**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate nutrition and hydration services for 2 out of 8 sampled residents (Resident 1 and 10). For Resident 1, the facility failed to identify, implement, and monitor interventions, consistent with the resident's assessed needs and facility policy, which resulted in a severe unplanned weight loss of 8.36% within a three month timeframe from 7/10/19 to 10/3/19. For Resident 10, the facility failed to provide fluid on the lunch meal tray, which had the potential to result in dehydration. Findings: 1. During a review of the clinical record for Resident 1, the admission Record, dated 10/16/19, at 11:53 a.m., indicated Resident 1 was admitted to the facility on [DATE]. The record indicated Resident 1 was admitted for the primary diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions). The record further indicated Resident 1 was diagnosed with anxiety, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Rheumatoid Arthritis (a disease in which the body's immune system attacks its own tissue, including joints and internal organs. It causes painful swelling and over time can cause bone erosion and joint deformity) and Type 2 Diabetes (a disease that affects how the body uses glucose, the main type of sugar in the blood). During a dining observation, on 10/8/19, at 1 p.m., Resident 1 was served her meal in her room. Facility staff delivered the meal tray, positioned the meal within reach, and exited the room. During an observation, and concurrent interview with Resident 1, on 10/16/19, at 9:25 a.m., in the resident's room, she stated breakfast was ok today. Resident 1 was sitting up in bed, she appeared to have no natural teeth. There was no dentures container within her reach. Resident 1's fingers, on both hands were abnormally bent at the joints, in the opposite angle of how each joint would naturally bend. During an interview with Certified Nurse Assistant J (CNA J), on 10/16/19, at 9:45 a.m., she stated she had worked at the facility for two months. CNA J confirmed she was Resident 1's regular CNA, and was familiar with her needs. CNA J said Resident 1 always ate in her room. CNA J stated Resident 1 needed a lot of encouragement to eat. CNA J stated she delivered the meal tray and positioned everything so Resident 1 could reach it. CNA J confirmed she opened and prepped some components on the tray. CNA J explained, she knew Resident 1 would not eat her oatmeal, so she did not set it up. CNA J stated sometimes Resident 1 would eat her eggs, so she made sure they were within reach and ready to eat. CNA J stated she would check on Resident 1 often, and encourage her to eat. CNA J stated she would check on Resident 1 after passing trays, and remind her breakfast is getting cold. Then, after she did something else she would check in again. CNA J stated Resident 1 would say she was hungry but did not eat. CNA J confirmed she would get Resident 1 an alternate, such as soup, if she did not eat. When asked what percentage of breakfast did Resident 1 eat, CNA J stated 75%. CNA J described 75% as most of the pancakes with syrup. She confirmed Resident 1 did not eat any oatmeal, did not drink any milk or nutritional supplement. CNA J stated she used to weigh the residents she provided care for, but recently the facility changed who was responsible for weights. CNA J knew Resident 1 had new silverware that was easier to grip with her meals. CNA J stated she had not been alerted to any change in Resident 1's health status, she did not know Resident 1 had lost weight. CNA J stated there had been no change in the care she needed to provide. During an interview with Licensed Nurse E (LN E), on 10/16/19, at 11 a.m., she confirmed she was the nurse caring for Resident 1. LN E stated she had worked at the facility for approximately 2 months, and had provided care for Resident 1 on a regular basis. LN E stated there was no change in Resident 1's condition, and there were no alerts in regards to her care. LN E was not aware Resident 1 was losing weight. LN E stated Resident 1 required setup assistance with meals, and ate independently. LN E confirmed there were no orders for weekly weights for Resident 1. LN E stated no concerns for Resident 1 had been reported to her. During an interview with the Director of Nursing (DON), on 10/16/19, at 11:08 a.m., she stated there were no concerns that she was aware of for Resident 1. The DON was not sure if the Interdisciplinary Team had reviewed Resident 1's care yet. The DON confirmed over 5% weight loss in thirty days would be a change in condition per the facility policy. The DON stated the expectation would have been a Change of Condition Report in the resident's electronic health record. The DON reviewed the clinical record for Resident 1 and was unable to find documentation of a change in condition. In addition, the DON stated nursing staff would chart every shift for three days, in relation specifically to the change. The DON reviewed the clinical record for Resident 1 and was unable to find documentation of shift reports specific to weight loss for 3 days. The DON stated the expectation could be for nursing or the weights committee to update the care plan, if indicated. The DON reviewed the care plan for Resident 1, the has nutritional problem or potential nutritional problem focus that was initiated on 7/10/19. Of the fourteen interventions, the DON could provide one that had been revised. The DON stated the brand of the supplement was added on 7/30/19. The DON stated weights would be taken weekly, until the weight stabilized, then monthly. The DON reviewed the Orders section, and was unable to find an order to take weights at any frequency. When asked if the review of care for Resident 1 was an accurate reflection of how the facility responded to resident weight loss, the DON stated no, not at all. During an interview with Registered Dietician 2 (RD 2), on 10/16/19, at 12:29 p.m., she stated Registered Dietician 1 (RD 1) was available by phone. RD 2 called RD 1 for interview. RD 1 stated she was familiar with Resident 1 and her care needs. RD 1 confirmed she was aware Resident 1 was losing weight. RD 1 stated she met with the interdisciplinary team a few times and spoke to the therapy department regarding Resident 1's weight loss. RD 1 stated the kitchen would put extra butter on her meal trays, and adaptive silverware was added two days ago. RD 1 stated all residents were seen at the time of admission to assess their nutritional needs and make recommendations to the physician. RD 1 stated if a resident was losing weight they were added to the RD workload to monitor and assist from a dietary perspective. RD 1 stated a different RD would have met with Resident 1 on 10/12/19 for a quarterly review and evaluation. RD 1 stated their department faxed recommendations to the physicians for their review. RD 1 confirmed her department did not monitor for the outcome of their recommendations. RD 1 stated the physician's decision to agree, disagree, or modify a recommendation would go to the nursing department, the same as any other physician orders. RD 1 and RD 2 both confirmed the recommendation to change Resident 1's supplement should have been sent by the facility, not the Dietay Department, because it was a team recommendation. When asked how often should the facility weigh a resident who had unintentional weight change, RD 1 stated weekly until the weight stabilized. RD 1 confirmed monthly weights would be reinstated. RD 1 stated if a resident she was monitoring did not have a weekly weight in the electronic health record she would follow up with the charge nurse or the DON. RD 1 explained the weights were taken and recorded on paper, then input into the record. RD 1 stated if the weights were not done, she would weigh the resident herself. RD 1 was asked; under what circumstance would a resident not have their weight taken at all? RD 1 stated the only example she could think of was if a resident was receiving end of life care and refused to be weighed. RD 1 went on to say the facility should provide education and encourage the resident to be weighed. RD 2 stated the kitchen was sending [brand] nutritional supplements out to Resident 1 at 10 a.m., and 2 p.m. RD 1 confirmed the brand RD 2 provided was not the same as the one recommended by the weights committee. She also confirmed the two supplements had different nutritional composition. Both RD1 and RD2 were asked if there were any additional actions taken by the dietary department to support Resident 1's goal of weight maintenance, neither had anything to add. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 111.3 pounds on 7/10/19 at 4:32 p.m. During a review of the clinical record for Resident 1, the Order Summary report, dated 10/16/19, at 11:59 p.m., indicated one active dietary order, started on 7/13/19. Resident 1 was ordered a controlled carbohydrate diet with mechanical soft food texture. During a review of the clinical record for Resident 1, the Nutrition Evaluation and RDN Review report, dated 7/13/19, at 11 2:0 a.m., indicated the reason for review was admission. The report indicated no supplements were ordered for Resident 1. The report indicated Resident 1's usual weight was 120-125 pounds. The Weight History/Consideration section indicated Resident 1 had not noticed any weight change in the six months prior to the assessment. The report indicated the author calculated Resident 1 had a 7% weight loss from her usual weight. The Dining Information section indicated Resident 1 fed herself and need assistance. The Meal Intake section indicated 60% for the last 5 meals. The report listed loss/gain as the only observed weight trend. The report indicated Resident 1's ideal body weight was 108-132 pounds. The report indicated Resident 1's desirable body weight range was 105-116 pounds. The report identified concerns with Resident 1's nutrition status. Specifically, Resident 1 was not eating enough to meet her nutrient needs. The Recommendations per Registered Dietician section indicated: supplement, weekly weights, provide diet of choice, offer preferences, dietary education, swallow evaluation by speech therapy and verify the diet order was accurate. During a review of the clinical record for Resident 1, the Care Plan, initiated on 7/10/19, indicated Resident 1 had a nutritional problem or potential nutritional problem related to chronic pain, rheumatoid arthritis and dementia. The goal was Resident 1 would maintain adequate nutritional status as evidenced by maintaining her weight. During a review of the clinical record for Resident 1, the Care Plan, the nutritional problem or potential nutritional problem section, dated 7/15/19, Indicated the facility had identified 14 interventions to support Resident 1 maintaining her weight. if eats less than 50%, offer meal replacement was listed as a nursing intervention. No charting or monitoring tools were attached to that intervention. The facility was unable to provide documentation to show how the implementation of the intervention was assessed. Weekly weights for four weeks and then monthly if weight was stable was an identified intervention. Resident 1 was weighed 9 times out of 13 opportunities. Additionally, monitor and report to the physician any signs or symptoms of decreased appetite or unexpected weight loss was an intervention. The facility was able to provide documentation of one fax to the physician requesting a second supplement per day due to weight loss. At the time of exit, no additional evidence showing communication with the physician was provided. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 106.7 pounds on 7/17/19 at 7:19 p.m. During a review of the clinical record for Resident 1, the Orders section, indicated [brand] nutritional supplement one time a day was started on 7/18/19. The supplement was ordered to be given at 5 p.m. During a review of the clinical record for Resident 1, the Care Plan, nutritional problem or potential nutritional problem intervention section, indicated one new intervention. Give supplement as ordered was added to Resident 1's care plan. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 102.5 pounds on 9/18/19 at 11:26 a.m. During a review of the clinical record for Resident 1, the physician communication form, dated 9/19/19, indicated the Interdisciplinary team contacted Resident 1's physician in regards to her weight loss. The form indicated, Resident 1 has a documented weight loss of 9.5# x 1 month (8.5%) and loss of 7.5# x 6 days. The form indicated the facility was going to reweigh the resident. The form indicated Resident 1's average intake over the week prior was 55%. The form indicated the facility requested to give Resident an additional nutritional supplement daily. The form indicated the physician agreed with the recommendation. During a review of the clinical record for Resident 1, the Orders section, indicated [brand] nutritional supplement one time a day in the morning was started on 9/27/19. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 104 pounds on 9/25/19 at 6:35 p.m. During a review of the clinical record for Resident 1, the LN-Nutrition Interdisciplinary Team Update report, dated 9/26/19, at 3: 25 p.m., indicated a most recent weight of 104 pounds. The report indicated Resident 1 had 7.1% weight loss. The report indicated Resident 1 had an average meal intake of 38%. The progress section indicated weight loss most likely due to poor oral intake. The report recommendation was to discontinue the current nutritional supplement and replace with a different brand supplement that contained 350 calories and 20 grams of protein. During a review of the clinical record for Resident 1, no change noted to the record. The facility was unable to provide documentation the LN-Nutrition Interdisciplinary Team Update report, dated 9/26/19, had been communicated to the physician. During a review of the clinical record for Resident 1, the Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 104 pounds on 9/25/19 at 6:35 p.m. Weights and Vitals Summary report, dated 10/16/19, at 11:55 a.m., indicated Resident 1 weighed 102 pounds on 10/3/19 at 2:32 p.m. During a review of the clinical record for Resident 1, a Registered Dietician Note, dated 10/5/19, at 1:48 p.m., indicated Resident 1's weight continued to trend down. The note indicated poor oral intake as a probable cause. The note indicated Resident 1 had eaten less than 50% eight times in ten meals reviewed. The note indicated the RD would continue to monitor Resident 1. During a review of the clinical record for Resident 1, the LN-Nursing Summary-Weekly report, dated 10/6/19, at 3:08 a.m., indicated Resident 1 was able to eat independently. The report indicated Resident 1's oral intake was an average 75% or more for the previous week. The report indicated Resident 1's weight was stable at 102 pounds. The report included a section to document what action had been taken to stabilize Resident 1's weight. That section was left blank. Licensed Nurse N electronically signed the report as complete on 10/6/19. During a review of the clinical record for Resident 1, the LN-Nursing Summary-Weekly report, dated 10/12/19, at 10:33 p.m., indicated Resident 1 was able to eat independently. The report indicated Resident 1's oral intake was an average 75% or more for the previous week. The report indicated Resident 1's weight was stable at 102 pounds. The report indicated the weight was taken on 10/3/19. The report included a section to document what action had been taken to stabilize Resident 1's weight. That section was left blank. Licensed Nurse N electronically signed the report as complete on 10/13/19. During a review of the clinical record for Resident 1, the POC Response History report, dated 10/16/19, provided a 30-day look back window. The report was for CNA task Amount Eaten. The question indicated in the report was, what percentage of the meal was eaten. From 10/12/19 look back 7 days, documentation indicated Resident 1 ate 76%-100% or more of her meal 3 times. The report indicated Resident 1 ate 0%-25% of her meal 4 times during the same timeframe. During a review of the clinical record for Resident 1, the POC Response History report, dated 10/16/19, provided a 30-day look back window. The report was for CNA task Amount Eaten. The question indicated in the report was, what percentage of the meal was eaten. From 10/5/19 look back 7 days, documentation indicated Resident 1 ate 76%-100% or more of her meal 3 times. The report indicated Resident 1 ate 0%-25% of her meal 4 times during the same timeframe. The report further indicated there was one meal Resident 1 refused. During an interview with the Director of Nursing (DON), 10/16/19, at 11:20 a.m., she reviewed the electronic health record for Resident 1. The DON reviewed the care plan interventions and confirmed weekly weights had not been implemented. The DON reviewed the CNA task charting for amount eaten. The DON stated the Nursing Summary report answers should match. The DON confirmed the two documents had conflicting information in regards to how much Resident 1 was eating. The DON reviewed both weekly nursing reports, and stated they were wrong, Resident 1's weight was not stable. The DON was unable to provide any documentation that a physician had evaluated Resident 1 for weight loss. The DON was unable to provide any documentation that a nurse had assessed Resident 1 for weight loss. The DON had no additional evidence or explanation for the lack of assessment and monitoring in regards to Resident 1's weight. During a review of the physical chart for Resident 1, the physician's progress note section, indicated Resident 1 had been seen by a physician on 10/6/19. The chief complaint recurrent headaches. The review of systems section indicated general: Appetite is satisfactory. No significant weight change. The report was electronically signed on 10/7/19 at 3:23 p.m. The facility policy and procedure titled, Nutrition and Weight Loss Policy, dated 7/19, indicated it was the policy of the facility to ensure that all residents maintained acceptable parameters of nutritional status. The policy indicated weight changes would be communicated to the doctor and the resident or resident representative. The policy further indicated the doctor or designee would assess and identify medical conditions, causes and problems related to the resident's nutritional status and needs. The procedure section indicated any resident weight that varied from the previous reported period by five percent in thirty days would be evaluated by the nutrition committee to determine cause and interventions required. The procedure indicated any resident at nutritional risk would be weighed weekly and reviewed during the weekly the nutrition committee meeting. The purpose section indicated the resident's response to interventions would be monitored and evaluated to discontinue or justify continuation of the approach. Resident 10, a [AGE] year-old female, was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone), and Diabetes Mellitus, according to the facility Face Sheet (A facility demographic). During dining observation on 10/08/19 at 12:56 p.m., in the main dining room of the facility, Resident 10 was observed during delivery of her lunch tray. Resident 10 received her meal, but did not receive any drinks with her meal. Resident 10 alerted the Activities Supervisor that she needed a drink, and requested the drink of her choice, which the Activities Director requested by phone to dietary personnel. The drink was delivered to Resident 10 approximately ten minutes after she received her lunch meal. The kitchen failed to include drinks for Resident 10 while preparing her lunch tray, and level of care staff failed to catch this omission during the delivery of the lunch tray. During a second interview on 10/09/19 at 10:23 a.m., Resident 10 confirmed she did not receive any drinks on 10/08/2019 for lunch. Resident 10 stated she was on a thin liquid diet and could drink regular water. During an interview on 10/08/19 at 4:31 p.m., with Registered Dietician (RD) 1 and RD 2, RD 1 stated that depending on the Resident 10's diet orders, she should receive some beverage with her meals. RD 1 stated tray meals were checked by kitchen personnel and Licensed Staff in the dining area. During an interview on 10/14/19 at 12:10 p.m., the Director of Nursing (DON) stated residents were expected to receive drinks with their meals unless they had a Physician's Orders indicating otherwise. The DON also stated she did not think Resident 10 was on fluid restrictions. Physician orders active as of 10/01/2019 indicated, CCHO (Controlled carbohydrate) diet PUREED texture, THIN LIQUIDS consistency. There was no Physician's Order for fluid restrictions. The education nursing book titled, Medical-Surgical Nursing Critical Thinking in Client Care, by P.L. and K.B., published in 2008, indicated, The older adult may become dehydrated without being aware of the need to increase fluid intake .Fluid volume deficit, or dehydration, is a common reason for hospitalization of people over age [AGE] .Older adults have a significant number or risk factors for fluid volume deficit .In addition, the older adult has fewer intracellular reserves, contributing to rapid development of dehydration. Without intervention, mortality from dehydration can exceed 50% in the older adult population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed its policies to provide pain management for two of twelve sampled residents (Resident 76 and Resident 77). This failure resulted in 1) Resident 76 suffering from intolerable pain, up to a level 10, on a pain scale from 0 to 10 (0 being no pain, 10 being the worst pain experienced in one's lifetime) and crying for two weeks from back pain, and 2) Resident 77 suffering from severe pain, up to a level 9, on a pain scale from 0 to 10 for four days from a left femur (Thigh bone) fracture, which made her unable to participate in physical therapy, and become depressed. Findings: 1) Resident 76 Resident 76 was admitted to the facility on [DATE] with medical diagnoses including Low Back Pain, Neuralgia (Intense, typically intermittent pain along the course of a nerve) and Pain in Thoracic Spine (Pain caused by joint dysfunction where the ribs attach to the spine), according to the facility Face Sheet (Facility demographic). Resident 76's MDS (Minimum Data Set-An assessment tool) dated 9/30/19 indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 14, which indicated her cognition was intact. Resident 76's MDS also indicated she required assistance with bed mobility and transfers. During an interview on 10/08/19 at 10:56 a.m., Resident 76 stated that for the last two weeks, the facility had not been able to obtain her pain medication, therefore, she had to call her husband to bring her pain medication from home. Resident 76 explained she had undergone several back surgeries that caused her intolerable pain, and she needed Oxycodone (A narcotic pain medication used to treat moderate to severe pain) 30 mg tablets to keep her pain under control. Resident 76 stated her pain level was a 10 on a scale from 0 to 10 during the interview and was observed crying. A Nursing Note for Resident 76 dated 09/30/19 at 2:01 p.m., indicated, Pt (Patient) c/o (complains) 10/10 pain. pain not controlled by current meds. A Nursing Note dated 10/08/19 at 1:00 p.m. indicated, PT (patient) continues to state pain 10/10. During a second interview on 10/09/19 at 8:57 a.m., Resident 76 stated Oxycodone 30 mg was the medication prescribed by her pain medication doctor to control her pain, and it was effective if administered as prescribed, every four hours. She stated she was told by facility staff that the facility contracted pharmacy had to drive her pain medication from Bakersfield, and as a result it took a long time to get it. Resident 76 also stated her pain level was greater than a 10, on a scale from 0 to 10, enough to where she thought she was going to throw up. Resident 76 stated her husband was bringing Oxycodone 30 mg tabs to the facility in a plastic zip lock bag, for medication administration by Licensed Staff. She stated she told everybody at the facility about her pain issues. Resident 76 stated her pain was so bad she could not sleep at night, and the facility would not give her anything to sleep. A Physician's Order, dated 09/29/19 at 6:20 p.m., indicated, oxycodone HCI Tablet 30 MG Give 30 mg by mouth every 4 hours as needed for PAIN MANAGEMENT. During a phone interview on 10/09/19 at 9:40 a.m., Resident 76's husband confirmed he brought Oxycodone 30 mg tablets from home for Resident 76's pain management at the facility. He stated he brought five tablets on three different occasions (for a total of 15 tablets) and gave them to Licensed Nurses at the facility. Resident 76's husband stated nothing was returned to him so he assumed Licensed Nurses used all the Oxycodone tablets he brought to the facility. During an interview on 10/09/19 at 2:07 p.m., the Director of Nursing (DON) stated Oxycodone 30 mg tablets were not in the facility's emergency kit during Resident 76's admission, and it had taken the facility contracted pharmacy longer than four hours for delivery. Other medications were administered to Resident 76 to control the pain but were ineffective. During an interview on 10/10/19 at 1:02 p.m., Licensed Nurse P, Resident 76's assigned nurse, confirmed administering Oxycodone 30 mg tablets brought to Resident 76 from home. Licensed Nurse P stated the medication came in a bottle labeled with the resident's name, description and dose. Licensed Nurse P stated she called the facility contracted pharmacy by phone to verify the medication brought from family was indeed Oxycodone 30 mg tablets. Licensed Nurse P stated after receiving verification from pharmacy, based on the description of the tablet, and obtaining a physician's order, she administered the medication Oxycodone 30 mg tablets to Resident 76. During an interview on 10/11/19 at 11:54 a.m., Licensed Nurse E confirmed Resident 76's husband brought three Oxycodone 30 mg tablets in a zip lock bag on 9/30/19, completely unlabeled, for administration. Licensed Nurse E stated she was the staff member who accepted the tablets, and had the husband sign a document indicating the type and dosage of medication brought from home for accountability purposes. She disproved Licensed Nurse P's statement on 10/10/19 at 1:02 p.m. that the Oxycodone 30 mg tablets from home came in a labeled bottle. Licensed Nurse E stated it usually took six hours for pharmacy to deliver pain medication not available at the facility. A facility document titled, Controlled Substance Accountability Sheet, dated 09/30/19, indicated Resident 76's husband brought three tablets of Oxycodone 30 mg to the facility, and they were accepted by Licensed Nurse E. A medication dispensing record provided by the DON on 10/16/19 at 9:45 a.m. indicated pharmacy delivered only two tablets of Oxycodone 30 mg to the facility on [DATE]. Resident 76's Medication Administration Record indicated these two 30 mg tabs of Oxycodone were administered to Resident 76 that same day (on 10/02/19), leaving her out of her prescribed medication again. According to the medication dispensing record, the pharmacy did not deliver more Oxycodone 30 mg tablets until 10/08/19 (six days later). For 6 days, Resident 76 received only two oxycodone 30 mg tabs from the facility contracted pharmacy, and fourteen tablets from other sources, presumably from medication brought from home. Resident 76's Medication Administration Record indicated Resident 76's pain level was an 8 out of 10 on 10/03/19, 10/04/19, 10/06/19 and 10/08/19. Resident 76's pain level was a 10/10 on 10/07/19. During an interview on 10/14/19 at 12:05 p.m., the DON stated medications that came in a zip lock bag, unlabeled, from home, were not acceptable for facility administration. During an interview on 10/11/19 at 9:42 a.m., Resident 76 stated she had been crying at the facility as a result of having a pain level of 10 out of 10. She stated it took a couple days to get her pain under control, but it had finally been managed. She confirmed her husband brought the Oxycodone 30 mg tablets from home in an unlabeled clear plastic zip lock bag, and they were accepted by the facility for administration. Resident 76 stated she was in misery (A cause of great distress or discomfort) for two weeks, often crying in pain. When asked if she had suffered as a result of this issue, Resident 76 stated, More than suffering. Resident 77 Resident 77 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lower End of Femur (Thigh bone) and Neuralgia, according to the facility Face Sheet. Resident 77's pain level had been documented as an 8 out of 10 on 10/07/19 and 10/08/19, in her Medication Administration Record. During an interview on 10/08/19 at 2:47 p.m., Resident 77 stated her pain level was a 9, on a scale from 0 to 10. She stated her pain level had not been controlled since admission, and the morning of 10/08/19 she was unable to do her physical therapy as a result of the intolerable pain. Resident 77 stated she had pain from a fracture to her left femur (thigh bone). Resident 77 stated staff informed her that facility physicians would not prescribe medication for her, and she had not seen a physician herself. During an interview on 10/08/19 at 4:43 p.m., Licensed Nurse P, nurse assigned to Resident 77, stated she called the physician that morning (10/08/19) to notify him that Resident 77's pain was not in control, and to request pain medication. The physician gave an order for Norco (Hydrocodone-Acetaminophen-A narcotic analgesic used to treat moderate to severe pain). Licensed Nurse P stated she immediately faxed and called pharmacy at 10:18 a.m., to obtain permission from pharmacy to withdraw the narcotic from the facility's emergency kit. Licensed Nurse P stated that in order to obtain a controlled medication from the emergency kit, pharmacy authorization was required. Licensed Nurse P explained that by 2:00 p.m. she had not received authorization from pharmacy to withdraw the medication from the emergency kit, therefore, she called back to follow up. Licensed Nurse P stated pharmacy put her on hold, and when she finally spoke to a pharmacy representative, was told they had just received her request in regards to Resident 77's Norco order. Licensed Nurse P stated she did not get approval from pharmacy until approximately 3:00 p.m. A Physician's Order dated 10/08/19 at 10:18 a.m., indicated, Norco Tablet 5-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for prn (as needed) pain. During a phone interview on 10/08/19 at 5:01 p.m., Pharmacy Technician U, employed by the facility contracted pharmacy, confirmed receiving a request for Norco the morning of 10/08/19, for Resident 77. She stated pharmacy, Got behind, and she did not know why the medication's withdrawal from the emergency kit was not approved earlier for facility use. Resident 77's Medication Administration Record indicated Norco (Hydromorphone-Acetaminophen) 5-325 mg, was administered for the first time to Resident 77 on 10/08/19 at 3:36 p.m., more than six hours after it was ordered by the physician. During an interview on 10/09/19 at 2:09 p.m., the DON confirmed Resident 77 had a new prescription for pain medication because her pain was not being controlled. The DON stated she had to call the pharmacy's general manager on 10/08/19 at around 3:00 p.m. to get the pharmacy's approval to obtain the medication from the emergency kit. Resident 77's Nursing Plan of Care for pain, initiated on 10/07/19, did not list specific pharmacological or non-pharmacological interventions to help alleviate or manage Resident' 77's pain. The care plan was not resident centered and had standardized pain interventions, including, Identify, record and treat resident's existing conditions which may increase pain and discomfort .Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. During an interview on 10/11/19 at 9:34 a.m., Resident 77 stated she suffered in horrible pain for several days and was starting to get depressed. During an interview on 10/14/19 at 12:30 p.m., the DON stated they were having issues with pharmacy. She stated pharmacy was not sending them controlled pain medications in a timely manner and made them wait on the phone a long time to speak to a representative. She also stated when pharmacy had to send medications out of stock at the facility, it took pharmacy four hours to deliver it, unless it was sent by satellite, in which case the medication was delivered a bit faster. The DON stated the facility's administrator knew about this issue. The facility policy titled, PROVIDER PHARMACY REQUIREMENTS, last revised in August of 2014, indicated, The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: 7) Providing routine and timely pharmacy service as contracted and emergency pharmacy service 24 hours per day, seven days per week. The facility policy titled, Recognition and Management of Pain, last revised in July of 2017 indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility policy titled, Pain Management, last revised in July of 2019, indicated, it is the policy of this facility that pain management is achieved through individualized recognition, assessment, treatments and monitoring of resident's needs through an interdisciplinary and holistic approach.