Health inspection·September 17, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **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. Residents Affected - Some 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: Page 1 of 20 675622 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. 675622 Page 2 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 3 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 4 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 5 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. 675622 Page 6 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 The immediate jeopardy is as follows: Level of Harm - Immediate jeopardy to resident health or safety Issue: Residents Affected - Some 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.

F697 Pain Management 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. 675622 Page 7 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 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. Level of Harm - Immediate jeopardy to resident health or safety Education/ System Change: Residents Affected - Some 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: 675622 Page 8 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 9 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. 675622 Page 10 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **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. 675622 Page 11 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 2 capsules by mouth two times a day for Neuropathy (nerve damage condition). Level of Harm - Immediate jeopardy to resident health or safety - Order date 09/07/24: Gabapentin Capsule 300 mg. Give 4 capsules by mouth at bedtime for Neuropathy. Residents Affected - Some - 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 675622 Page 12 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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). 675622 Page 13 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 14 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 15 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 675622 Page 16 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 accurate medication profile. Level of Harm - Immediate jeopardy to resident health or safety 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. Residents Affected - Some 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 675622 Page 17 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 If a medication is unavailable and you can obtain from E-Kit. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Some o Nursing staff training on use of implanted pain pump use 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 675622 Page 18 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 sufficiently to remove the IJ by: Level of Harm - Immediate jeopardy to resident health or safety 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. Residents Affected - Some 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 675622 Page 19 of 20 675622 09/17/2024 Cityview Nursing and Rehabilitation Center 5801 Bryant Irvin Rd Fort Worth, TX 76132

F 0726 place. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 675622 Page 20 of 20