**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Resident #1) of five residents reviewed for abuse. The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from sexual abuse. CNA A was observed, on a camera video footage, engaging in an inappropriate, sexual oriented activity with Resident #1 on 02/02/24. The noncompliance was identified as PNC. The IJ began on 02/02/24 and ended on 02/04/24. The facility had corrected the noncompliance before the survey began on 02/05/24. This failure placed residents at risk for serious injuries, abuse, and serious psychosocial harm. Findings included: Record Review of Resident #1's Comprehensive MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life], elevated blood pressure, and muscle weakness. Her BIMS score not assessed related to Resident #1 never understood. Functional status reflected Resident #1 was totally dependent and required assistance of 1 to 2 staff for toileting hygiene, shower, and personal hygiene. Bladder and bowel assessment reflected Resident #1 was always incontinent of bladder and bowel. Record review of Resident #1's Care Plan reflected the following: -Resident #1 had dementia evidenced by severe cognitive impairment and inability to communicate. Interventions: Offer resident two simple choices to reduce the stress of decision making and increase resident's sense of autonomy. Initiated on 08/17/21 and last revised on 02/05/24. -Resident #1 at risk for problems with elimination (bladder and bowel). Interventions: check resident every 2 hours and assist with toileting as needed, provide peri-care after each incontinent episode. Initiated on 8/17/21 and last revised on 02/05/24. Record review of Resident #1's Order Summary for February 2024 revealed: -Transfer to the hospital for evaluation and SANE exam with an order date of 02/03/2024. -Memantine tablet 5 mg, give 1 tablet by mouth two times a day for dementia with an order date of 08/17/2021. Review of the facility's Provider Investigation Report involving Resident #1 dated 02/04/24 reflected, .Incident date 02/02/24 at 6:50 PM revealed local PD reported that family member of roommate to Resident #1 had made an allegation of possible sexual abuse to resident #1 based on camera footage. Local PD came to the facility. Investigation initiated by PD and facility. Employee suspended. MD notified, Resident #1's family notified and came to the facility. DON assessed Resident #1 with RP present at the bedside. No destress or change in behavior noted upon assessment. Resident #1 was sent to the hospital for SANE exam, and she returned back to the facility with no new orders. Every shift observation put in place to monitor for any behavioral, cognitive changes. Resident #1 was seen by MD and Psychiatric with no new orders. Police initial request was to hold off on staff interviews until further directive. On 2/5/24 detectives arrived in the facility to continue investigation. At this time, permission was given to interview staff but advised we could not contact the accused. On 2/6/24, the PD disclosed to the Administrator that the Alleged Perpetrator had been arrested in connection with this allegation. Provider response included in-service on abuse/neglect completed, QAPI was held on 2/6/24, and resident safe survey was completed. The Investigation Summary revealed after reviewing the findings, it is summarized that the facility has confirmed that abuse occurred. Record review of a camera video footage, dated 02/02/2024 not timed, reflected CNA A removed Resident #1 brief. He moved Resident #1 to the edge of the middle of the bed. Resident #1 was lying on her back with legs extended in an upright position. CNA A was facing the resident in a standing position between the legs. CNA A was observed putting his hands on the shoulders of the resident to pull her closer to him. CNA A moved in a repetitive forward motion and the resident moving with the motion. The resident was heard making unintelligible sounds on the video. CNA A then placed the brief on the resident, repositioned her in the bed and left the room. Record review of Resident #1's nurses note dated 02/04/24 electronically signed at 08:52 AM revealed on 02/03/24 at 11:20 PM DON went to Resident #1 room with RP at the bed side. The DON did head to toe skin assessment with no open areas or concerns noted. Record review of Resident #1's pain risk assessment dated [DATE] reflected pain intensity of 0 Record review of Resident #1 medical record reflected Resident #1 was sent to the hospital on [DATE] at 11:45 PM Record review of Resident #1's emergency room Hospital Records, dated 02/04/24, reflected the following: [AGE] year-old female with past medical history of dementia presented to the emergency department for SANE exam. Visit Diagnosis: Abrasion of labia. Record review of Resident #1's hospital records dated 02/04/24 reflected the following: RN assisted SANE nursing in cleaning and changing Resident #1, rash visible around groin and genital area. Resident #1 seen scratching multiple times throughout process. Record review of Resident #1's hospital records dated 02/04/24 reflected Resident #1 was discharged from the hospital, on 02/04/24, back to the facility. In an interview on 02/05/24 at 10:15 AM, the Administrator stated the DON got the call from RN E on 02/03/24 at 9:50 PM, police officer in the facility. Around 9:30 to 10 PM he was in the building. The officer told him on the phone he had evidence of sexual potential assault. By the time Administrator got to the facility CNA A had already left. The officer would not share the video with the facility. The facility requested the video from Resident #1's roommate's family member. The facility notified Resident #1's RP. They were in the facility 15 - 20 min later. The DON went with the RP to Resident#1's room. Assessment reflected redness could be from the brief. Resident#1 transferred to Baylor [NAME] & with Medical Center. The facility talked to the RP on Sunday 02/03/24, she said at the hospital they did the exam at 4:00 AM on Sunday. Resident came back the same morning. The facility received the video on 02/04/24 at 12:56 PM In an interview on 02/05/24 at 11:21 AM, Resident #1's roommate's family member stated Resident #2 called her on the phone on 02/03/24 and told her she heard, last evening, sexual comments between Resident #1 and a CNA. The family member stated she looked at the camera, she observed inappropriate act from the CNA. She stated she took the camera footage to the police station. The officer watched the camera footage with other officers, and they went to the facility. In an interview on 02/05/24 at 12:46 PM, Detective C assigned to the case requested to hold off on staff interviews until further directive. On 2/5/24 at 2:35 PM, Detective C arrived in the facility to continue investigation. At this time, permission was given to interview staff, but he advised not to contact CNA A. On 02/05/24 at 2:40 PM, attempted to interview Resident #1, she responded illogically to most questions asked of her or did not respond at all. When attempted to discuss the recent sexual abuse allegation Resident #1 responded with unmeaningful words. On 02/05/24 at 2:45 PM, RN E stated he worked on 02/03/24 from 2 PM to 10 PM. RN E stated around 9:50 PM a police officer approached him and asked him about the manager. RN E called the DON. RN E did not know why the police where in the facility, he stated couple minutes later the DON, and the Administrator came to the facility. RN E stated he was not assigned to Resident #1. In an interview on 02/07/24 at 9:00 AM, Administrator stated, on an interview on 02/06/24, Detective C told him CNA A admitted he attempted to sexually assault Resident #1. He told him CNA A was arrested on 02/05/24. On 02/07/24 at 11:06 AM attempted to call Detective C; left message. Observation on 02/07/24 at 11:25 AM with CNA F who performed incontinent care for Resident #1 revealed redness to the left inner thigh at brief lining area. In an interview on 02/07/24 at 1:12 PM, Resident #1' RP stated the police department called her and informed her CNA A was arrested on 02/05/24 because he confessed to the sexual act. Review of CNA A's timesheets reflected he worked on 02/02/24 from 1:54 PM to 10:09 PM. Record review of Resident #1 psychiatric services note dated 02/06/24 revealed Resident #1 was seen for trauma/stressor related disorders, issues with trauma. The report stated Resident #1 was the recent victim of possible sexual assault. The report indicated Resident #1 was very confused with severe cognitive impairment. The document was signed by PA B Review CNA A's personal file reflected no barrier for employment: - Criminal history conviction name search on 12/19/22 - No search results found. - Nurse aide: NA certification status: Active. Certification number: NA0008319536. Issue date: 4/27/2005. Expiration: 6/12/2025 - Texas HHS Employability status check search results date 12/19/2022: Unemployable? NO. NAR status: Active. NAR active unemployable: NO. MAR status: Active. Incident on the EMR: NO - No result found for CNA A. Annual checklist: - Office of inspector general: 11/22/23 - DADS Employability status: 11/22/23 - DPS CCH Verification: 11/22/23 - Performance Evaluation: 11/20/23 - Compliance Code of Conduct Certification: 11/20/23 In-Services: Abuse - 10/13/23, Abuse - 12/20/22, Abuse - 12/1/23, Abuse - 1/26/24. In an interview on 02/07/24 at 1:17 PM, the Administrator revealed CNA A was suspended on 02/03/24 and terminated on 02/04/24. In an Interview on 02/07/24 at 1:25 PM, the DON stated she never got any complaint about CNA A. She stated some family members requested him to assist there loved one. She stated she watched the video, and it was disturbing. She stated all staff had been in serviced on abuse neglect before they start their shift. Review grievance log for last 3 months reflected no grievance about CNA A. An impromptu Quality Assurance and Performance Improvement was completed on 02/06/24 with the MD, Psych, Psychology, Administrator, DON, and Social Worker. Review of facility's in-services to nursing staff dated 02/03/24 to 02/05/24 reflected eleven nurses and twelve CNAs were in-serviced on Abuse and neglect reporting and prevention. Individual interviews with LVNs, RNs, CNAs, and MA from different shifts (LVN G, LVNH, LVN I, RN J, RN E, RN K, CNA L, CNA F, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, and MA S) on 02/05/24 and 02/07/24 revealed they had received in-service training on abuse and neglect. All staff were able to verbalize understanding of in-service training regarding abuse and sexual abuse. Review of the facility's policy titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property, dated 06/23/2017 and reviewed 02/12/2020 reflected, .1. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members Definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. On 02/07/24 at 4:40 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 02/02/24 to 02/04/24. The IJ was determined to have been removed on 02/04/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/05/24. On 02/08/24 at 2:30 PM, Detective D stated she was calling from Detective C's office. She stated they arrested CNA A on 02/25/24, and he was in jail. She stated, he admitted it. The detective was very short on the information she provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representatives when there was a significant change in the resident's physical, mental, or psychosocial status and a need for 1 (Resident #63) of 5 residents reviewed for physician notification. The facility failed to immediately notify Resident #63's attending physician when she had significant pain which was unrelieved by ordered Tylenol. An immediate Jeopardy (IJ) situation was identified on 10/05/22 at 5:40 PM. The DON and the ADM were notified, the IJ template was provided, and a POR was requested. While the IJ was removed on 10/07/22 at 6:19 PM, the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure led to one resident experiencing significant pain and placed residents who had a significant change and a need to alter treatment significantly at risk for not receiving appropriate, timely treatment. Findings include: Record review of Resident #63's quarterly MDS, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. Section B reflected she had minimal difficulty hearing, unclear speech, rarely made herself understood, rarely understood others, and had moderately impaired vision. Her BIMS score was 0, which indicated a severe cognitive impairment. Her behavior assessment reflected she did not have hallucinations, delusions, or any other behavioral symptoms. The assessment of her functional status reflected she was totally dependent on one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #63 had an indwelling catheter and was always incontinent of bowel. Review of the pain management assessment reflected Resident #63 was unable to answer questions and in the previous 5 days the staff had not observed nor documented indicators of pain or possible pain. Review of Section M reflected Resident #62 was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. Further review reflected Resident #63 had five stage 4 pressure ulcers and three were present on admission or re-entry. Record review of the facility's wound report, dated 10/05/22, reflected Resident #63 had Stage 4 pressure wounds to her back, sacrum, and right toe. She had an unstageable pressure wound to her left toe, and trauma from a medical device to her right elbow and her left toe. Record review of Resident #63's order report, dated 10/05/22, reflected the following orders: 1. 03/09/22- Pain scale every shift. 2. 08/04/22- Tylenol 650 mg every 4 hours PRN for pain/temperature. 3. 10/05/22- Norco 5 mg/325 mg 1 tablet 1 time per day. 4. 10/05/22- Norco 5 mg/325 mg 1 tablet every 8 hours PRN for pain. Her diagnosis listed on the order report were metabolic encephalopathy (impaired brain function), Stage 4 sacral pressure ulcer (area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage), dehydration, dementia, legal blindness, restlessness, insomnia, depressive episodes, pain, generalized anxiety disorder, and schizophrenia. Record review of Resident #63's care plans, dated 10/05/22, reflected Resident #63 had a severe cognitive impairment related to dementia, a hearing deficit, a speech deficit, and a visual impairment. A care plan for pain with onset date of 03/09/22 was updated on 10/05/22 at 1:22 PM and reflected Resident #63 had chronic pain and the PAINAD scale would be used due to the resident's cognitive impairment. Interventions included: 1. Administer pain medications as ordered. 2. Analyze and document factors that precipitate pain and what may reduce it. 3. Non-pharmacological comfort measures: relaxation and repositioning. 4. Notify the physician of any changes in level or frequency of pain, any increase in use of PRN pain medications, and any noted side effects of pain medications. 5. Observe resident for signs of pain with care and interactions. 6. Provide rest periods to facilitate comfort, sleep, and relaxation. 7. Re-assess interventions with any changes in response to pain or pain medications and with every assessment. A care plan for behavioral changes was updated on 10/05/22 at 12:53 PM by RN F due the resident's previous living situation of known elderly abuse and the following goals and interventions were added on 10/05/22: 1. Receive culturally competent trauma-informed care to reduce triggers that may re-traumatize. 2. Analyze key times, places, circumstances, triggers, and was de-escalates behavior. 3. Complete residence life story in order to know the resident. 4. Cue the resident prior to care delivery. Use one step directions and a slow pace. 5. Decreased stimulation. 6. Remain non-judgmental. Be alert to changes in behavior. 7. Be aware of your proximity, ask before touching or hugging. 8. Focus on creating an atmosphere of trust. 9. Maintain respectful physical and emotional boundaries. Prior to 10/05/22, the interventions for trauma-informed care were promoting independence and personal choices and providing a pleasant and home-like environment. Record review of Resident #63's MARs from 06/01/22 to 10/05/22 reflected the following: 1. Order for Norco 5 mg/325 mg 1 tablet PRN every 6 hours of pain was ordered from 03/09/22 to 09/03/22 and administered for generalized pain on: 06/01/22, 06/03/22, 06/04/22, 06/07/22, 06/09/22, 06/13/22, 06/14/22, 06/15/22, 06/16/22, 06/17/22, 06/21/22, 06/22/22, 06/23/22, 06/24/22, 06/27/22, 06/28/22, 06/29/22, 06/30/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/12/22, 07/17/22, 07/19/22, 07/20/22, and 07/21/22. 2. Order for Tylenol 650 mg every 4 hours PRN Pain was started on 08/04/22 and administered on: 08/04/22, 08/08/22, 08/09/22, 09/25/22, 09/27/22, and 10/05/22. Record review of Resident #63's pain assessments from 06/01/22 to 10/05/22 reflected 4 pain assessments were documented during that time frame: 1. On 06/07/22 at 11:15 AM, LVN D documented Resident #63 had pain 6 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, tense body language, and was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with positioning and movement. LVN C documented she administered PRN Norco for pain. The pain was affective the resident's quality of life with ADLs, activities, ambulation and mobility. 2. On 09/05/22 at 1:05 PM, LVN C documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, relaxed body language, and there was no need to console. Activities and movement made the pain worse. LVN C documented she administered PRN Tylenol for pain. LVN C documented the pain was not affecting the resident's quality of life. 3. On 10/07/22 at 10:15 AM, the Wound Care Nurse documented a late entry from 10/05/22. He documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with movement. The Wound Care Nurse documented the pain was affecting the resident's quality of life with depression. 4. On 10/05/22 at 8:34 PM, LVN E documented Resident #63 had pain 4 of 10 using the PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain. LVN E documented the pain was not affecting the resident's quality of life. Record review of Resident #63 Daily Wound TARs from 06/01/22 to 10/04/22 documented signs of pain during wound care on 06/06/22 (4 of 10), 06/11/22 (5 of 10), and 06/12/22 (6 of 10) (interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain). An observation and interview on 10/05/22 at 9:45 AM revealed the Wound Care Nurse and the Staffing Nurse completed wound care on a Resident #63. Prior to the wound care, Resident #63 was smiling and said, Good morning. Resident #63 had four pressure wounds which required a wound treatment, three of which were stage 4 wounds and one which was an unstageable deep tissue injury (DTI). The Staffing Nurse and the Wound Care Nurse turned the resident onto her right side and the resident cried out, That hurts! The Wound Care Nurse proceeded to complete the wound care to the resident's sacrum and during the wound care the resident cried out twice, saying That hurts! That hurts! Both times, the Wound Care Nurse told her he was sorry and would try to be gentle but continued with the wound care. In addition to her verbal communication of pain, Resident #63 also displayed facial grimacing, intermittent rapid breathing when the Wound Care Nurse touched the wound to her sacrum and was tense and rigid. The Wound Care Nurse also asked Resident #63 if she was OK twice during the sacral wound care, and she did not give a verbal response. Once the Wound Care Nurse completed the wound care to Resident #63's sacrum, the Staffing Nurse turned the resident onto her back and the resident cried out, Oh no! Oh no! That hurts! The Wound Care Nurse told the Staffing Nurse he would need to turn Resident #63 onto her back to complete the wound care to her lower back. The State Surveyor intervened and asked the Wound Care Nurse if Resident #63 had been medicated for pain prior to wound care. The Wound Care Nurse stated he had assessed Resident #63 for pain prior to the wound care and the resident had complained of pain at a level of 4 out of 10. He said he notified Resident #63's nurse, LVN D, and asked her to give Resident #63 a medication for pain. The Wound Care Nurse stated he believed LVN D gave Resident #63 Tylenol 10 to 15 minutes ago (10/05/22 at 9:30 AM). The Staffing Nurse said Resident #63 would cry out every time she was turned. The State Surveyor asked the Staffing Nurse to check what Resident #63 had received for pain. The Staffing Nurse left the room. In an interview on 10/05/22 at 10:00 AM, the Staffing Nurse stated Resident #63 received Tylenol for pain 30 minutes ago, 10/05/22 at 9:30 AM. The Staffing Nurse said Resident #63 did not have anything else ordered for pain, and the State Surveyor intervened and asked if the doctor could be notified since it appeared the Tylenol was not effective in managing Resident #63's pain. The Staffing Nurse stated he would have LVN D call Resident #63's doctor. In an interview on 10/05/22 at 10:15 AM, Resident #63 was notified by the State Surveyor the nurse would call the doctor since she was still experiencing pain. Resident #63 stated, Please do. It's hurting. Resident #63 indicated she experienced pain to her back but was unable to provide a numerical level of pain on a scale of 1 to 10. In an interview with the DON on 10/05/22 at 1:00 PM, the DON said Resident #63 had a history of abuse and when touched she would moan. The DON said nurses were expected to differentiate between Resident #63's trauma response and pain by assessing their vital signs and body language. The DON stated signs of pain could include facial grimacing. The DON said if Resident #63 said That hurts, she would expect the nurse to give a medication for pain and if a pain medication was already given, the nurse should call the doctor. The DON said if Resident #63 said That hurt, during wound care, the nurse should have stopped and that was what the Wound Care Nurse told her he did that day (10/05/22). In a telephone interview with MD G on 10/05/22 at 1:10 PM, MD G said she was Resident #63's attending physician. MD G said she was not aware of Resident #63 experiencing pain that was not relieved by the ordered Tylenol. MD G said if she was notified of pain for a resident, she would typically order a consult for pain management with MD H. MD G said at times, the nurses would contact MD H directly to get a medication for pain ordered. MD G said because the wound care was important for Resident #63, it would be important that Resident #63 had a PRN medication for pain ordered so the wound care could be completed, and nurses were expected to call her or MD H to ask for a stronger pain medication if the ordered medication was not affective. In a telephone interview on 10/05/22 at 1:23 PM, MD H stated she was a physiatrist (medical doctor that specializes in the field of physical medicine and rehabilitation), and she also handled the pain management at the facility. MD H said she received a call on 10/05/22 from a facility nurse and stated she was told Resident #63's wound care could not proceed due to her pain. MD H said she re-ordered the Norco routinely to be given prior to wound care and told the nurse they needed to coordinate with the Wound Care Nurse to ensure the Norco was given in the morning prior to wound care. MD H said prior to 10/05/22 she had not been contacted about Resident #63's pain. MD H said when she visited Resident #63 in the past, she never complained of pain, was pleasantly confused, and would hold her hand and smile. MD H said she was also unaware of Resident #63 displaying signs of pain with movement. MD H said as Resident #63's wounds began to heal, the nerves could start to regenerate, and she could experience more pain and if she had been notified of the pain with wound care, she would have ordered Norco with wound care like she did when she was notified on 10/05/22. MD H said she had not followed Resident #63 since May 2022. In a telephone interview on 10/05/22 at 1:38 PM, MD I said she was the facility's wound physician. MD I said he observed Resident #63's wounds weekly and would perform wound care for Resident #63 with the Wound Care Nurse. MD I said the last time he observed Resident #63 was on 10/03/22. MD I said, one out of every few times, Resident #63 would moan during wound care, and said she was largely non-verbal. MD I said rarely would he need to take a break during the wound care for Resident #63 due to her signs of pain, and one or two times he had to stop wound care for Resident #63 due to her pain. MD I said the Wound Care Nurse was present when he stopped the wound care for Resident #63 due to her pain. MD I said aside from stopping the wound care, he would defer to the pain management physician as to what a nurse should do if a resident displayed signs of pain during wound care. In an interview on 10/05/22 at 4:10 PM, the Wound Care Nurse said he heard Resident #63 say Oh! Oh! I hurt! when he touched her backside during her sacral wound care on 10/05/22. He said his plan was to finish up the wound care. The Wound Care Nurse said Resident #63 hardly ever displayed signs of pain during wound care and she was, totally fine the majority of the time. The Wound Care Nurse said today, 10/05/22 was the first time in a while, Resident #63 displayed signs of pain during wound care. He said the last time Resident #63 displayed signs of pain during wound care was maybe in the summertime when her wounds were bad (Summer 2022). The Wound Care Nurse said Resident #63's wounds had started healing and were starting to granulate so her nerve endings may be starting to come back, and she may be in more pain than normal. The Wound Care Nurse said the signs of pain Resident #63 displayed while he was performing her sacral wound care on 10/05/22 he would not necessarily say were signs she was in pain, rather her displaying signs of past trauma. The Wound Care Nurse said he last received training on pain management, which included the different types of pain assessments, in August 2022. The Wound Care Nurse said he would have rated Resident #63's pain during the sacral wound care at a level 3 or 4 out of 10. The Wound Care Nurse said if Resident #63 had kept hollering, he would have rated her pain at maybe a 6 or 7 out of 10. The Wound Care Nurse said if Resident #63 would have screamed the roof off he would rate her pain at a level of 10 out of 10. The Wound Care Nurse said indicators of pain included yelling, grimacing, clutching, grabbing, holding, not wanting to turn, rubbing a specific area, or crying out. The Wound Care Nurse said if a resident displayed these signs of pain, he would assess the pain by asking the resident questions such as if the pain was sharp or how long they had it. The Wound Care Nurse said he would then tell the resident's nurse about the pain. The Wound Care Nurse said if a resident displayed signs of pain during wound care, he would not want to leave the wound open, so he would first finish the wound care. The Wound Care Nurse said he should not continue wound care, until the resident received pain medication and the resident was re-assessed for pain. The Wound Care Nurse said the signs Resident #63 displayed during the sacral wound care he performed on 10/05/22 were not signs of pain, he said they were signs of trauma from her past. The Wound Care Nurse said he could differentiate between Resident #63's pain and trauma symptoms because when it was trauma, she would say things like, I'm scared, or, daddy. The Wound Care Nurse said if given a chance to repeat the wound care he performed for Resident #63's sacral wound on 10/05/22 he would give her more time for the pain medication to kick in. The Wound Care Nurse said he should have waited and hour or so for the Tylenol to take effect. The Wound Care Nurse said MD I worked at the facility for 2 months and he was present when MD I assessed Resident #63's wounds. The Wound Care Nurse denied being present when the wound care for Resident #63 was stopped by MD I due to her pain. In an interview on 10/05/22 at 4:31 PM, the Staffing Nurse said he did not know what happened in Resident #63's past life because when she was turning onto her side she would cry out Oh, you're hurting me. The Staffing Nurse said he would be able to know if Resident #63 had pain based on her facial expressions and if she continued to cry out. The Staffing Nurse said Resident #63's pain should be assessed using the PAINAD scale. The Staffing Nurse said Resident #63 had pain during wound care on 10/05/22 and she said she was hurting. The Staffing Nurse said he would have rated her pain a 5 of 10 during sacral wound care on 10/05/22. The Staffing Nurse said if a resident showed signs of pain during care, staff should stop what they were doing and check orders for pain medications. The Staffing Nurse said if the resident was medicated for pain prior to care, that meant the medication was not working and the nurse needed to call the doctor. In a follow-up interview on 10/07/22 at 12:06 PM, the Staffing Nurse said Resident #63 would always cry out saying Ouch, don't hurt me. The Staffing Nurse said he did not work with Resident #63 often but noted, on at least 3 occasions, her crying when she was repositioned and she said, Don't hurt me. I'm hurting. The Staffing Nurse could not provide dates of the incidents and stated based on his nursing judgement he determined Resident #63 was not in pain. The Staffing Nurse said he never completed a PAINAD or any pain assessment for Resident #63, but he should have completed and documented a pain assessment if Resident #63 complained of hurting. In an interview on 10/05/22 at 4:37 PM, CNA J said she regularly worked with Resident #63. She said Resident #63 would cry, but she did not think Resident #63 was in pain. CNA J said she believe crying was a reaction to someone touching her or being moved. CNA J said she thought Resident #63 had some discomfort with her contractures, and, normally cries out when she's being moved. Record review of the facility's policy titled, Change if Condition (Acute), dated 02/12/20, reflected: The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication with the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is a physician response. The practitioner needs a detailed description of the patient's condition to determine whether a symptom is problematic or simply a normal or expected variant . Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help practitioners their potential causes and consequences . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms or signs, or unrelieved by measures already prescribed . As part of the interdisciplinary team, Certified Nursing Assistants (C.N.A.'s) . are expected to report findings that might represent ACOC's . The nurse notifies the responsible physician utilizing the appropriate channels and chain of command. Notify the physicians in the following order unless otherwise indicated by physician order, by routine service, or as indicated by patient condition: a) Attending Physician b) Advanced Practice Registered Nurse (APRN) or c) As necessary, notify the nursing supervisor . d) The nursing supervisor (in hours) and nursing administrator (on call) will determine the need to initiate the following steps: a. Notification of the Medical Director . Document in the medical record the date, time and name of each physician notified, actions taken and/or patient's response to treatment . Review of the facility's policy titled Pain Management and Basic Comfort Measures, dated 01/12/20, reflected, . Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines . Procedure: Identify the resident. Ask the resident if he or she is in pain. Perform hand hygiene if appropriate. Examine the site of the patient's pain, which may include subjective and objective data collection measures. Evaluate the resident's medical history . Provide pain medication as prescribed . Evaluate for analgesic [pain medication] side effects and pharmacological/ non-pharmacological effectiveness . Observe for unresolved pain and address per physician's orders. Record pain management techniques in the record . The policy did not address pain assessments in residents who were non-verbal or had a cognitive impairment. This was determined to be an Immediate Jeopardy (IJ) on 10/05/22 at 5:40 PM. The ADM and the DON were notified. The ADM and the DON were provided with the IJ template on 10/05/22 at 5:40 PM. The following Plan of Removal submitted by the facility was accepted on 10/06/22 at 4:40 PM and reflected: Date: 10/05/2022 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY For F697 To Whom it may concern, Summary of Details which lead to outcomes On 10/5/2022, during annual survey initiated at [Facility Name/Address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F697 The notification of the alleged immediate jeopardy states as follows: The facility failed to assess, provide effective pain treatment, and address pain promptly for two residents with significant pain, Resident #63 and Resident #188. What corrective action will be taken for those residents found to have been affected by the deficient practice: [Resident #63] was immediately assessed by 6-2 LVN charge nurse for any concerns of unrelieved pain or distress following wound care. Clinical staff were educated regarding pain at 6:30 PM. Follow up pain assessment in advanced dementia (PAINAD) was conducted at 8 PM by MDS Nurse Manager. Tylenol 325 mg tablets, 2 tablets by mouth every 4 hours as needed prn for pain or [temperature) Original order date 8/4/22 and remains a current order An additional order for hydrocodone 5/325 was received and given to the resident prior to completion of remainder of her wound care. Pain Management MD notified at 10:08 AM of potential pain during wound care for [Resident #63] with new order received for hydrocodone 5/325mg given on 10/5/2022. Pain was reassessed as being effective on 10/5/22 at 11:10 AM by 6-2 LVN. 'Resident sleeping with eyes closed. No signs of distress noted.' [Resident #63] showed no further signs of pain post wound care upon assessment by ADON on 10/5/2022. [Resident # 188] was immediately assessed for any unrelieved pain with no further complaints upon assessment by ADON on 10/5/2022. Physician notified of residents 5/10 pain after Tylenol administered. Voltren Gel 1% three times a day (T.I.D.) to right shoulder. was ordered 10/6/22, and a telemedicine visit was conducted by primary physician to discuss residents' treatment plan. How other residents with the potential to be affected by the same deficient practice will be identified; Residents experiencing pain have the potential to be affected What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; The Administrator/Director of Nursing/Assistant Director of Nursing have received Training by the Regional Nurse Consultant on 10/5/2022 on: Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Change of Condition (acute) InterAct 4.5 Stop and Watch Early Warning System, Policy on how to review pain management and physician notification in Facility Daily Clinical Morning meeting. Policy on how to review pain management and physician notification in the Weekly Interdisciplinary Team Meeting Wound Care nurse and LVN A In-service was conducted by DON/Designee on 10/05/2022 on Integrative Approaches for pain management with post-test to include proper notifications to MD with documentation including any follow up post medication administration. Policy and Procedure on Pain Management including approach to Pain Management InterAct 4.5 Stop and Watch Early Warning System InterAct 4.5 Change of Condition (acute) To include signs and symptoms of pain. Subjectivity of pain for residents able to verbalize pain. Objectivity of pain for residents who are unable to verbalize pain by use of Pain in Advanced Dementia patients (PAINAD). Residents tolerable pain level Assure pain medication, if ordered, has been administered prior to treatment Immediately stop if resident has any complaint of pain. Notification to physician if additional pain medication is needed. Participation and Policy on how to review pain management and physician notification in Facility Daily Clinical Morning meeting. Participation and Policy on how to review pain management and physician notification in the Weekly Interdisciplinary Team Meeting Wound Nurse will be educated on documenting pain level pre-procedure, during procedure, and post procedure to assure pain is being assessed and managed. Wound nurse will monitor subjective and objective signs and symptoms of pain during wound dressing changes and if objective or subjective pain identified will assess patient using P.A.I.N.D. scale of pain for cognitively impaired, and pain scale of 1-10 for alert residents. Results will be documented in resident Medical Record. Wound nurse will note residents tolerable pain level per most recent pain assessment for those residents who are able to verbalize pain level. The PAINAD will be utilized for those residents not able to verbalize pain. The PAINAD assess breathing, negative vocalization, facial expression, body language, and consolability, providing an objective level of pain by score system. Wound Nurse and nurses' notes will be reviewed daily Monday-Friday for any indication of pain to assure pain was managed and physician notified if needed. Nursing staff (full time, PRN, and those who are on vacation/leave) are being in-serviced by DON/Designee on proper notifications to MD with documentation including follow up assessment for pain. This in-service was started on 10/05/2022 by the DON/designee. PRN staff and those staff on PTO will be identified and staffing coordinator will flag to assure in-service is completed prior to working. This in-service was started on 10/5/2022 by the DON/designee and will continue until all staff has been in serviced. If staff was not present at the in-service, they will not be able to work until in-service has been completed. PRN staff and those staff on PTO will be identified and staffing coordinator will flag to assure in-service is completed prior to working. All new licensed clinical nursing staff will receive education on All clinical nursing staff including PRN staff and those staff on PTO or leave will receive education on Pain assessment for all residents in facility completed on 10/5/2022 with no significant findings. All new licensed clinical nursing staff including PRN staff and those staff on PTO or leave will be identified and staffing coordinator will flag to assure in-service is completed prior to working. Review of pain assessment scores were reviewed and follow up of unrelieved pain. Physician will be notified for alternate treatment plans. The Interdisciplinary team will monitor effectiveness of pain management weekly in Standards of Care Committee to assure current treatment plans are adequate and covering pain. Physician will be notified if treatment plan found not to be effective per Interdisciplinary Team review for any new orders to treatment plan. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and DON or designee will audit proper notifications for complaints of pain per review of TAR and nurses' notes M-F in clinical morning meetings. Administrator will be responsible for ensuring audit completion DON or designee will audit pain medication administration for completion of follow-up and effectiveness of pain medication in daily clinical[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 24 residents (Residents #63 and #188) reviewed for pain management. 1. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #63 when she showed signs and symptoms of significant pain which was unrelieved by ordered Tylenol during wound care for her Stage 4 pressure wounds on 10/05/22. 2. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #188 when she complained of significant pain that woke her from sleep on 10/05/22. An immediate Jeopardy (IJ) situation was identified on 10/05/22. While the IJ was removed on 10/07/22 at 6:19 PM, the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures led to two residents experiencing significant pain and placed resident who require pain management at risk for significant pain. Findings include: 1. Record review of Resident #63's quarterly MDS, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. Section B reflected she had minimal difficulty hearing, unclear speech, rarely made herself understood, rarely understood others, and had moderately impaired vision. Her BIMS score was 0, which indicated a severe cognitive impairment. Her behavior assessment reflected she did not have hallucinations, delusions, or any other behavioral symptoms. The assessment of her functional status reflected she was totally dependent on one-person physical assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Resident #63 had an indwelling catheter and was always incontinent of bowel. Review of the pain management assessment reflected Resident #63 was unable to answer questions and in the previous 5 days the staff had not observed nor documented indicators of pain or possible pain. Review of Section M reflected Resident #62 was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. Further review reflected Resident #63 had five stage 4 pressure ulcers and three were present on admission or re-entry. Record review of the facility's wound report, dated 10/05/22, reflected Resident #63 had Stage 4 pressure wounds to her back, sacrum, and right toe. She had an unstageable pressure wound to her left toe, and trauma from a medical device to her right elbow and her left toe. Record review of Resident #63's order report, dated 10/05/22, reflected the following orders: 1. 03/09/22- Pain scale every shift. 2. 08/04/22- Tylenol 650 mg every 4 hours PRN for pain/temperature. 3. 10/05/22- Norco 5 mg/325 mg 1 tablet 1 time per day. 4. 10/05/22- Norco 5 mg/325 mg 1 tablet every 8 hours PRN for pain. Her diagnosis listed on the order report were metabolic encephalopathy (impaired brain function), Stage 4 sacral pressure ulcer (area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage), dehydration, dementia, legal blindness, restlessness, insomnia, depressive episodes, pain, generalized anxiety disorder, and schizophrenia. Record review of Resident #63's care plans, dated 10/05/22, reflected Resident #63 had a severe cognitive impairment related to dementia, a hearing deficit, a speech deficit, and a visual impairment. A care plan for pain with onset date of 03/09/22 was updated on 10/05/22 at 1:22 PM and reflected Resident #63 had chronic pain and the PAINAD scale would be used due to the resident's cognitive impairment. Interventions included: 1. Administer pain medications as ordered. 2. Analyze and document factors that precipitate pain and what may reduce it. 3. Non-pharmacological comfort measures: relaxation and repositioning. 4. Notify the physician of any changes in level or frequency of pain, any increase in use of PRN pain medications, and any noted side effects of pain medications. 5. Observe resident for signs of pain with care and interactions. 6. Provide rest periods to facilitate comfort, sleep, and relaxation. 7. Re-assess interventions with any changes in response to pain or pain medications and with every assessment. A care plan for behavioral changes was updated on 10/05/22 at 12:53 PM by RN F due the resident's previous living situation of known elderly abuse and the following goals and interventions were added on 10/05/22: 1. Receive culturally competent trauma-informed care to reduce triggers that may re-traumatize. 2. Analyze key times, places, circumstances, triggers, and was de-escalates behavior. 3. Complete residence life story in order to know the resident. 4. Cue the resident prior to care delivery. Use one step directions and a slow pace. 5. Decreased stimulation. 6. Remain non-judgmental. Be alert to changes in behavior. 7. Be aware of your proximity, ask before touching or hugging. 8. Focus on creating an atmosphere of trust. 9. Maintain respectful physical and emotional boundaries. Prior to 10/05/22, the interventions for trauma-informed care were promoting independence and personal choices and providing a pleasant and home-like environment. Record review of Resident #63's MARs from 06/01/22 to 10/05/22 reflected the following: 1. Order for Norco 5 mg/325 mg 1 tablet PRN every 6 hours of pain was ordered from 03/09/22 to 09/03/22 and administered for generalized pain on: 06/01/22, 06/03/22, 06/04/22, 06/07/22, 06/09/22, 06/13/22, 06/14/22, 06/15/22, 06/16/22, 06/17/22, 06/21/22, 06/22/22, 06/23/22, 06/24/22, 06/27/22, 06/28/22, 06/29/22, 06/30/22, 07/01/22, 07/04/22, 07/06/22, 07/08/22, 07/11/22, 07/12/22, 07/17/22, 07/19/22, 07/20/22, and 07/21/22. 2. Order for Tylenol 650 mg every 4 hours PRN Pain was started on 08/04/22 and administered on: 08/04/22, 08/08/22, 08/09/22, 09/25/22, 09/27/22, and 10/05/22. Record review of Resident #63's pain assessments from 06/01/22 to 10/05/22 reflected 4 pain assessments were documented during that time frame: 1. On 06/07/22 at 11:15 AM, LVN D documented Resident #63 had pain 6 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, tense body language, and was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with positioning and movement. LVN C documented she administered PRN Norco for pain. The pain was affective the resident's quality of life with ADLs, activities, ambulation and mobility. 2. On 09/05/22 at 1:05 PM, LVN C documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, repeated trouble calling out, loud moaning/groaning, crying, facial grimacing, relaxed body language, and there was no need to console. Activities and movement made the pain worse. LVN C documented she administered PRN Tylenol for pain. LVN C documented the pain was not affecting the resident's quality of life. 3. On 10/07/22 at 10:15 AM, the Wound Care Nurse documented a late entry from 10/05/22. He documented Resident #63 had pain 4 of 10 using PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain and the pain was made worse with movement. The Wound Care Nurse documented the pain was affecting the resident's quality of life with depression. 4. On 10/05/22 at 8:34 PM, LVN E documented Resident #63 had pain 4 of 10 using the PAINAD scale (moderate pain). Resident #63 had normal breathing, occasional moaning/groaning, was smiling or inexpressive, her body language was rigid, and she was distracted or reassured by voice or touch. Resident #63 had a Stage 4 pressure ulcer which was likely to cause pain. LVN E documented the pain was not affecting the resident's quality of life. Record review of Resident #63 Daily Wound TARs from 06/01/22 to 10/04/22 documented signs of pain during wound care on 06/06/22 (4 of 10), 06/11/22 (5 of 10), and 06/12/22 (6 of 10) (interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain). An observation and interview on 10/05/22 at 9:45 AM revealed the Wound Care Nurse and the Staffing Nurse completed wound care on a Resident #63. Prior to the wound care, Resident #63 was smiling and said, Good morning. Resident #63 had four pressure wounds which required a wound treatment, three of which were stage 4 wounds and one which was an unstageable deep tissue injury (DTI). The Staffing Nurse and the Wound Care Nurse turned the resident onto her right side and the resident cried out, That hurts! The Wound Care Nurse proceeded to complete the wound care to the resident's sacrum and during the wound care the resident cried out twice, saying That hurts! That hurts! Both times, the Wound Care Nurse told her he was sorry and would try to be gentle but continued with the wound care. In addition to her verbal communication of pain, Resident #63 also displayed facial grimacing, intermittent rapid breathing when the Wound Care Nurse touched the wound to her sacrum and was tense and rigid. The Wound Care Nurse also asked Resident #63 if she was OK twice during the sacral wound care, and she did not give a verbal response. Once the Wound Care Nurse completed the wound care to Resident #63's sacrum, the Staffing Nurse turned the resident onto her back and the resident cried out, Oh no! Oh no! That hurts! The Wound Care Nurse told the Staffing Nurse he would need to turn Resident #63 onto her back to complete the wound care to her lower back. The State Surveyor intervened and asked the Wound Care Nurse if Resident #63 had been medicated for pain prior to wound care. The Wound Care Nurse stated he had assessed Resident #63 for pain prior to the wound care and the resident had complained of pain at a level of 4 out of 10. He said he notified Resident #63's nurse, LVN D, and asked her to give Resident #63 a medication for pain. The Wound Care Nurse stated he believed LVN D gave Resident #63 Tylenol 10 to 15 minutes ago (10/05/22 at 9:30 AM). The Staffing Nurse said Resident #63 would cry out every time she was turned. The State Surveyor asked the Staffing Nurse to check what Resident #63 had received for pain. The Staffing Nurse left the room. In an interview on 10/05/22 at 10:00 AM, the Staffing Nurse stated Resident #63 received Tylenol for pain 30 minutes ago, 10/05/22 at 9:30 AM. The Staffing Nurse said Resident #63 did not have anything else ordered for pain, and the State Surveyor intervened and asked if the doctor could be notified since it appeared the Tylenol was not effective in managing Resident #63's pain. The Staffing Nurse stated he would have LVN D call Resident #63's doctor. In an interview on 10/05/22 at 10:15 AM, Resident #63 was notified by the State Surveyor the nurse would call the doctor since she was still experiencing pain. Resident #63 stated, Please do. It's hurting. Resident #63 indicated she experienced pain to her back but was unable to provide a numerical level of pain on a scale of 1 to 10. In an interview with the DON on 10/05/22 at 1:00 PM, the DON said Resident #63 had a history of abuse and when touched she would moan. The DON said nurses were expected to differentiate between Resident #63's trauma response and pain by assessing their vital signs and body language. The DON stated signs of pain could include facial grimacing. The DON said if Resident #63 said That hurts, she would expect the nurse to give a medication for pain and if a pain medication was already given, the nurse should call the doctor. The DON said if Resident #63 said That hurt, during wound care, the nurse should have stopped and that was what the Wound Care Nurse told her he did that day (10/05/22). In a telephone interview with MD G on 10/05/22 at 1:10 PM, MD G said she was Resident #63's attending physician. MD G said she was not aware of Resident #63 experiencing pain that was not relieved by the ordered Tylenol. MD G said if she was notified of pain for a resident, she would typically order a consult for pain management with MD H. MD G said at times, the nurses would contact MD H directly to get a medication for pain ordered. MD G said because the wound care was important for Resident #63, it would be important that Resident #63 had a PRN medication for pain ordered so the wound care could be completed, and nurses were expected to call her or MD H to ask for a stronger pain medication if the ordered medication was not affective. In a telephone interview on 10/05/22 at 1:23 PM, MD H stated she was a physiatrist (medical doctor that specializes in the field of physical medicine and rehabilitation), and she also handled the pain management at the facility. MD H said she received a call on 10/05/22 from a facility nurse and stated she was told Resident #63's wound care could not proceed due to her pain. MD H said she re-ordered the Norco routinely to be given prior to wound care and told the nurse they needed to coordinate with the Wound Care Nurse to ensure the Norco was given in the morning prior to wound care. MD H said prior to 10/05/22 she had not been contacted about Resident #63's pain. MD H said when she visited Resident #63 in the past, she never complained of pain, was pleasantly confused, and would hold her hand and smile. MD H said she was also unaware of Resident #63 displaying signs of pain with movement. MD H said as Resident #63's wounds began to heal, the nerves could start to regenerate, and she could experience more pain and if she had been notified of the pain with wound care, she would have ordered Norco with wound care like she did when she was notified on 10/05/22. MD H said she had not followed Resident #63 since May 2022. In a telephone interview on 10/05/22 at 1:38 PM, MD I said she was the facility's wound physician. MD I said he observed Resident #63's wounds weekly and would perform wound care for Resident #63 with the Wound Care Nurse. MD I said the last time he observed Resident #63 was on 10/03/22. MD I said, one out of every few times, Resident #63 would moan during wound care, and said she was largely non-verbal. MD I said rarely would he need to take a break during the wound care for Resident #63 due to her signs of pain, and one or two times he had to stop wound care for Resident #63 due to her pain. MD I said the Wound Care Nurse was present when he stopped the wound care for Resident #63 due to her pain. MD I said aside from stopping the wound care, he would defer to the pain management physician as to what a nurse should do if a resident displayed signs of pain during wound care. In an interview on 10/05/22 at 4:10 PM, the Wound Care Nurse said he heard Resident #63 say Oh! Oh! I hurt! when he touched her backside during her sacral wound care on 10/05/22. He said his plan was to finish up the wound care. The Wound Care Nurse said Resident #63 hardly ever displayed signs of pain during wound care and she was, totally fine the majority of the time. The Wound Care Nurse said today, 10/05/22 was the first time in a while, Resident #63 displayed signs of pain during wound care. He said the last time Resident #63 displayed signs of pain during wound care was maybe in the summertime when her wounds were bad (Summer 2022). The Wound Care Nurse said Resident #63's wounds had started healing and were starting to granulate so her nerve endings may be starting to come back, and she may be in more pain than normal. The Wound Care Nurse said the signs of pain Resident #63 displayed while he was performing her sacral wound care on 10/05/22 he would not necessarily say were signs she was in pain, rather her displaying signs of past trauma. The Wound Care Nurse said he last received training on pain management, which included the different types of pain assessments, in August 2022. The Wound Care Nurse said he would have rated Resident #63's pain during the sacral wound care at a level 3 or 4 out of 10. The Wound Care Nurse said if Resident #63 had kept hollering, he would have rated her pain at maybe a 6 or 7 out of 10. The Wound Care Nurse said if Resident #63 would have screamed the roof off he would rate her pain at a level of 10 out of 10. The Wound Care Nurse said indicators of pain included yelling, grimacing, clutching, grabbing, holding, not wanting to turn, rubbing a specific area, or crying out. The Wound Care Nurse said if a resident displayed these signs of pain, he would assess the pain by asking the resident questions such as if the pain was sharp or how long they had it. The Wound Care Nurse said he would then tell the resident's nurse about the pain. The Wound Care Nurse said if a resident displayed signs of pain during wound care, he would not want to leave the wound open, so he would first finish the wound care. The Wound Care Nurse said he should not continue wound care, until the resident received pain medication and the resident was re-assessed for pain. The Wound Care Nurse said the signs Resident #63 displayed during the sacral wound care he performed on 10/05/22 were not signs of pain, he said they were signs of trauma from her past. The Wound Care Nurse said he could differentiate between Resident #63's pain and trauma symptoms because when it was trauma, she would say things like, I'm scared, or, daddy. The Wound Care Nurse said if given a chance to repeat the wound care he performed for Resident #63's sacral wound on 10/05/22 he would give her more time for the pain medication to kick in. The Wound Care Nurse said he should have waited and hour or so for the Tylenol to take effect. The Wound Care Nurse said MD I worked at the facility for 2 months and he was present when MD I assessed Resident #63's wounds. The Wound Care Nurse denied being present when the wound care for Resident #63 was stopped by MD I due to her pain. In an interview on 10/05/22 at 4:31 PM, the Staffing Nurse said he did not know what happened in Resident #63's past life because when she was turning onto her side she would cry out Oh, you're hurting me. The Staffing Nurse said he would be able to know if Resident #63 had pain based on her facial expressions and if she continued to cry out. The Staffing Nurse said Resident #63's pain should be assessed using the PAINAD scale. The Staffing Nurse said Resident #63 had pain during wound care on 10/05/22 and she said she was hurting. The Staffing Nurse said he would have rated her pain a 5 of 10 during sacral wound care on 10/05/22. The Staffing Nurse said if a resident showed signs of pain during care, staff should stop what they were doing and check orders for pain medications. The Staffing Nurse said if the resident was medicated for pain prior to care, that meant the medication was not working and the nurse needed to call the doctor. In a follow-up interview on 10/07/22 at 12:06 PM, the Staffing Nurse said Resident #63 would always cry out saying Ouch, don't hurt me. The Staffing Nurse said he did not work with Resident #63 often but noted, on at least 3 occasions, her crying when she was repositioned and she said, Don't hurt me. I'm hurting. The Staffing Nurse could not provide dates of the incidents and stated based on his nursing judgement he determined Resident #63 was not in pain. The Staffing Nurse said he never completed a PAINAD or any pain assessment for Resident #63, but he should have completed and documented a pain assessment if Resident #63 complained of hurting. In an interview and observation on 10/07/22 at 8:53 AM, LVN D said on 10/05/22, after her morning medication pass, the Wound Care Nurse asked her if she had already given Resident #63 pain medication and she told him, No. She said the Wound Care Nurse told her Resident #63 had complained of pain and she told him she would give Resident #63 Tylenol. LVN D said she had never been asked to give Resident #63 pain medications before wound care. LVN D said she had never observed wound care or incontinent care for Resident #63. LVN D said, in the past, Resident #63 had PRN Norco ordered and she would receive it every morning for pain. LVN D said she would assess Resident #63 for pain using the PAINAD scale when Resident #63 was moaning/groaning and had facial grimacing. LVN D said recently, Resident #63 complained of a headache, and she had given her Tylenol. LVN D said she did not know when or why the order for Resident #63's PRN Norco for pain was discontinued. LVN D said she had never been notified by the aides that Resident #63 had signs of pain. In an interview on 10/05/22 at 4:37 PM, CNA J said she regularly worked with Resident #63. She said Resident #63 would cry, but she did not think Resident #63 was in pain. CNA J said she believe crying was a reaction to someone touching her or being moved. CNA J said she thought Resident #63 had some discomfort with her contractures, and, normally cries out when she's being moved. 2. Record review of Resident #188's admission Assessment, dated 09/27/22, reflected a female resident who was admitted to the facility on [DATE] at 6:20 PM from an acute care hospital. Resident #188 was alert and oriented to person, place, time, year, and month. She had a diagnosis which included acute and chronic pain. She wore hearing aids, her speech was clear, and she made herself understood. Resident #188's had diagnoses which included a history of falling, edema (swelling) , diabetes, and chronic kidney disease. The resident was able to report pain and denied pain. Resident #188's tolerable/acceptable pain level was 0 (0-10 scale). Record review of Resident #188's orders, dated 10/07/22, reflected she was an [AGE] year-old female. Her orders included: 1. 09/27/22- Pain scale every shift. 2. 10/05/22- Tylenol 650 mg every 6 hours PRN for moderate pain (4-6). 3. 10/06/22- Voltren Arthritis Pain gel 1%, 1 gel topically 3 times per day. Record review of Resident #188's MARs from 09/27/22 through 10/06/22, reflected she received PRN Tylenol for pain on: 09/29/22, 09/30/33, 10/01/22, 10/05/22, and 10/06/22. Record review of Resident #188's care plan, dated 10/07/22, reflected a care plan for pain initiated on 09/27/22. Interventions included: administering pain medications as ordered, analyzing and reducing factors that precipitated pain, assessing characteristics of pain, encouraging the resident to attend activities and exercise, giving pain medications before the pain became severe, non-pharmacological pain measures of relaxation/rest, notifying the physician of any changes in level or frequency of pain or any increase in use of PRN pain medications, observing the resident for signs of pain with care and interactions. Record review of Resident #188's PT evaluation on 09/28/22 reflected she was assessed for pain and verbalized a pain level of 8/10 (severe pain) to her left lower extremity at rest and with movement. Her pain caused a decrease in activity tolerance and participation. Prolonged activity worsened the pain and remaining still relieved the pain. Record review of Resident #188's PT notes from 09/28/22 to 10/06/22 reflected on 09/28/22 and 10/04/22 Resident #188 had pain. A numerical pain level was not documented. In an interview and observation on 10/05/22 at 6:52 AM, revealed Resident #188 told LVN A she had pain in her right shoulder. She stated she told the overnight nurse at 3:30 AM but the night nurse had not done anything and walked out of her room. Resident #188 rated her pain an 8 to 9 out of 10. LVN A gave Resident #188 Tylenol 650 mg for her pain. In interview and observation on 10/05/22 at 2:50 PM, revealed Resident #188 was lying in bed, awake and alert. She said she had pain which woke her up on 10/05/22 at 3:30 AM, pressed her call light, and told the nurse about her pain. She said the nurse did not do anything and walked out of the room. The resident could not identify the nurse. Resident #188 said the Tylenol she received from LVN A that morning (10/05/22 at 6:52 AM) was somewhat effective and rated the pain to her shoulder a 5 or 6 out of 10. Resident #188 said LVN A did not re-assess her pain after he administered the Tylenol. Resident #188 said she had bursitis (painful condition that affects the small, fluid-filled sacs - called bursae (bur-SEE) - that cushion the bones, tendons and muscles near your joints. Bursitis occurs when bursae become inflamed) to her right shoulder which caused her pain. She said it made working with therapy at the facility difficult. A telephone interview with LVN R who worked overnight on 10/04/22 into 10/05/22 was attempted on 10/07/22 1:04 PM and 3:21 PM, but contact was unsuccessful. A telephone interview with LVN S who worked overnight on 10/04/22 into 10/05/22 was attempted on 10/07/22 at 1:11 PM and 3:24 PM, but contact was unsuccessful. Record review of the facility's policy titled Treatment of Wounds: Dressing Changes, dated 07/2018, reflected the policy did not address pain management during wound dressing changes. Record review of the facility's policy titled Pain Management and Basic Comfort Measures, dated 01/12/20, reflected, . Staff will evaluate pain and provide basic comfort measures in accordance with standard practice guidelines . Procedure: Identify the resident. Ask the resident if he or she is in pain. Perform hand hygiene if appropriate. Examine the site of the patient's pain, which may include subjective and objective data collection measures. Evaluate the resident's medical history . Provide pain medication as prescribed . Evaluate for analgesic [pain medication] side effects and pharmacological/ non-pharmacological effectiveness . Observe for unresolved pain and address per physician's orders. Record pain management techniques in the record . The policy did not address pain assessments in residents who were non-verbal or had a cognitive impairment. Record review of the Pain Assessment in Advanced Dementia (PAINAD) pain scale on 10/12/22 at https://geriatricpain.org/sites/geriatricpain.org/files/2020-06/PAINAD.pdf reflected the assessment for pain was based on the following factors: breathing, negative vocalizations (moan, groaning, calling out, crying), facial expressions (smiling, inexpressive, sad, frowning, facial grimacing), body language (relaxed, tense, rigid, pulling or pushing away), and consolability (no need to console, distracted or reassured by voice or touch, or unable to console, distract or reassure). The total scores ranged from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain. Instructions included: Observe the older person both at rest and during activity/with movement. For each of the items included in the PAINAD, select the score (0, 1, or 2) that reflects the current state of the person's behavior. Add the score for each item to achieve a total score. Monitor changes in the total score over time and in response to treatment to determine changes in pain. Higher scores suggest greater pain severity. Note: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and report from an individual knowledgeable of the person and their pain behaviors. Remember that some individuals may not demonstrate obvious pain behaviors or cues. This was determined to be an Immediate Jeopardy (IJ) on 10/05/22 at 5:40 PM. The ADM and the DON were notified. The ADM and the DON were provided with the IJ template on 10/05/22 at 5:40 PM. The following Plan of Removal submitted by the facility was accepted on 10/06/22 at 4:40 PM and reflected: Date: 10/05/2022 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY For F697 To Whom it may concern, Summary of Details which lead to outcomes On 10/5/2022, during annual survey initiated at [Facility Name/Address]. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. F697 The notification of the alleged immediate jeopardy states as follows: The facility failed to assess, provide effective pain treatment, and address pain promptly for two residents with significant pain, Resident #63 and Resident #188. What corrective action will be taken for those residents found to have been affected by the deficient practice: [Resident #63] was immediately assessed by 6-2 LVN charge nurse for any concerns of unrelieved pain or distress following wound care. Clinical staff were educated regarding pain at 6:30 PM. Follow up pain assessment in advanced dementia (PAINAD) was conducted at 8 PM by MDS Nurse Manager. Tylenol 325 mg tablets, 2 tablets by mouth every 4 hours as needed prn for pain or [temperature) Original order date 8/4/22 and remains a current order An additional order for hydrocodone 5/325 was received and given to the resident prior to completion of remainder of her wound care. Pain Management MD notified at 10:08 AM of potential pain during wound care for [Resident #63] with new order received for hydrocodone 5/325mg given on 10/5/2022. Pain was reassessed as being effective on 10/5/22 at 11:10 AM by 6-2 LVN. 'Resident sleeping with eyes closed. No signs of distress noted.' [Resident #63] showed no further signs of pain post wound care upon assessment by ADON on 10/5/2022. [Resident # 188] was immediately assessed for any unrelieved pain with no further complaints upon assessment by ADON on 10/5/2022. Physician notified of residents 5/10 pain after Tylenol administered. Voltren Gel 1% three times a day (T.I.D.) to right shoulder. was ordered 10/6/22, and a telemedicine visit was conducted by primary physician to discuss residents' treatment plan. How other residents with the potential to be affected by the same deficient practice will be identified; Residents experiencing pain have the potential to be affected What measures will be put into place or what systemic changes will be made to ensure that the deficient practice[TRUNCATED]