approximately 30 degrees, head propped on pillows. Resident #1 right hip off loaded and heel protectors on both feet. Resident #1 had partial movement of right hand and arm, limited movement of left hand, and paralyzed below the waist. Resident #1 was alert and oriented x 4 (to self, place, time, and situation). Resident #1 had a flat affect. Resident #1 verbalized a current pain level of 6 out of 10. Resident #1 described the pain as a constant dull ache, throbbing, burning, shooting, and stinging pain. Resident #1 said the pain was generalized and fluctuated between a 6-8 out of 10 during various times on 06/07/24 - 06/14/24. Resident #1 said her pain level was a 3-4 out of 10 when her pain was managed. Resident #1 said when the pain level increased it could be persistent if not controlled by the bolus dose of medicine from her pain pump. Resident #1 said that she could activate the bolus dose by pressing the button on a personal therapy manager device if it was within reach, or if necessary, could teach the staff what to do. Resident #1 said that she asked the nurse (LVN A) to assist her with the bolus dose for pain on the day she admitted (09/07/24). Resident #1 said that LVN A told her that she [LVN A] needed to check with another nurse because she was not familiar with the pain pump. Resident #1 said that she asked the next shift (09/07/24 at 10:00 PM-6:00 AM) to assist with the bolus dose for pain but the nurse told [Resident #1] she could not assist with the bolus administration. Resident #1 said the facility PCP visited on 09/08/24 and said that it was unusual for nurses to administer extra doses from the pump because the pump infused pain medication for 24 hours and an extra dose was not possible. Resident #1 said that the facility PCP said that he could order her something to take as needed by mouth for pain. Resident #1 said she told the facility PCP she could show the facility staff how to activate the bolus dose if she [Resident #1] was not allowed to self-administer. Resident #1 said she asked the nurse on the evening shift (09/08/24 on 10:00 PM-6:00 AM) to assist with the bolus dose for pain and the nurse said she would check with the facility PCP. Resident #1 said that she asked the charge nurse on Monday, 09/09/24 (6:00 AM-2:00 PM) to assist with the bolus dose for pain and the nurse (LVN D) said he would have to ask someone what he should do. Resident #1 said (LVN D) did not come back for 1 and ½ hours and told her that he forgot. Resident #1 said (LVN D) never acknowledged her request or offered alternative pain measures during his shift. Resident #1 said that the facility PCP visited on 09/09/24 and offered Dilaudid to take by mouth as needed for pain. Resident #1 said she declined because it was against her pain medication doctors advise and did not feel comfortable with taking other medications in addition to the pain pump for fear she could overdose. Resident #1 said that if her pain was not managed, she could experience AD (Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury. It is an abnormal response to pain or discomfort). Resident #1 said that she had not received the bolus dose from 09/07/24 - 09/14/24. Resident #1 said that the personal therapy device was in the top drawer of the nightstand. The personal therapy device was packed inside a travel case. Resident #1 said no one asked how to administer the bolus dose or asked about the personal therapy device. During an interview on 09/14/24 at 5:35 PM, the facility PCP said that he was Board Certified for Pain Management, and he did not know of a pain pump that allowed the patient to self-administer a bolus dose of medicine. The facility PCP said that he talked with Resident #1 about alternative pain measures and was willing to write a prescription for Dilaudid that Resident #1 could take by mouth as needed every 6 hours for pain. The facility PCP said that Resident #1 refused, and he told her he could write an order for whatever she wanted to take for breakthrough pain. The facility PCP offered to write a prescription for Dilaudid (the brand name for hydromorphone) that belonged to a class of drugs called opioids for breakthrough pain as needed. The facility PCP said that he told Resident #1 that he would also order Narcan in case she had an overdose from the medications. The facility PCP said that he asked the charge nurse (LVN D) on Monday (09/09/24) to contact the pain doctor and get a list of medications that were infused via the pain pump so he could write an order for pain medication that would not interact. The facility PCP did not ask Resident #1 how the bolus dose was administered. Record review of Hydromorphone (2023) revealed hydromorphone (Brand name: Dilaudid) is utilized to effectively manage and treat moderate-to-severe pain and severe chronic pain in patients. Hydromorphone also exerts its effects centrally, leading to respiratory depression, interactions, and potential toxicity. Objectives included to screen patients for contraindications, potential risks, and drug interactions before prescribing; and collaborate with interprofessional healthcare team members to monitor for adverse effects and to ensure comprehensive patient care. Abi-Aad KR, [NAME] A. Hydromorphone. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470393/ During an interview on 09/14/24 at 6:30 PM, the DON said she did not know that Resident #1 had a pain pump prior to admission. The DON said the facility did not typically accept residents with pain pumps. The DON said the Clinical Liaison/Marketer made the decision about residents who could admit to the facility. The DON denied that she reviewed the clinicals (pre-admission paperwork) to make an informed decision about potential residents for admission. The DON said that she did not learn about the pain pump until Tuesday (09/10/24) and that was when she entered the order to Do Not access resident pain pump. The DON said that she had not assessed or evaluated Resident #1's pain level. The DON said that she did not speak with Resident #1 to obtain more information about the pain pump or how to administer the bolus dose. During an interview on 09/15/24 at 10:30 AM, the DON said that she conducted a self-administration medications assessment with Resident #1. The DON said that the staff should have inquired more about the bolus dose and how Resident #1 would administer the dose. The DON said that the staff should have conducted a self-administration medication assessment once it was determined Resident #1 had a patient-controlled option with the pain pump. The DON said that Resident #1 demonstrated the ability to administer the bolus dose with the assistance by nurses to place the device within reach. The DON said that she updated the orders to reflect the medication, dose, and frequency on the administration record and the PRN dose every six hours. During an interview on 09/15/24 at 1:57 PM, RN B said that she was not assigned to and did not provide direct care to Resident #1. RN B said that she assisted LVN A with Resident #1's admission (on 09/07/24). RN B said that she entered the orders from the Discharge Medication Orders and the orders did not reflect the pain pump or the medications infused via the pain pump. RN B said that it was important to know the medications, even if the nurses did not physically administer, to reflect the medications on the medication profile for the Pharmacy to review for interactions, and to have a full clinical picture of a resident. RN B said that best practice would be to contact the pain management physician for orders related to the pain pump. Record review of the facility's Physician Visits and Physician Delegation policy, implemented 10/24/22, reflected the Physician must provide orders for the resident's immediate care and needs. Record review of the facility's Self-Administration of Medications policy, revised 10/01/19, reflected the facility's overall goal to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team determined that the practice would be safe. Procedure: An assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. For residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or significant change in condition. Review of the facility's Pain Management Program Policy revised January 2023, indicated the facility will ensure that residents receive the treatment and care in accordance with professional management. The Nurse will assess the resident q shift for pain, depending on the type of resident being assessed, using the PAINAD or [NAME] Pain Evaluation Scale as indicated on the MAR. If a resident is assessed as experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered. Effectiveness of the intervention should be documented to determine if pain is reduced or alleviated appropriately. The DON and the RCS were notified of an Immediate Jeopardy (IJ) on 09/15/24 at 5:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/16/24 at 6:27 PM and included: September 15, 2024 [Name of Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 15, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F697 Pain Management 1.The facility failed to obtain admission medication orders for a surgically implanted device that delivers medication directly to the spinal cord to help control chronic pain. The surgically implanted device delivers pain medication solution at a continuous rate and an on-demand dose as needed for breakthrough pain. The on-demand dose must be manually administered by pushing a button to tell the surgically implanted device to administer an as needed dose. 2. The facility failed to assist the resident with the on-demand dose by placing the on-demand button out of the reach of the resident. 3. The facility ordered do not give bolus (on demand) on resident's pain pump. 4. The facility physician recommended Dilaudid pain medication by mouth for breakthrough pain instead of allowing the resident to self-administer pain medication from the surgically implanted device. (Taking Dilaudid and the medication ([Baclofen (muscle relaxer) /Hydromorphone (opioid medication to treat moderate to severe pain) /Clonidine (alternative use for chronic pain) /Droperidol (prevents nausea and vomiting)] can lead to serious side effects such as profound sedation, respiratory distress, coma, and death). 5. The facility failed to conduct a self-administration medication assessment to determine if the resident was capable of self-administering the on-demand dose of pain medication via the surgically implanted device. 6. The facility failed to provide pain management to a resident experiencing pain that was in accordance with the care plan and resident's goals for care and preferences. Actions Taken: For those Identified: Resident # 1 was assessed for signs and symptoms of pain by the Licensed Nurse on 9/15/24 - her pain level was a 6. After medication administration, pain level assessed as effective. Order for prn bolus is every 6 hours was entered in the PCC orders 9/15/24. Self-Administration of meds was completed 9/14/24 for resident involved. Pain care plan was updated by DON/ designee 9/14/24. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management. To Identify Other Residents: No other residents in the center have a pain pump. All residents have been evaluated for pain beginning 9/15/24. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain. Education/ System Change: Director of Nursing or designee educated the licensed nurses on the following educational components beginning 9/15/24: o Medication orders need to include; name of medication, dosage, frequency of administration and route o Pain Management includes evaluation of pain and administering medication as ordered by the attending physician. o If a medication is unavailable and you can obtain from E-Kit. o Nursing staff training on use of implanted pain pump use o Completion of the self-administration of medication evaluation All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Beginning 9/15/24, and ongoing, newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents. Director of Nursing educated by the regional clinical specialist on 9/15/24. Administrator educated by the regional clinical specialist on 9/16/24. The training will include the above-stated educational components. The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist on 9/15/24. On 9/15/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 9/15/24 and going forward, The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist on 9/15/24. Trends will be presented and discussed in the monthly QAPI meeting for three months. On 09/16/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of Resident #1's self-administration of medication assessment performed on 09/14/24 at 8:27 PM revealed Resident #1's ability to self-administer the bolus dose via pain pump, knowledge of medications and side effects, understanding that there is a 6-hour lock out, and was cognitively intact to self-administer the bolus dose via the pain pump. Record review of Resident #1's Active Order History reflected the medications infused via the pain pump, dose, frequency, and the PRN bolus dose every 6 hours. The staff are to assist by placing the device within Resident #1's reach and provide standby assistance as needed. Record review of Resident #1's September 2024 MAR reflected a PRN bolus dose (Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg) was administered on 09/14/24 at 9:27 PM. Record review of Resident #1's care plan printed 09/17/24, reflected updated interventions for pain management on 09/14/24. The interventions reflected pain pump management, pain medication therapy, and signs of medication side effects. On 09/17/24 (10:30 AM-11:00 AM), interviews with random residents revealed staff provided as needed pain medications or other pain relief alternatives in a timely manner. The residents denied unmanaged pain relief during their stay at the facility. During an observation and interview on 09/17/24 at 11:02 AM, Resident #1 was observed lying in a left lateral position in bed. With the assistance of (RN B), Resident #1 demonstrated how to self-administer the bolus medication via the pain pump when the nurse placed the device within reach. The screen of the device revealed it was too soon to administer a bolus. Resident #1 said that her current pain level was a 4 out of 10 and it was getting better. Resident #1 said that the goal was to maintain her pain level at a 2 or 3 out of 10 with the continuous infusion of medication via the pain pump. Record review of an in-service conducted by the RCS dated 09/15/24 with the NFA and DON reviewed care of residents with pain pumps and the management of pain pumps. Objectives of the in-service included necessary assessment(s), orders, notifications, and care plans. Record review of in-services conducted by the DON dated 09/15/24 with all nursing staff were on-going. Topics of the in-services included Policy on pain management, Intrathecal Pump, and Pain Assessments. Handouts that covered related policies and [Resident #1's specific] pain pump overview were provided to staff. The nursing staff were required to demonstrate how to assist Resident #1 with the personal therapy manager device and verbalized reportable signs and symptoms to ensure understanding of the information provided and steps of procedure. Interviews conducted with nurses scheduled (09/16/24 and 09/17/24) on the 6:00 AM-2:00 PM shift [LVN D and RN B], on the 2:00 PM-10:00 PM shift [RN E and RN C], 10:00 PM-6:00 AM shift [LVN G], and Weekend Doubles - 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift [LVN A] indicated they participated in the in-service trainings. The staff stated topics of discussion included pain management and how to care for a resident with a pain pump. Each nurse stated in their own words reportable concerns regarding the pain pump, signs and symptoms of pain, and pain assessment. During an interview on 09/17/24 at 11:38 AM, LVN D said he worked Monday - Friday 6:00 AM-2:00 PM shift. LVN D said Resident #1 was a new admission from over the weekend and on Monday, 09/09/24, while he conducted rounds, Resident #1 told [LVN D] that she needed something for pain and asked if [LVN D] would assist with the bolus dose from her pain pump. LVN D said he asked how to (administer the bolus dose via the pain pump) and Resident #1 replied that the device was in her nightstand drawer and needed somebody to give it to her. LVN D said that he never provided care to a resident with a pain pump in 18 years and was not familiar with a resident self-administering medication via a pain pump. LVN D said he told Resident #1 that he needed to speak with the doctor. LVN D said that Resident #1 stated she could demonstrate to the staff how to administer the bolus dose if needed. LVN D said on Tuesday (09/10/24) staff were informed not to administer the bolus dose via [Resident #1] pain pump. LVN D said that he did not know the reason why. LVN D said he requested the orders from the pain management physician (on 09/10/24) per the facility PCP request. LVN D said that he gave the (pain management physician) orders to the DON when they arrive via fax on 09/10/24. The DON and RCS were informed the Immediate Jeopardy was removed on 09/17/24 at 4:00 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and records review, the facility failed to ensure that licensed nurses have the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan for one (Resident #1) of one resident reviewed for nursing care/services, in that: Prior to admission, the facility failed to determine the knowledge, competencies, or skill sets of nursing staff to meet the needs of Resident #1 with an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord). The facility failed to educate, train, and assess nursing staff performance for the effective application of knowledge and skill provide competencies and skills sets necessary to provide care to Resident #1 who is a quadriplegic with chronic pain, a surgically implanted pain pump, and the risk of Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury, when there is unmanaged pain or discomfort. An IJ was identified on 09/15/24. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was removed on 09/17/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could cause residents on pain medications to experience unnecessary pain, an abnormal response to pain, or serious harm. Findings included: Record review of Resident #1's admission MDS assessment, dated 09/11/24, reflected a [AGE] year-old female who admitted from an inpatient rehabilitation hospital to the facility on [DATE] with Neuromuscular Dysfunction of Bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem); Osteoporosis (a bone disease that causes bones to become brittle and break easily); Quadriplegia, incomplete (weakness or paralysis of all four limbs); Pressure ulcer of sacral region, stage 4; Pressure ulcer of unspecified buttock, stage 4; and Anxiety. A BIMS score of 15 suggested Resident #1 was cognitively intact. Resident #1 required maximum assistance to total dependence for ADLs. Section J - Health Conditions of the admission MDS assessment reflected Resident #1 received scheduled pain medication. Response(s) in the pain assessment interview revealed No to pain presence. All other questions related to pain were skipped based on the answer No if [Resident #1] had pain or hurting at any time in the last 5 days? A response was not selected if the Staff Assessment for Pain be Conducted? Resident #1's Order Summary Report, dated 09/14/24 at 2:06 PM, reflected: - Order date 09/07/24: Vital signs every shift. [BP, Temp, Pulse, Resp, O2 Sats, Pain Level] - Order date 09/07/24: Monitor for pain every shift. Use 0 - 10 scale for alert residents. - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 2 capsules by mouth two times a day for Neuropathy (nerve damage condition). - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 4 capsules by mouth at bedtime for Neuropathy. - Order date 09/07/24: Myrbetriq extended release 24-hour tablet [NO DOSE]. Give 1 tablet by mouth two times a day for Bladder Spasms. - Order date 09/07/24: Pyridium 100 mg tablet. Give 2 tablets by mouth as needed for urinary discomfort TID. - Order date 09/10/24 (The DON discontinued this order after surveyor intercession on 09/14/24): DO NOT give bolus on resident's Pain Pump. - Order date: 09/14/24 (The DON discontinued this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen, hydromorphone, clonidine and Droperidol. Staff is not to access pump. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Resident has pain pump RLQ that delivers: Baclofen 285.1 mcg, hydromorphone 51.83 mcg, clonidine 9.719 mcg and Droperidol 5.183 mcg/24 hours. Pump is to be refilled prior to 12/07/24. Must contact pain management if dislodged or malfunctioning. - Order date: 09/14/24 (The DON entered this order after surveyor intercession on 09/14/24): Baclofen Solution 15 mcg via implant every 6 hours as needed for Pain related to Quadriplegia. Supervised self-administration bolus includes Hydromorphone 2.73 mcg, clonidine 0.511 mcg and Droperidol 0.273 mcg. Place personal therapy manager device on implanted device to RLQ so she [Resident #1] can self-administer medication bolus. Record review of the Pain Medicine Physician Orders faxed to the facility on [DATE] at 2:24 PM, effective 04/15/24, reflected: - A simple continuous 24-hour pain medication infusion (Baclofen 2,200.0 mcg/mL; Hydromorphone 400.0 mcg/mL; Clonidine 75.0 mcg/mL; and Droperidol 40.0 mcg/mL) in a 39.0 mL reservoir. - The 24 hour dose infused Baclofen 10.8 mcg/hr (259.8 mcg/day); Hydromorphone 1.97 mcg/hr (47.25 mcg/day); Clonidine 0.369 mcg/hr (8.859 mcg/day); and Droperidol 0.197 mcg/hr (4.725 mcg/day). - The bolus dose infused Baclofen 15.0 mcg; Hydromorphone 2.73 mcg; Clonidine 0.511 mcg; and Droperidol 0.273 mcg, 1 bolus every 6 hours as needed for breakthrough pain. The bolus duration was for 1 minute. There was a 6-hour bolus restriction window (lockout duration 6 hours). Record review of Resident #1's Baseline care plan, printed 09/14/24 at 3:24 PM, reflected: - [Resident #1] was on pain medication therapy (Date initiated: 09/07/24; Revised on 09/14/24). Interventions initiated on 09/07/24 included, Ask physician to review medication if side effects persist; For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications; Monitor/document/report PRN adverse reactions to analgesic therapy .; and Review for pain medication efficacy . The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through the review date. - Interventions added (revised) by the DON on 09/14/24 after surveyor intercession: Administer po Analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Facility Dr. offered to switch to PO medications; Resident has pain pump. Staff is not to access must go see pain mgmt. doctor when needed if pump not functioning or dislodged contact MD and pain management doctor. Pump delivers: Baclofen, hydromorphone, clonidine and Droperidol. Needs refill prior to 12/07/24. Record review of Resident #1's September 2024 MAR reflected nurse initials that attested to medication/treatment administration as ordered on 09/07/24 - 09/14/24. Pain monitoring every shift revealed zeros each shift (2:00 PM-10:00 PM and 10:00 PM-6:00 AM) on 09/07/24; three times a day (6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM) on 09/08/24 - 09/14/24. The vital signs reflected zeros for the pain level on 09/07/24 - 09/13/24. Record review of the Medication Reconciliation Report for discharge date d 09/03/24 at 4:49 PM, sent from the rehabilitation hospital, reflected an incomplete order for a Baclofen Pump. The order did not list the medications infused via the Baclofen pump, doses, or frequency. Record review of the Discharge Orders dated 09/07/24 did not reflect the Baclofen Pump. During an interview on 09/14/24 at 2:14 PM, LVN A said that she worked weekend doubles (6:00 AM-2:000 PM and 2:00 PM-10:00 PM) and was the admission nurse for Resident #1 on 09/07/24. LVN A said that she was responsible for up to 17 residents on a regular basis during her shift(s). LVN A said she had enough time to complete required assignments each day. LVN A said that she did not know about the pain pump until she performed the head-to-toe skin assessment. LVN A said the pain pump was located at the right lower quadrant of [Resident #1] abdomen. LVN A said that she worked alongside with (RN B) who was a reliable resource to her. LVN A said that she asked RN B was she familiar with care of a resident with a pain pump. LVN A could not explain why the admission pain assessment reflected Resident #1 did not have pain. LVN A said that she had heard of a pain pump but did not have experience with hands-on medication administration via the pump. LVN A said that she did not receive training or in-services about pain pumps in her on-hire orientation. LVN A said she received report from the off-going nurse during change of shift. LVN A said the care plan would outline a resident care need(s). During an interview on 09/14/24 at 4:28 PM, ADON C stated on 09/09/24, the 6:00 AM-2:00 PM nurse (LVN D) reported that Resident #1 asked for assistance with a bolus dose from the pain pump. ADON C said that he was unaware that Resident #1 had a pain pump and was not experienced with providing care to a resident with a pain pump. ADON C said during the morning clinical meeting, the Medical Director (the facility PCP) stated that the nurses should not access the pain pump to administer a bolus dose. ADON C indicated that the facility was concerned about the amount of pain medication Resident #1 received and if the bolus was administered, Resident #1 could overdose. ADON C said that he completed the pain assessment on 09/09/24 and entered no pain because [Resident #1] had a pain pump and received medicine for pain. ADON C said that he did not ask Resident #1 her pain level. ADON C said that he did not receive training or in-services about pain pumps in his on-hire orientation or annual training(s). ADON C said that he reviewed the care plan to know if a resident required specific care need(s). During an observation and interview on 09/14/24 at 4:59 PM, Resident #1 observed in bed lying on her back, head of bed raised approximately 30 degrees, head propped on pillows. Resident #1 right hip off loaded and heel protectors on both feet. Resident #1 had partial movement of right hand and arm, limited movement of left hand, and paralyzed below the waist. Resident #1 was alert and oriented x 4 (to self, place, time, and situation). Resident #1 had a flat affect. Resident #1 verbalized a pain level of 6 out of 10. Resident #1 described the pain as a constant dull ache, throbbing, burning, shooting, and stinging pain. Resident #1 said the pain was generalized. Resident #1 said her pain level was a 3 - 4 out of 10 when her pain was managed. Resident #1 said when the pain level increased it could be persistent if not controlled by the bolus dose of medicine from her pain pump. Resident #1 said that she could activate the bolus dose by pressing the button on a personal therapy manager device if it was within reach, or if necessary, could teach the staff what to do. The Resident #1 said that she asked the nurse (LVN A) to assist her with the bolus dose on the day she admitted (09/07/24). Resident #1 said that LVN A told her that she [LVN A] needed to check with another nurse because she was not familiar with the pain pump. Resident #1 said that she asked the next shift (09/07/24 at 10P - 6A) to assist with the bolus dose but the nurse told [Resident #1] she could not assist with the bolus administration. Resident #1 said the facility PCP visited on 09/08/24 and said that it was unusual for nurses to administer extra doses from the pump because the pump infused medication for 24 hours and an extra dose was not possible. Resident #1 said that the facility PCP said that he could order her something to take as needed by mouth for pain. Resident #1 said she told the facility PCP she could show the facility staff how to activate the bolus dose if she [Resident #1] was not allowed to self-administer. Resident #1 said she asked the nurse on the evening shift (09/08/24 on 10:00 PM-6:00 AM) and the nurse said she would check with the facility PCP. Resident #1 said that she asked the charge nurse on Monday, 09/09/24 (6:00 AM-2:00 PM) to assist with the bolus dose and the nurse (LVN D) said he would have to ask someone what he should do. Resident #1 said (LVN D) did not come back for 1 and ½ hours and told her that he forgot. Resident #1 said (LVN D) never acknowledged her request or offered alternative pain measures during his shift. Resident #1 said that the facility PCP visited on 09/09/24 and offered Dilaudid to take by mouth as needed for pain. Resident #1 said she declined because it was against her pain medication doctors advise and did not feel comfortable with taking other medications in addition to the pain pump for fear she could overdose. Resident #1 said that if her pain was not managed, she could experience AD (Autonomic Dysreflexia a life-threatening condition that can occur in people who have had a spinal cord injury. It is an abnormal response to pain or discomfort). Resident #1 said that she had not received the bolus dose from 09/07/24-09/14/24. Resident #1 said that the personal therapy device was in the top drawer of the nightstand. The personal therapy device was packed inside a travel case. Resident #1 said no one asked how to administer the bolus dose or asked about the personal therapy device. During an interview on 09/14/24 at 5:35 PM, the facility PCP said that he was Board Certified for Pain Management, and he did not know of a pain pump that allowed the patient to self-administer a bolus dose of medicine. The facility PCP said that he talked with Resident #1 about alternative pain measures and was willing to write a prescription for Dilaudid that Resident #1 could take by mouth as needed every 6 hours for pain. The facility PCP said that Resident #1 refused, and he told her he could write an order for whatever she wanted to take for breakthrough pain. The facility PCP offered to write a prescription for Dilaudid (the brand name for hydromorphone) that belonged to a class of drugs called opioids for breakthrough pain as needed. The facility PCP said that he told Resident #1 that he would also order Narcan in case she had an overdose from the medications. The facility PCP said that he asked the charge nurse (LVN D) on Monday (09/09/24) to contact the pain doctor and get a list of medications that were infused via the pain pump so he could write an order for pain medication that would not interact. The facility PCP did not ask Resident #1 how the bolus dose was administered. Record review of Hydromorphone (2023) revealed hydromorphone (Brand name: Dilaudid) is utilized to effectively manage and treat moderate-to-severe pain and severe chronic pain in patients. Hydromorphone also exerts its effects centrally, leading to respiratory depression, interactions, and potential toxicity. Objectives included to screen patients for contraindications, potential risks, and drug interactions before prescribing; and collaborate with interprofessional healthcare team members to monitor for adverse effects and to ensure comprehensive patient care. Abi-Aad KR, [NAME] A. Hydromorphone. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470393/ During an interview on 09/14/24 at 6:30 PM, the DON said that she did not know that Resident #1 had a pain pump prior to admission. The DON said that the facility did not typically accept residents with pain pumps. The DON said that the Clinical Liaison/Marketer made the decision about residents who could admit to the facility. The DON denied that she reviewed the clinicals (pre-admission paperwork) to make an informed decision about potential residents for admission. The DON could not give a direct answer to how she determined the competency needed to meet each resident's needs each day and during emergencies. The DON could not give a direct answer to how she assured that staff were appropriately assigned to meet the needs of residents and implemented care-planned approaches for each resident on each shift and unit. The DON said that resident status and care plan appropriateness was discussed each morning during a clinical meeting. The DON said that nurses were assigned a preceptor during their on-board orientation and training. The DON said that the preceptor was responsible for assessment and observation of the new-hire nurse's skill sets and competencies. The DON said that nurses were assessed for different types of clinical skill sets such as, IV therapy, wound care, and catheter care. The DON could not state for sure if nurses were checked off for pain pump competency. The DON said that she was initially checked off for her competencies when she was hired. The DON did not recall if she was checked off for knowledge and understanding of pain pumps. The DON denied that staff, residents, or family members have brought about concerns related to staff competency. The DON said that the facility did not utilize temporary/contract staff. The DON said that PRN staff participated in the same training and in-services as full-time staff. During an interview on 09/15/24 at 1:57 PM, RN B said that she was not assigned to and did not provide direct care to Resident #1. RN B said that she assisted LVN A with Resident #1's admission (on 09/07/24). RN B said that she entered the orders from the Discharge Medication Orders and the orders did not reflect the pain pump or the medications infused via the pain pump. RN B said that it was important to know the medications, even if the nurses did not physically administer, to reflect the medications on the medication profile for the Pharmacy to review for interactions, and to have a full clinical picture of a resident. RN B said that best practice would be to contact the pain management physician for orders related to the pain pump. RN B said that she provided care to residents with a pain pump before, however, never experienced a resident with a pain pump that had patient-controlled bolus doses. RN B said that she did not receive training or in-services about pain pumps during her on-hire orientation or annual training(s). RN B said that she familiarized herself with a resident care need(s) by reviewing the care plan and orders. RN B said that if it was a resident was a new admission, she reviewed the discharge paperwork from the transferring facility to learn more about the resident. Review of the Facility Assessment Tool dated 08/22/24 reflected services provided included Pharmacy ancillary services (medical services that are not provided by acute care hospitals, doctors, or health care professionals). General care for pain management included assessment of pain, pharmacological and nonpharmacological pain management. General care for medication administration included administration of medications that residents need by intravenous route. The Facility Assessment Tool revealed residents present in the facility included special care needs -quadriplegia and clinical needs - IV therapy and transfusions. The clinical profile reflected residents with intravenous therapy, on pain management program, and on opioids. Record review of RN/LVN Orientation Skills Checklists (signed and dated when completed) for licensed nurses did not reflect competency skills/duties for medication administration via intrathecal administration (A parenteral route, intravenous administration of nutrition and medications by bypassing the gastrointestinal system) pain pump, demonstrated proficiency or understanding. Review of the facility's Nursing Services and Sufficient Staff policy implemented 10/24/22, reflected the facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care. Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. The DON and the RCS were notified of an Immediate Jeopardy (IJ) on 09/15/24 at 5:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/16/24 at 6:27 PM and included: September 15, 2024 [Name of Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 15, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F726 Competent Nursing Staff Prior to admission, the facility failed to determine if they could meet the needs of a resident with a surgically implanted device that delivers pain medication directly to the spinal cord. The facility failed to provide competencies and skill sets necessary to provide nursing services related to admission orders for a resident receiving pain medication via a surgically implanted device. The facility failed to provide competencies and skill sets necessary to ensure each resident has an accurate medication profile. The facility failed to provide competencies and skill sets necessary to provide nursing services related to care of a resident with a surgically implanted device that administers pain medication. The facility failed to provide competencies and skill sets necessary to provide nursing services for pain assessment and pain management. The facility failed to provide competencies and skills sets necessary to ensure the resident has the right to be pain free. The facility failed to provide competencies and skill sets necessary to have a resident participate in care. The facility failed to provide competencies and skills sets necessary to assess if a resident is able to self-administer medications. Actions Taken: For those Identified: Resident # 1 was assessed for signs and symptoms of pain by the Licensed Nurse on 9/15/24 - her pain level was a 6. After medication administration, pain level assessed as effective. Order for prn bolus is every 6 hours was entered in the PCC orders 9/15/24. Self-Administration of meds was completed 9/14/24 for resident involved. Pain care plan was updated by DON/ designee 9/14/24. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management. To Identify Other Residents: No other residents in the center have a pain pump. All residents have been evaluated for pain beginning 9/15/24. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain. Education/ System Change: Director of Nursing or designee educated the licensed nurses on the following educational components beginning 9/15/24: o Pain Management includes evaluation of pain and administering medication as ordered by the attending physician. o If a medication is unavailable and you can obtain from E-Kit. o Nursing staff training on use of implanted pain pump use o Completion of the self-administration of medication evaluation o The regional clinical specialist educated the director of nursing and admissions director on 7/15/24 for reviewing preadmission screening and admission documents as much as they are available prior to admission. All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Beginning 9/15/24, and ongoing, newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents. Director of Nursing educated by the regional clinical specialist on 9/15/24. Administrator educated by the regional clinical specialist on 9/16/24. The training will include the above-stated educational components. The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist on 9/15/24. On 9/15/24, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 9/15/24 and going forward, The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist on 9/15/24. Trends will be presented and discussed in the monthly QAPI meeting for three months. Beginning 9/16/24, the administrator will ensure that the director of nursing and the admissions coordinator are reviewing preadmission screening and admission documents prior to admission to ensure that medication orders / equipment / DME are available upon admission for resident condition. On 09/16/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an in-service conducted by the RCS dated 09/15/24 with the NFA and DON discussion overview included preadmission screening and admission documents reviewed prior to resident admission. Objectives of the in-service included necessary assessment(s), orders, notifications, and care plans for residents with pain pumps. Record review of in-services conducted by the DON dated 09/15/24 with all nursing staff were on-going. Topics of the in-services included Policy on pain management, Intrathecal Pump, and Pain Assessments. Handouts that covered related policies and [Resident #1's specific] pain pump overview were provided to staff. The nursing staff were required to demonstrate how to assist Resident #1 with the personal therapy manager device and verbalized reportable signs and symptoms to ensure understanding of the information provided and steps of procedure. During an observation and interview on 09/17/24 at 11:02 AM, Resident #1 was observed lying in a left lateral position in bed. With the assistance of the nurse, Resident #1 demonstrated how to self-administer the bolus medication via the pain pump when the nurse placed the device within reach. The screen of the device revealed it was too soon to administer a bolus. Resident #1 said that her current pain level was a 4 out of 10 and it was getting better. Resident #1 said that the goal was to maintain her pain level at a 2 or 3 out of 10 with the continuous infusion of medication via the pain pump. During an interview on 09/17/24 at 11:38 AM, LVN D said he worked Monday-Friday 6:00 AM-2:00 PM shift. LVN D said Resident #1 was a new admission from over the weekend and on Monday, 09/09/24, while conducted rounds, Resident #1 told [LVN D] that she needed something for pain and asked if [LVN D] would assist with the bolus dose from her pain pump. LVN D said he asked how to (administer the bolus dose via the pain pump) and Resident #1 replied that the device was in her nightstand drawer and needed somebody to give it to her. LVN D said that he never provided care to a resident with a pain pump in 18 years and was not familiar with a resident self-administering medication via a pain pump. LVN D said he told Resident #1 that he needed to speak with the doctor. LVN D said that Resident #1 stated she could demonstrate to the staff how to administer the bolus dose if needed. LVN D said on Tuesday (09/10/24) staff were informed not to administer the bolus dose via [Resident #1] pain pump. LVN D said that he did not know the reason why. LVN D said he requested the orders from the pain management physician (on 09/10/24) per the facility PCP request. LVN D said that he gave the (pain management physician) orders to the DON when they arrive via fax on 09/10/24. LVN D said that he did not receive training or in-services about pain pumps during her on-hire orientation or annual training(s). Interviews conducted with nurses scheduled (09/16/24 and 09/17/24) on the 6:00 AM-2:00 PM shift [LVN D and RN B], on the 2:00 PM-10:00 PM shift [RN E and RN C], 10:00 PM-6:00 AM shift [LVN G], and Weekend Doubles - 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift [LVN A] indicated they participated in the in-service trainings. The staff stated topics of discussion included pain management and how to care for a resident with a pain pump. Each nurse stated in their own words reportable concerns regarding the pain pump, signs and symptoms of pain, and pain assessment. The DON and RCS were informed the Immediate Jeopardy was removed on 09/17/24 at 4:00 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put into place.