Ignite Medical Resort Fort Worth, Llc

F-F697 - Pain Management

Immediate Interventions:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 676449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Fort Worth, LLC 6301 Oakmont Blvd Fort Worth, TX 76132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 1. Notification made to [Physician Name] and [Physician Name], physicians and Medical Directors, of Immediate Jeopardy on 6-28-2024 at 1:12 PM. Level of Harm - Immediate jeopardy to resident health or 2 . Emergent Meeting conducted with action plan developed. This occurred at 1:15 PM on 6-28-2024. safety Attendance included:

Residents Affected - Some [Administrator Name] - Administrator

[DON Name] - Director of Nursing

Action Plan: Daily Pain Assessment will be completed on patients

3. Direct Care Nursing Staff in-serviced on Pain Management, pain medication follow up on effectiveness

after medication administration, physician notification if no improvement in pain level after medication administration on 6-28-2024 by [DON], DON, [ADON A] ADON, and [ADON B] ADON.

- All PRN Pain Medications require a pre and post administration pain assessment number (or Wong-Baker Scale)

- This must be documented

- All guest who have received PRN pain medication must have a follow-up to determine level of pain relief achieved.

- If there was a little to no improvement with the level of pain, a call must be make to the guest's physician for further intervention.

- Please document this in clinical record

- If a guest is asking for pain medication sooner than ordered, a call must be made to the physician for further intervention.

- Please document this in clinical record.

4. Meeting with the following managers to review Immediate Jeopardy on 6-28-2024. We reviewed Pain Management, notifying physician when Pain Medications are not effective. The following managers attended:

a. [Administrator Name], Administrator

b. [DON Name], Director of Nursing

c. [DOR], Director of Rehabilitation

d. [ADON A] Assistant Director of Nursing

e. [ADON B], Assistant Director of Nursing

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 676449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Fort Worth, LLC 6301 Oakmont Blvd Fort Worth, TX 76132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 f. [Activities Director], Activities Director

Level of Harm - Immediate g. [Dietary Manager], Dietary Manager jeopardy to resident health or safety h. [SW] Social Services

Residents Affected - Some i. [LVN Name], MDS Nurse

j. [LVN Name], MDS Nurse

Training:

1. [DON] Director of Nursing, to be in-serviced by [Corporate Nurse] [NAME] President of Clinical Services. [NAME] will be in-serviced on Pain Management, Physician Notification, Monitoring Pain management, and reviewing Pain Assessments.

2. An immediate in-service was initiated on 6/27/24 and 6/28/24 By [DON], Director of Nursing, on Pain Management and physician notification.

3. Beginning 6/28/2024 and on-going: A posttest will be completed by direct care nursing staff to ensure competency on Pain Management. Staff must answer all questions correctly before returning to work.

4. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in

the facility until they have completed in-service training and post-test.

5. A payroll report listing current employees will be used to track in-service completion.

Monitoring:

1. Nursing Administration ([DON], [ADON A], and [ADON B]) will interview random patients that receive pain medication to ensure effective pain management is in place.

2. [Administrator], Administrator, or appointed designee will review this process in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's decision. This will be on-going.

[Facility Name] requests that the measures we have implemented be reviewed and that our allegation of removal of jeopardy be accepted as of 6/ 28/ 24.

The facility was monitored for compliance with the POR on 6-28-2024 as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 676449 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676449 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Fort Worth, LLC 6301 Oakmont Blvd Fort Worth, TX 76132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 In an interview on 6-28-2024 at 3:28 PM, it was discovered that LVN C has worked at the facility for one year, was on vacation, returned today from vacation, and was not in-serviced on pain management yet. She Level of Harm - Immediate said her procedure for pain management was to know when it is scheduled, give the medicine within a jeopardy to resident health or one-hour timeframe. If the medicine is PRN, she would only give it as the patient request it. She checks back safety 30 minutes to an hour to see if the pain level decreases. If the pain level was still above a level 6, she would call the doctor. LVN C stated the risk to a patient for having constant levels of pain above a 6 is the patient Residents Affected - Some might not be able to do their therapy, it would affect their blood pressure, and the patient may have an infection. The nurses and CNAs are responsible for monitoring patient's pain levels by asking the patients where the pain is and how bad the pain is using the 0-10 pain scale.

In an interview on 6-28-2024 at 3:45 PM RN B disclosed she had been in-serviced on pain management. RN B stated the procedure for pain management depends on whether it is a scheduled medicine or PRN. If the medicine is PRN, she would determine whether it was the right time to give it or not. If the medicine was scheduled, she would just follow the schedule. If the pain was a break through pain, occurs in less than 24 hours, and is at least a level 7, then the pain medicine would not be working, and changes would need to be made. RN B said he would notify a doctor if the pain medicine would not bring the patient's level of pain below a level 7. The risk to the patient for not getting pain relief would be increased vital signs, increased blood pressure, and unreliable statistics. RN B conveyed the nursing staff are responsible for monitoring patients pain levels by verbal communication, looking at vital signs, seeing sweating, agitation, and grasping at the same spot.

In an interview on 6-28-2024 at 3:57 PM LVN D revealed he has worked at the facility for 3 months and was in-serviced on pain management. He stated the procedure for pain management was to assess a patient using a scale of 0-10. If a patient has more than one pain medication ordered, start with the weaker one and see if it reduces the pain level. LVN D said they he would check back with the patient and if the pain level did not decrease, he would notify the doctor. He stated the risk to patients for having constant pain levels was having behavioral problems, agitation, high blood pressure, or could be a sign of something else going on.

The nurses are responsible for monitoring pain levels by looking for grimacing, groaning, breathing hard, and verbal communication.

In an interview on 6-28-2024 at 4:20 PM, RN C stated she had been in-serviced on pain management. She[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 676449