Gateway Vista

During an interview on 9/17/2025 at 3:45 PM with Licensed Practical Nurse (LPN) - B confirmed that Resident 1 came from the hospital with an order for Hydromorphone (Dilaudid) for five days and it was scheduled to be stopped during the weekend and when residents come with a stop date on pain meds, the facility will reassess their pain and address it from there. LPN-B further confirmed the facility did not have a plan for when Resident 1's five day scheduled order for Dilaudid was discontinued, and there was no plan to taper (gradually reduce) the medication.

Record review of Resident 1's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) with a focus area dated 9/9/25, revealed the resident had chronic pain with a goal of adequate relief of pain, interventions included to identify previous pain history and management of that pain, administer analgesics, and document response.

During an interview on 9/18/25 at 1:37 PM with Director of Clinical Operations (DCO) confirmed there was no documentation of the resident pain assessment or condition between 12:20 PM and 2:35 PM for Resident 1 on 9/14/2025, the day of discharge.

The DCO also confirmed that pain is subjective (subjective means pain is described and reported based on the individual's perception and interpretation).

Record review of Resident 1's Minimum Data Set (MDS - this comprehensive assessment evaluates each resident's functional capabilities) dated 9/14/2025 revealed the resident discharged from the facility on 9/14/2025.

During an interview on 9/18/2025 at 3:43 PM with the Director of Nursing (DON) confirmed that Resident 1's pain was not under control, based on the pain assessment, when the resident was discharged .

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