**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to develop and implement a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care for one (1) of sixteen (16) sampled residents (Resident #207). Resident #207 was admitted to the facility on the evening of 09/23/19 at approximately 8:00 PM, with diagnoses to include Fracture of Shaft of Humerus, Left Arm. However, there was no documented evidence the Baseline Care Plan dated 09/23/19, was developed and implemented to address the resident's Left Arm Fracture and associated pain. Upon admission, Physician's Orders were received for Percocet 10-325 milligrams (mg), one (1) tablet by mouth three (3) times a day PRN (as needed) related to the Left Humerus Fracture. Staff interview, and interview with Resident #207, revealed the resident was experiencing pain and requesting pain medication on 09/23/19 and 09/24/19, and the resident was treated with an ice pack to the affected arm. However, there was no documented evidence the resident received Percocet pain medication until 09/24/19 at 8:44 PM, which was over twenty-four (24) hours after admission. Furthermore, new Physician's Orders dated 09/25/19, were received for Percocet 10-325 mg, one (1) tablet every four (4) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. The Baseline Care Plan was revised on 09/26/19, with a focus of at risk for pain related to a diagnosis of Left Arm Fracture, with an intervention to administer pain medication as ordered by the Physician; however, the Baseline Care Plan was not implemented. According to the Controlled Drug Record, the resident received the last dose of the Percocet 10-325 mg on 09/29/19 at 9:50 AM, and did not receive another dose of the pain medication until 09/30/19 at 5:06 PM, which was approximately thirty-one (31) hours later. Resident #207 complained, he/she requested pain medication and was experiencing a high level of pain during the timeframes in which the pain medication was unavailable. (Refer to F-697 and F-755) The Findings Include: Interview with the DON on 10/04/19 at 8:42 AM revealed the facility did not have a policy related to Baseline Care Plans. 1. Review of Resident #207's medical record revealed the facility admitted the resident on 09/23/19, with diagnoses to include Unspecified Fracture of Shaft of Humerus, Left Arm, Closed Fracture; Chronic Pain due to Trauma; and Parkinson's Disease. Resident #207's admission Minimum Data Set (MDS) Assessment was not completed at the time of the survey, due to the resident being newly admitted . Review of Resident #207's Baseline Care Plan, dated 09/23/19, revealed the resident could communicate easily and understood staff, and was alert and cognitively intact. Additional review revealed presence of pain was marked, No. There was no goal or evidence of interventions in place to address the resident's pain, although the resident had a diagnosis of Left Humerus Fracture and Chronic Pain due to Trauma, and Physician's Orders for Percocet PRN (narcotic pain medication). Review of the Admit/Readmit Screener dated 09/23/19 at 8:43 PM, revealed the resident was alert to person, place and situation. Additional review revealed Resident #207's pain intensity was documented as three (3) out of ten (10) on a rating scale of zero (00) to ten (10) with ten (10) being the highest level of pain. Further review revealed no documentation of the location, onset or duration, quality of the pain, coping, lifestyle effects or treatments on the document. Observation of Resident #207, on 10/01/19 at 5:05 PM, revealed the resident was in bed and had a sling in place to his/her left arm. Interview with Resident #207 during this observation, revealed he/she was prescribed Percocet 10 mg and was used to taking the medication four (4) times a day. Further, the prescribed Percocet was not available the first twenty-four (24) hours after admission to the facility, although he/she requested the medication on 09/23/19 and 09/24/19 for pain in his/her left arm. Additional interview revealed he/she received the Percocet last Sunday morning (09/29/19), and then there was no more Percocet available until Monday (09/30/19), at around 5:00 PM. Subsequent interview with Resident #207, on 10/03/19 at 8:33 AM, revealed going without pain medication for his/her fractured arm during his/her stay at this facility was Ridiculous. Further interview revealed when he/she had to go a day without pain medication he/she was hurting really bad. Per interview, his/her pain level was a seven (7), an eight (8), or a nine (9), on a scale of one (1) to ten (10), with ten (10) being the highest level of pain when he/she had to go without the pain medication during his/her stay at the facility. Review of Resident #207's Order Recap Report, revealed orders dated 09/23/19, for Oxycodone/Acetaminophen (Percocet) 10/325 mg, one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Review of Resident #207's Medication Administration Record (MAR), dated September 2019, revealed orders for Percocet 10-325 mg, one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm, Closed Fracture, with a start date of 09/23/19 at 8:00 PM. However, further review of the MAR, revealed there was no PRN Percocet 10-325 milligram signed out as administered on 09/23/19 or 09/24/19. (This MAR which revealed the time as 8:00 PM, which was the first documented time in the medical record to indicate the time the resident was admitted to the facility). Additional review of the MAR, revealed orders for Percocet 5-325 mg, two (2) tablets by mouth one (1) time only with a start date of 09/24/19 at 6:30 PM. According to the MAR, the resident received the one (1) time dose on 09/24/19 at 8:44 PM. This was the first dose of the Percocet medication Resident #207 received since the resident was admitted on [DATE] at approximately 8:00 PM, revealing the resident went over twenty-four (24) hours without pain medication. The Pharmacy correspondence, dated 10/04/19 at 12:38 PM, revealed the prescription for Oxycodone-Acetaminophen 10/325 mg for one (1) tablet PO TID PRN was received on 09/24/19 at 2:22 PM, and the medication was delivered to the facility on [DATE] at 2:32 AM. Interview with Licensed Practical Nurse (LPN) #2, on 10/03/19 at 6:25 PM and 10/04/19 at 11:44, revealed she admitted Resident #207 sometime after 7:00 PM on 09/23/19. Per interview, she received the Discharge Summary from the transferring hospital, which included the list of discharge medications upon the resident's admission and verified Physician's Orders with the Physician via phone. Further, she entered the orders into the point click care electronic medical record, which was then automatically electronically transferred to pharmacy. She stated she then faxed the prescription sent by the hospital for the resident's Oxycodone/Acetaminophen to pharmacy. Continued interview with LPN #2, revealed Resident #207 did ask for an ice pack for his/her shoulder after admission on [DATE], and was persistent about it, but she could not remember if the resident was in pain or if the resident requested pain medication. She stated the resident's Percocet medication was not delivered by pharmacy and she did not call pharmacy in an attempt to get a code in order to get the Percocet out of the Nexsys the evening of the resident's admission. LPN #2 stated when she left around 10:00 PM on 09/23/19, the resident's Percocet pain medication had not yet arrived from pharmacy. Interview with State Registered Nurse Aide (SRNA) #3, on 10/04/19 at 5:00 PM, revealed he was working the evening Resident #207 was admitted to the facility on [DATE] from 3:00 PM to 11:00 PM, and recalled the resident being in pain and requesting pain medication. Further, SRNA #3 stated Resident # 207 would ask every three (3) to four (4) hours for pain medicine as he/she was in pain, but the pain medication was unavailable. Continued interview revealed staff used ice packs on the resident's affected arm. Interview on 10/04/19 at 4:30 PM, with SRNA #1, revealed she was working the night Resident #207 was admitted to the facility, and she recalled the resident was in pain. However, she could not recall if the resident received any pain medication. Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed Resident #207 asked for pain medication and had grimacing on his/her face when she arrived at work on 09/24/19, at 2:00 PM. LPN #1 further stated the Registered Nurse (RN) Supervisor was trying to get the code for the Nexsys from pharmacy in order to obtain Percocet pain medication for the resident due to the pharmacy not receiving the prescription. Interview with the RN Supervisor, on 10/03/19 at 6:25 PM, revealed Resident #207 was requesting pain medication on 09/24/19, and after the Director of Nursing (DON) refaxed the prescription for Percocet to pharmacy, she (RN Supervisor) called the pharmacy and was informed Resident #207's Percocet would not be delivered until 10:00 PM or 11:00 PM that night. The RN Supervisor further stated she had to call the Physician to obtain orders for a one (1) time dosage of two (2) Percocet 5/325 tablets. She further stated she then called Pharmacy to get the code to the Nexsys in order to obtain the medication. Interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed facility pharmacy did not receive the prescription for Oxycodone/Acetaminophen for Resident #207 until 09/24/19 at 2:22 PM. Per interview, the prescription was for Oxycodone/Acetaminophen 10/325 tablets, give one (1) tab TID or five (5) days PRN for mild to severe pain for fifteen (15) doses and the pharmacy delivered twelve (12) tablets to the facility on [DATE] at 2:32 AM. Continued interview revealed the pharmacy received a verbal order to get a one (1) time emergent dose for Resident #207 for two (2) tablets of Oxycodone 5/325 mg on 09/24/19 at 5:25 PM, and the facility obtained the medication from the Nexsys. 2. Additional review of Resident #207 medical record revealed an Order Summary Report, including new Physician's Orders dated 09/25/19 for Oxycodone/Acetaminophen 10-325 mg, give (1) one tab every four (4) hours PRN pain related to Fracture of Shaft of Humerus Left Arm. Review of Resident #207 revised Baseline Care Plan, dated 09/26/19, revealed the resident was at risk for pain due to diagnosis of left arm fracture. Continued review revealed a goal stating the resident would not have any unaddressed episodes of pain. Interventions included administer pain medication as ordered by the Physician; monitor for effectiveness; and observe for nonverbal signs of pain. Review of Resident #207's MAR, dated September 2019, revealed orders for Percocet tablet 10-325 mg, give one (1) tablet by mouth every four (4) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Further review of the MAR, revealed Resident #207 received the medication on 09/29/19 at 9:50 AM, for a pain level of seven (7) out of ten (10). According to the Controlled Drug Record, this dose was the last dose of the medication available, and was signed out by LPN #1. Continued review of the September 2019 MAR, revealed Resident #207 was not administered another dosage of Oxycodone-Acetaminophen tablet 10-325 mg until 09/30/19 at 5:06 PM, for a pain level of eight (8) out of ten (10). Therefore, the resident went approximately thirty-one (31) hours between doses of the PRN Percocet pain medication, indicating the Baseline Care Plan was not implemented. Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed she thought she reordered the Oxycodone for Resident #207 when she administered the last dose of the medication on 09/29/19 at 9:50 AM; however, she could not remember for sure. She stated she left work on 09/29/19 at 2:00 PM and another nurse was working on obtaining the prescription; however, she could not recall which nurse. Further, she stated Resident #207's medication should have been reordered and the prescription obtained prior to the medication running out. Additional interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed the facility did not request the re-order for Percocet for Resident #207 until 09/29/19 at 9:17 AM. Per interview, at that time the facility was notified a new prescription was required because the facility had already changed the order in the electronic system to dose every four (4) hours PRN. Further, pharmacy did receive the prescription on 09/30/19 at 8:54 AM, for Percocet 10/325 mg one (1) tablet every four (4) hours PRN, and the medication was delivered to the facility on [DATE] at 4:56 PM. Interview with the MDS Coordinator, on 10/04/19 at 4:43 PM, revealed the admission nurse starts the Baseline Care Plan as it was autopopulated by the computerized system. Further, the Baseline Care Plan was reviewed in the morning meeting by the Interdisciplinary Team (IDT) to ensure it was accurate. Further, interview revealed there were no interventions on Resident #207's Baseline Care Plan dated 09/23/19, but the Baseline Care Plan needed to have interventions to ensure necessary care was delivered by the nurses and SRNAs until the Comprehensive Care Plan was developed. Further interview revealed Resident #207's Baseline Care Plan update on 09/26/19 did have interventions related to administering pain medications as ordered; and she acknowledged the resident's Care Plan was not implemented. Per interview, the resident did not have medication available to administer upon request on admission and also for a timeframe between 09/29/19 and 09/30/19. Interview with the DON, on 10/04/19 at 8:42 AM, and on 10/04/19 at 7:47 PM, revealed it was unacceptable for the resident to wait over twenty-four (24) hours after admission to receive PRN pain medication if requested. Further, she was unaware Resident #207's Oxycodone pain medication was unavailable from 09/29/19 at 9:50 AM until 09/30/19 at 5:06 PM, until this Survey, and this was unacceptable. The DON, reviewed Resident #207's Baseline Care Plan, and acknowledged it did not address the resident's pain on admission, 09/23/19, even though the resident was admitted with a Fractured Arm. Further, the DON acknowledged the Baseline Care Plan interventions added on 09/26/19 were not implemented related to administration of pain medication. Interview with the Administrator on 10/04/19 at 7:44 PM, revealed staff was to deliver care as per Physician's Orders. Further, she acknowledged the Baseline Care Plan should be developed and implemented in order to provide a guideline for staff in delivery of care. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure pain management was provided to residents who require such services for one (1) of sixteen (16) sampled residents (Resident #207). Resident #207 was admitted to the facility on [DATE] at approximately 8:00 PM, and Physician's Orders were obtained for Oxycodone/Acetaminophen (Percocet) 10-325 milligrams (mg), one (1) tablet PO TID (by mouth three (3) times a day) PRN (as needed) related to a Closed Fracture of the Left Humerus. However, there was no documented evidence the resident received any pain medication until 09/24/19 at 8:44 PM, after orders were received for a one (1) time dose of Percocet 5-325 mg, two (2) tablets. Staff interviews revealed the resident did request the PRN Percocet pain medication after admission, and an ice pack was used to treat the resident's pain due to the medication being unavailable. Resident #207 went over twenty-four (24) hours after admission without the ordered Percocet pain medication, while experiencing pain in the left arm. In addition, new Physician's Orders dated 09/25/19 were received for Oxycodone/Acetaminophen, 10-325 mg, one (1) tablet every four (4) hours PRN for pain related to Fracture of Shaft of Humerus Left Arm for Resident #207. Per the Controlled Drug Record, the resident received the last dose of the medication on 09/29/19 at 9:50 AM. However, the facility failed to ensure the medication was re-ordered and a prescription was obtained timely. There was no documented evidence the resident received the medication from 09/29/19 at 9:50 AM, until 09/30/19 at 5:06 PM, which was approximately thirty-one (31) hours later. Interview with Resident #207, revealed he/she was experiencing a high level of pain during the time periods in which the pain medication was unavailable. (Refer to F-655 and F-755) The findings include: Interview with the Administrator, on 10/03/19 at 2:03 PM, revealed the facility did not have a policy related to pain management; however, she stated it was her expectation residents were on an effective pain regimen. 1. Review of Resident #207's medical record revealed the facility admitted the resident on 09/23/19 with diagnoses including Unspecified Fracture of Shaft of Humerus, Left Arm, Closed Fracture; Chronic Pain due to Trauma; Seizures; and Parkinson's Disease. Resident #207's admission Minimum Data Set (MDS) Assessment was not completed at the time of the survey, as the resident was newly admitted . Review of the Baseline Care Plan, dated 09/23/19, revealed the resident could communicate easily and understood staff, and was alert and cognitively intact. Further review revealed presence of pain was marked No. There was no goal or evidence of interventions in place related to pain, although the resident had a diagnosis of Left Humerus Fracture and Chronic Pain due to Trauma, and Physician Orders for PRN (as needed) pain medication (Oxycodone/Acetaminophen). Review of the Admit/Readmit Screener dated 09/23/19 at 8:43 PM, revealed Resident #207 was alert to person, place and situation. Further review revealed Resident #207's pain intensity was documented as three (3) out of ten (10) on a rating scale of zero (00) to ten (10) with ten (10) being the highest level of pain. Additional review revealed no documentation of the location, onset or duration, quality of the pain, coping, lifestyle effects or treatments on the document. Observation of Resident #207, on 10/01/19 at 5:05 PM, revealed the resident was in bed with family identified as the resident's spouse, at the bedside. Resident #207 was observed with a sling in place to his/her left arm. Interview with Resident #207 during this observation, revealed he/she was prescribed Percocet 10 mg and was used to taking the medication four (4) times a day. Continued interview with Resident #207, revealed the prescribed Percocet was not available the first twenty-four (24) hours after admission to the facility, although he/she requested the medication on 09/23/19 and 09/24/19 for pain in his/her left arm. Resident #207 stated the nurses told him/her the Physician's Orders for pain medication had been sent to pharmacy, but the medication was not delivered. Further interview revealed he/she received the Percocet last Sunday morning (09/29/19) and then there was no more Percocet available until Monday (09/30/19) at around 5:00 PM. Additional interview revealed the facility staff told him/her they were waiting on pharmacy to deliver the medication. Subsequent interview with Resident #207, on 10/03/19 at 8:33 AM, revealed during the times his/her pain medications were not available, after admission, and also between 09/29/19 and 09/30/19, he/she was in a lot of pain. Per interview, he/she could take a lot of pain as he/she had been in car wrecks and worked construction, and was tough, but going without pain medication for his/her fractured arm during his/her stay at this facility was Ridiculous. Further, when he/she had to go a day without pain medication he/she was hurting really bad. The resident stated his/her pain level was a seven (7), an eight (8), or a nine (9), on a scale of one (1) to ten (10), with ten (10) being the highest level of pain when he/she had to go without the pain medication during his/her stay at the facility. Review of Resident #207's Hospital Discharge Summary, from the transferring hospital, printed on 09/23/19 at 3:39 PM, revealed a list of discharge medications including Percocet 10/325 mg one (1) tablet PO TID PRN. (by mouth three (3) times a day as needed). Review of Resident #207's Order Recap Report, revealed orders dated 09/23/19, for Oxycodone/Acetaminophen 10/325 mg, give one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Review of Resident #207's Medication Administration Record (MAR), dated September 2019, revealed the resident was ordered Percocet 10-325 mg, one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm, Closed Fracture, with a start date of 09/23/19 at 8:00 PM. However, further review of the MAR, revealed there was no PRN Percocet 10-325 milligram administered on 09/23/19 or 09/24/19. (This MAR which revealed a time of 8:00 PM, was the first documented time in the medical record to indicate the time the resident was admitted to the facility). Additional review of the MAR, revealed orders for Percocet (Oxycodone-Acetaminophen) tablet 5-325 mg, two (2) tablets by mouth one (1) time only with a start date of 09/24/19 at 6:30 PM. Per the MAR, the resident received the one (1) time dose on 09/24/19 at 8:44 PM. This was the first dose of the Percocet medication received since admission on [DATE] at approximately 8:00 PM, revealing the resident went over twenty-four (24) hours without pain medication. (There was no documentation to indicate the resident's pain level at the time this dose was administered). Review of the written Pharmacy correspondence, dated 10/04/19 at 12:38 PM, revealed the prescription for Oxycodone-Acetaminophen 10/325 mg for one (1) tablet PO TID PRN was received on 09/24/19 at 2:22 PM, and the medication was delivered to the facility on [DATE] at 2:32 AM. Interview with Licensed Practical Nurse (LPN) #2, on 10/03/19 at 6:25 PM and 10/04/19 at 11:44, revealed Resident #207 arrived sometime after 7:00 PM on 09/23/19, and she completed his/her admission. Per interview, she received the Discharge Summary from the transferring hospital, which included the list of discharge medications upon the resident's admission. She stated she talked to the facility Physician to verify medications before entering the resident's Physician's Orders into the point click care electronic medical record, which was then automatically electronically transferred to pharmacy. Further, the hospital sent a prescription for the resident's Oxycodone/Acetaminophen and she faxed this prescription to pharmacy the evening of the resident's admission. Continued interview with LPN #2, revealed the transferring facility called a report in related to Resident 207, but when she was to the nurse at the transferring hospital, she did not receive a clear answer as to what time the resident received the last doses of his/her medications. Per interview, the transferring hospital did not send the MAR, and therefore she did not know when the resident last received his/her medications, including Percocet. LPN #2 stated she did not think to ask the facility Physician if she should administer Resident #207's evening doses of medications once delivered from pharmacy or obtained from the Nexsys (emergency box), and she did not administer any medication to the resident on her shift, 09/23/19. Continued interview with LPN #2, revealed new admission's orders were automatically Stat orders and if a controlled drug was ordered, staff was to get the controlled drug from the Nexsys. She stated facility staff had to call the pharmacy to obtain a code number to enter into the Nexsys in order to obtain controlled medications, and pharmacy needed the prescription before they could give out the code. Per interview, if Resident #207's medications were not delivered from pharmacy on the night shift after the resident's admission, the night nurse should have pulled the resident's medications from Nexsys for the night doses, or called pharmacy to have the medications sent Stat. Continued interview with LPN #2, revealed Resident #207 did ask for an ice pack for his/her shoulder after admission on [DATE] and was persistent about it, but she could not recall if the resident was in pain or if the resident requested pain medication. Per interview, she did not call pharmacy in an attempt to get a code in order to get the Percocet out of the Nexsys the evening of the resident's admission. LPN #2 stated she left around 10:00 PM on 09/23/19, and the resident's Percocet pain medication had not yet arrived from pharmacy when she left. She stated she completed the admission paperwork, verified the orders with the Physician, entered the orders in the electronic record, and then went home. Interview with State Registered Nurse Aide (SRNA) #3, on 10/04/19 at 5:00 PM, revealed he was working the evening Resident # 207 was admitted to the facility on [DATE] from 3:00 PM to 11:00 PM, and was assigned to the resident that evening. Further interview revealed he recalled the resident being in pain and requesting pain medication. SRNA #3 stated he remembered the nurses saying they were waiting to get pain medication from the pharmacy. Further, SRNA #3 stated Resident # 207 would ask every three (3) to four (4) hours for pain medicine as he/she was in pain. Per interview, staff used ice packs on the resident's affected arm. Interview on 10/04/19 at 4:30 PM, with SRNA #1, revealed she was working the night Resident #207's was admitted to the facility. Additional interview revealed Resident #207 was having pain, but she could not recall the pain being severe. Per interview, she could not recall if the resident received any pain medication. Interview with LPN #4, on 10/03/19 at 6:25 PM, revealed she was assigned to the resident on 09/24/19 when the pharmacy called and said they did not receive the prescription for Resident #207's pain medication. LPN #4 stated she then faxed the prescription from the nurse's station fax machine and later realized the faxes were not going through. She stated the Director of Nursing (DON) then refaxed the prescription to the pharmacy on 09/24/19. Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed Resident #207 asked for pain medication and had grimacing on his/her face when she came in to work on 09/24/19, at 2:00 PM. LPN #1 stated the Registered Nurse (RN) Supervisor was trying to get the code for the Nexsys from pharmacy in order to obtain pain medication for the resident. Per interview, pharmacy said they did not get the prescription and had to call the Physician to get a prescription sent over to pharmacy. LPN #1 stated Resident #207 should have had pain medication available for administration as the resident was having pain related to his/her fractured arm. Interview with the RN Supervisor, on 10/03/19 at 6:25 PM, revealed Resident #207 was asking for his/her pain medication on 09/24/19. Per interview, after the DON refaxed the prescription for Oxycodone, she (RN Supervisor) called the pharmacy and was informed Resident #207's Percocet would not be delivered until 10:00 PM or 11:00 PM that night. The RN Supervisor further stated she then called the Physician to obtain orders for a one (1) time dosage of two (2) Percocet 5/325 tablets. She stated she then called Pharmacy to get the code to the Nexsys in order to obtain the medication. Interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed facility staff enters the orders into the electronic system and the pharmacy receives them electronically. Further, if the medication order was for a controlled drug, a prescription was needed in order to fill the medication. Per interview, the pharmacy did not receive the prescription for Oxycodone/Acetaminophen for Resident #207 until 09/24/19 at 2:22 PM. Per interview, the prescription was for Oxycodone/Acetaminophen 10/325 tablets, give one (1) tab TID or five (5) days PRN for mild to severe pain for fifteen (15) doses and twelve (12) tablets were delivered to the facility on [DATE] at 2:32 AM. Further interview revealed the pharmacy received a verbal order to get a one (1) time emergent dose for Resident #207 for two (2) tablets of Oxycodone 5/325 mg on 09/24/19 at 5:25 PM, and the facility obtained the medication from the Nexsys. 2. Further review of Resident #207 medical record revealed an Order Summary Report, including new Physician's Orders dated 09/25/19 for Oxycodone/Acetaminophen 10-325 mg, give (1) one tab every four (4) hours PRN pain related to Fracture of Shaft of Humerus Left Arm. Review of Resident #207's MAR, dated September 2019, revealed orders for Percocet tablet 10-325 mg, one (1) tablet by mouth every four (4) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Continued review of the MAR, revealed Resident #207 received the medication on 09/29/19 at 9:50 AM, for a pain level of seven (7) out of ten (10). Review of the Controlled Drug Record, revealed this dose was the last dose of the medication available, and was signed out by LPN #1. Additional review of the September 2019 MAR, revealed Resident #207 was not administered another dosage of Oxycodone-Acetaminophen tablet 10-325 mg until 09/30/19 at 5:06 PM, for a pain level of eight (8) out of ten (10). Therefore, the resident went approximately thirty-one (31) hours between doses of the PRN Percocet pain medication. Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed the nurses were to reorder the medication through the electronic medical record in the computerized system by pushing the re-order button on the electronic MAR, when the medication was getting low. Further, she thought she reordered the Oxycodone for Resident #207 when she administered the last dose of the medication on 09/29/19 at 9:50 AM; however, she could not remember for sure. She stated she left work on 09/29/19 at 2:00 PM and another nurse was working on obtaining the prescription, but she could not recall which nurse. However, she stated Resident #207's medication should have been reordered and the prescription obtained prior to the medication running out to ensure the medication was delivered from pharmacy promptly. Further interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed it was the facility's responsibility to send refill requests before the resident ran out of medication. Additional interview revealed the facility did not request the re-order for Oxycodone/Acetaminophen for Resident #207 until 09/29/19 at 9:17 AM, and at that time the facility was notified a new prescription was required because the facility had already changed the order in the electronic system to dose every four (4) hours PRN. Per interview, pharmacy did not receive the prescription until 09/30/19 at 8:54 AM, for Percocet 10/325 mg one (1) tablet every four (4) hours PRN, and the medication was delivered to the facility on [DATE] at 4:56 PM. Additional interview revealed if the pharmacy receives specific requests to deliver sooner than the normal delivery times, via Instant Message system or phone call, the pharmacy can make as special delivery. However, further interview revealed the facility did not put in a special request for the medication to be delivered sooner. Interview with the DON, on 10/04/19 at 8:42 AM, and on 10/04/19 at 7:47 PM, revealed when the facility received a new admission from the hospital, the nurse verified the Hospital Discharge Summary list of medications with the Physician by phone, then entered the Physician's Orders into the electronic record which was automatically electronically transmitted to pharmacy. The DON stated the Physician reconciled and signed off on the orders during their next visit. She stated for a controlled drug, the prescription needed to be faxed to the pharmacy. Further, upon a resident's admission to the facility, the nurse should check with the transferring facility to find out what time the residents received his/her last dose of medication in order to know when to start administration of medication. Per interview, the staff nurses should ensure medications were obtained from pharmacy or the Nexsys in a timely manner for administration. The DON reviewed Resident #207 MAR, and stated it was unacceptable for the resident to wait over twenty-four (24) hours after admission to receive PRN pain medication if requested. Per interview, it was not acceptable for a resident to have to suffer in pain and it could cause psychosocial harm. Continued interview with the DON, revealed any medication should be re-ordered prior to the medication running out. Per interview, the nurse should re-order the medication through the electronic system, which was automatically transmitted electronically to pharmacy. Per interview, if a prescription was needed for a controlled medication such as Percocet, pharmacy would inform the facility and the facility would contact the Physician who would send the prescription directly to pharmacy via phone application or via fax. Additional interview revealed she was unaware Resident #207's Oxycodone pain medication was unavailable from 09/29/19 at 9:50 AM until 09/30/19 at 5:06 PM, until this Survey. She stated Resident #207's Percocet controlled pain medication should have been ordered and a prescription sent to pharmacy prior to the resident running out of medication on 09/29/19. She further stated, staff could have called the Physician and asked them to order alternate medication or alternate dosages of the Percocet, which could have been obtained from the Nexsys system. The DON stated Resident #207's Attending Physician was out of the country and unavailable for interview. Interview with the Medical Director, on 10/04/19 at 1:00 PM, revealed it was important the admitting nurse clarify with the transferring facility the date and time in which a new admission received his/her last dose of medications. Per interview, this was important to ensure the new resident had continuity of care and received medications including PRN pain medications timely and as needed. Continued interview revealed it was his expectation, a new resident had pain medications available for administration. Per interview, it was also important for the nurses to ensure controlled pain medications such as Percocet were reordered timely to ensure the resident did not have to go without the pain medications. The Medical Director stated Physicians could send a script by phone application or write script and fax it to pharmacy if a new prescription was needed for a controlled medication. The Medical Director stated there was also the Nexsys system for emergency medications that could be utilized and this system did include controlled pain medications. Per interview, the facility should have ensured Resident #207 had pain medications available for administration as needed. Interview with the Administrator, on 10/04/19 at 7:44 PM, revealed it was her expectation facility staff follow the process to obtain medications and ensure residents received medications for pain as ordered. Continued interview revealed it was uncomfortable and possibly psychologically harmful for Resident #207 to not have pain medications available upon request and as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (2) of sixteen (16) sampled residents (Resident #32, and Resident #207). Although the facility admitted Resident #207 on 09/23/19 at approximately 8:00 PM, and Physician's Orders were obtained for Oxycodone/Acetaminophen (Percocet) 10-325 milligrams (mg), one (1) tablet PO TID (by mouth three (3) times a day) PRN (as needed) related to a Closed Fracture of the Left Humerus, there was no documented evidence the resident received any pain medication until 09/24/19 at 8:44 PM, when the resident received a one (1) time dose of Percocet 5-325 mg, two (2) tablets. Interviews with staff who cared for the resident during this timeframe, revealed the resident had requested pain medication and an ice pack was used to treat the pain to the resident's affected arm. Additionally, new Physician's Orders dated 09/25/19 were received for Oxycodone/Acetaminophen (Percocet) 10-325 mg, one (1) tablet every four (4) hours PRN for pain related to Fracture of Shaft of Humerus Left Arm for Resident #207. According to the Controlled Drug Record, the resident received the last dose of the medication on 09/29/19 at 9:50 AM. However, there was no documented evidence the resident received the pain medication after 09/29/19 at 9:50 AM, until 09/30/19 at 5:06 PM, which was approximately thirty-one (31) hours later, due to the facility's failure to ensure the medication was reordered and a prescription obtained timely. Resident #207 complained of experiencing a high level of pain during the time the pain medication was unavailable. (Refer to F-655, and F-697) Furthermore, record review revealed Resident #32 missed three (3) consecutive scheduled doses of Ativan 0.5 milligrams (mg), as doses were not administered on 09/30/19 at 11:00 PM, and on 10/01/19 at 3:00 AM and 7:00 AM, due to the facility failing to reorder the medication and obtain a prescription for the medication. (Refer to F-656, and F-849) The findings include: Review of the facility Provider Pharmacy Requirements Policy, undated, revealed regular and reliable pharmaceutical service is available to provide residents with prescription and non prescription medications, services, and related equipment and supplies. The provider pharmacy agrees to provide routine and timely pharmacy service as contracted, and emergency pharmacy service twenty-four (24) hours per day, seven (7) days per week. Emergency or STAT medications are available for administration and all other new medication orders are received and available for administration as soon as possible on the next routine delivery, unless indicated otherwise by facility staff. Medications will be delivered by the primary pharmacy or back-up pharmacy, or are available from the emergency medication kit/back up medication supply. Interview on 09/30/19 at 8:54 AM with the Pharmacist, who worked for the Pharmacy utilized by the facility, revealed new orders were dispensed from Ohio, and if orders were received by 9:00 AM, the medication would leave pharmacy by Noon. Further interview revealed 4:00 PM was the second delivery and the next delivery was at 9:00 PM. Continued interview revealed refill or reorder requests received by 1:00 PM were dispensed that day and refills received after 1:00 PM were processed for the next day. Per interview, if the pharmacy received specific requests to deliver sooner, via Instant Message system or phone call, the pharmacy could deliver sooner. Further interview revealed any controlled medication such as Percocet or Ativan required a prescription in order for the medication to be filled and delivered. 1. Review of Resident #207's clinical record revealed the facility admitted the resident on 09/23/19 with diagnoses including Unspecified Fracture of Shaft of Humerus, Left Arm, Closed Fracture; Chronic Pain due to Trauma; and Parkinson's Disease. Observation of Resident #207, on 10/01/19 at 5:05 PM, revealed the resident was in bed and was observed to have a sling to his/her left arm. Interview with Resident #207 during this observation, revealed he/she was prescribed Percocet 10 mg and was used to taking the medication four (4) times a day. Continued interview revealed the prescribed Percocet was not available the first twenty-four (24) hours after he/she was admitted to the facility. Per interview, he/she did request the medication on 09/23/19 and 09/24/19 for the pain in his/her left arm, and he/she was informed by the nurses the Physician's Orders for his/her pain medication had been sent to pharmacy, but the medication was not delivered due to the facility changing pharmacies. Additional interview revealed he/she received the Percocet last Sunday morning (09/29/19) and then there was no more Percocet available until Monday (09/30/19) at around 5:00 PM. He/she stated the nurses informed him/her they were waiting on pharmacy to deliver the medication. Subsequent interview on 10/03/19 at 8:33 AM, with Resident #207, revealed during the times his/her Percocet was not available, after admission and also between 09/29/19 and 09/30/19, he/she was in a lot of pain. The resident stated he/she could take a lot of pain related to his/her fractured arm. Additional interview revealed when he/she had to go a day without any pain medication he/she was hurting really bad. The resident stated his/her pain level was a seven (7), an eight (8), or a nine (9), based on a scale of one (1) to ten (10), with ten (10) being the highest level of pain during the time he/she had to go without the pain medication while at the facility. Review of Resident #207's Hospital Discharge Summary, printed on 09/23/19 at 3:39 PM, revealed a list of discharge medications which included Percocet 10/325 mg, one (1) tablet PO TID PRN (by mouth three (3) times a day as needed). Review of Resident #207's Order Recap Report, revealed orders dated 09/23/19, for Oxycodone/Acetaminophen (Percocet) 10/325 mg, give one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Review of Resident #207's Medication Administration Record (MAR), dated September 2019, revealed orders for Oxycodone/Acetaminophen (Percocet) 10-325 mg one (1) tablet every eight (8) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm with a start date of 09/23/19 at 8:00 PM. However, further review of the MAR, revealed there was no PRN Percocet 10-325 milligram administered on 09/23/19 or 09/24/19. (This MAR revealing a time of 8:00 PM, was the first documented time noted in the medical record to indicate the time the resident was admitted to the facility). Additional review of the MAR, revealed orders for Oxycodone-Acetominophen (Percocet) tablet 5-325 mg, two (2) tablets by mouth one (1) time only with a start date of 09/24/19 at 6:30 PM. Per the MAR, the resident received the one (1) time dose on 09/24/19 at 8:44 PM. This was the first documented dose of Percocet medication received since admission on [DATE] at approximately 8:00 PM, revealing the resident went over twenty-four (24) hours without pain medication. (There was no documentation to indicate the resident's pain level at the time this dose was administered). Review of the written Pharmacy correspondence, dated 10/04/19 at 12:38 PM, revealed the prescription for Oxycodone-Acetaminophen 10/325 mg for one (1) tablet PO TID PRN was received on 09/24/19 at 2:22 PM, and the medication was delivered to the facility on [DATE] at 2:32 AM. Interview with Licensed Practical Nurse (LPN) #2, on 10/03/19 at 6:25 PM and 10/04/19 at 11:44, revealed Resident #207 arrived sometime after 7:00 PM on 09/23/19, and she completed his/her admission. Per interview, upon the resident's admission, she received the Hospital Discharge Summary which included the list of medications from the transferring hospital and called the Physician to verify Physician's Orders. Per interview, she then entered the orders into the point click care electronic medical record which was then automatically electronically transferred to pharmacy. Further, the hospital sent a prescription for the resident's Oxycodone/Acetaminophen and she faxed this prescription to pharmacy the evening of the resident's admission. Continued interview with LPN #2, revealed the transferring facility called a report in related to Resident 207, but when she was communicating with the nurse at the transferring hospital, she did not receive a clear answer as to what time the resident received the last doses of his/her medications, nor did the hospital send the resident's hospital MAR. She stated she was unsure when the resident last received his/her last dose of pain medication at the hospital. LPN #2 stated she did not think to ask the facility Physician if she should administer Resident #207's evening doses of medications once delivered from pharmacy or obtained from the Nexsys (emergency box), and she did not administer any medication to the resident on her shift, 09/23/19. Continued interview with LPN #2, revealed new admission's orders were automatically Stat orders and if a controlled drug was ordered, staff was to get the controlled drug from the Nexsys. She stated facility staff had to call the pharmacy to obtain a code number to enter into the Nexsys in order to obtain controlled medications, and pharmacy needed the prescription before they could give out the code. Per interview, if Resident #207's medications were not delivered from pharmacy on the night shift after the resident's admission, the night nurse should have pulled the resident's medications from Nexsys for the night doses, or called pharmacy to have the medications sent Stat. Continued interview with LPN #2, revealed Resident #207 did ask for an ice pack for his/her shoulder after admission on [DATE] and was persistent about it, but she could not recall if the resident was in pain or if the resident requested pain medication. Per interview, she did not call pharmacy in an attempt to get a code in order to get the Percocet out of the Nexsys the evening of the resident's admission. LPN #2 stated she left around 10:00 PM on 09/23/19, and the resident's Percocet pain medication had not yet arrived from pharmacy when she left. She stated she completed the admission paperwork, verified the orders with the Physician, entered the orders in the electronic record, and then went home. Interview with State Registered Nurse Aide (SRNA)#3, on 10/04/19 at 5:00 PM, revealed he was working the evening the resident was admitted on [DATE] from 3:00 PM to 11:00 PM and was assigned to the resident. He stated he did recall Resident #207 being in pain and requesting pain medication. SRNA #3 stated he remembered the nurses saying they were waiting to get pain medication from the pharmacy. Further, SRNA #3 stated Resident #207 would ask every three (3) to four (4) hours for pain medicine as he/she was in pain. Per interview, staff used ice packs on the resident's affected arm. Interview on 10/04/19 at 4:30 PM, with SRNA #1, revealed she was working the night of Resident #207's admission to the facility. Further interview revealed Resident #207 was having pain, but she could not recall the pain being severe. Per interview, she could not recall if the resident received pain medication. Interview with LPN #4, on 10/03/19 at 6:25 PM, revealed she was assigned to Resident #207 on 09/24/19 when the pharmacy called and said they did not receive the prescription for the resident's Percocet medication. LPN #4 stated she then faxed the prescription from the nurse's station fax machine and later realized the faxes weren't going through. She stated the Director of Nursing (DON) then refaxed the prescription to the pharmacy on 09/24/19. (A copy of the faxes sent to the pharmacy on 09/24/19 for Resident #207's Percocet was requested; however, not submitted for review) Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed Resident #207 asked for pain medication and had grimacing on his/her face when she came in to work on 09/24/19, at 2:00 PM. LPN #1 stated RN Supervisor was trying to get the code for the Nexsys from pharmacy in order to obtain pain medication for the resident. Per interview, pharmacy said they did not get the prescription and the RN Supervisor had to call the Physician to get a prescription sent over to pharmacy. LPN #1 stated Resident #207 should have had pain medication available for administration as the resident was having pain related to his/her fractured arm. Interview with the Registered Nurse (RN) Supervisor, on 10/03/19 at 6:25 PM, revealed Resident #207 was asking for his/her pain medication on 09/24/19. Per interview, after the DON refaxed the prescription for Oxycodone on 09/24/19, she (RN Supervisor) called the pharmacy and was informed Resident #207's Percocet would not be delivered until 10:00 PM or 11:00 PM that night. The RN Supervisor further stated she then called the Physician to obtain orders for a one (1) time dosage of two (2) Percocet 5/325 mg tablets. Per interview, she then called Pharmacy to get the code to the Nexsys in order to obtain the medication. Interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed the pharmacy began services with the facility on 08/29/19. Per interview, for this facility, staff enters the orders into the electronic system and the pharmacy receives them electronically. Continued interview revealed if the medication order was for a controlled drug, a prescription was needed in order to fill the medication. Per interview, the pharmacy did not receive the prescription for Oxycodone/Acetaminophen for Resident #207 until 09/24/19 at 2:22 PM. Per interview, the script was for Oxycodone/Acetaminophen 10/325 tablets, give one (1) tab TID for five (5) days as needed for mild to severe pain for fifteen (15) doses. Per interview, twelve (12)tablets were delivered to the facility on [DATE] at 2:32 AM. Further interview revealed the pharmacy received a verbal order to get a one (1) time emergent dose for Resident #207 for two (2) tablets of Oxycodone 5/325 mg on 09/24/19 at 5:25 PM, and the facility obtained the medication from the Nexsys. 2. Further review of Resident #207's clinical record revealed an Order Summary Report, including new Physician's Orders, dated 09/25/19, for Oxycodone/Acetaminophen 10-325 mg, give (1) one tablet every four (4) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Review of Resident #207's MAR, dated September 2019, revealed orders for Percocet tablet 10-325 mg, one (1) tablet by mouth every four (4) hours PRN for pain related to Fracture of Shaft of Humerus, Left Arm. Continued review of the MAR, revealed Resident #207 received the medication on 09/29/19 at 9:50 AM, for a pain level of seven (7) out of ten (10). Review of the Controlled Drug Record, revealed this dose was the last dose of the medication available and it was signed out by LPN #1. Additional review of the September 2019 MAR, revealed Resident #207 was not administered another dosage of Oxycodone-acetaminophen tablet 10-325 mg until 09/30/19 at 5:06 PM, for a pain level of eight (8) out of ten (10). Thus, the resident went approximately thirty-one (31) hours between doses of the PRN Percocet pain medication. Interview with LPN #1, on 10/04/19 at 11:12 AM, revealed when medication was getting close to running out, the nurses were to reorder the medication through the electronic medical record in the computerized system by pushing the re-order button on the electronic MAR. LPN #1 stated she thought she reordered the Oxycodone for Resident #207 when she administered the last dose of the medication on 09/29/19 at 9:50 AM; however, she could not remember for sure. Further, she left work on 09/29/19 at 2:00 PM, and another nurse was working on obtaining the prescription, but she could not recall which nurse. However, she stated the medication should have been ordered and the prescription obtained prior to the medication running out to ensure the medication was delivered from pharmacy timely. Further interview with the Pharmacist, on 09/30/19 at 8:54 AM and 10/04/19 at 9:40 AM, revealed in order to obtain refills for controlled drugs such as Oxycodone/Acetaminophen, pharmacy would send a Controlled Form to the prescriber or the facility per the prescriber's request. Per interview, it was the facility's responsibility to send refill requests before the resident ran out of medication. Additional interview revealed the facility did not request the re-order for Oxycodone/Acetaminophen for Resident #207 until 09/29/19 at 9:17 AM, and at that time the facility was informed a new prescription was required because the facility had already changed the order in the electronic system to dose every four (4) hours PRN. Per interview, pharmacy did not receive the prescription until 09/30/19 at 8:54 AM, for Percocet 10/325 mg one (1) tablet every four (4) hours PRN, and the medication was delivered to the facility on [DATE] at 4:56 PM. Further interview revealed the facility did not put in a special request for the medication to be delivered sooner. Interview with the Director of Nursing (DON), on 10/04/19 at 8:42 AM, and on 10/04/19 at 7:47 PM, revealed when the facility received a new admission from the hospital, the nurse reviewed the Hospital Discharge Summary list of medications with the Physician by phone, then entered the orders into the electronic record which was automatically electronically transmitted to pharmacy. The DON stated the Physician reconciled the orders and signed off on the orders during their next visit. Further, for a controlled drug, the script needed to be faxed to pharmacy. Per interview, for a new admission, the facility nurse should check with the transferring facility to find out what time the resident last received his/her last dose of medication in order to know when to start administration of medication. The DON stated the staff nurses should ensure medications were obtained from pharmacy or the Nexsys in a timely manner for administration. Continued interview revealed Resident #207 was admitted on the very day the facility went live, and started using the computerized system, electronic record and that may be the reason there was confusion and a delay in receiving Resident #207's pain medications on admission. The DON reviewed Resident #207's MAR, and stated it was unacceptable for the resident to wait over twenty-four (24) hours after admission to receive PRN pain medication. Per interview, it was not acceptable for a resident to have to suffer in pain and it could also cause psychosocial harm. Continued interview with the DON, revealed any medication should be re-ordered prior to the medication running out. Per interview, the nurse should re-order the medication through the electronic system which was automatically transmitted electronically to pharmacy. She stated if a prescription was needed for a refill for a controlled medication such as Percocet, pharmacy would inform the facility and the facility would contact the Physician who would send the prescription directly to pharmacy via phone application or via fax. Additional interview revealed she was unaware Resident #207's Oxycodone pain medication was unavailable from 09/29/19 at 9:50 AM until 09/30/19 at 5:06 PM, until this Survey. She stated Resident #207's Percocet controlled pain medication should have been ordered and a prescription sent to pharmacy prior to the resident running out of medication on 09/29/19. She further stated, staff could have called the Physician and asked them to order alternate medication or alternate dosages of the Percocet which could have been obtained from the Nexsys system. The DON stated Resident #207's Attending Physician was out of the country and unavailable for interview. Interview with the Medical Director, on 10/04/19 at 1:00 PM, revealed it was important the admitting nurse clarify with the transferring facility the date and time in which a new admission received his/her last dose of medications. Per interview, this was important to ensure the new resident had continuity of care and received medications including PRN medications timely. Further, it was important for the staff nurses to follow through with pharmacy and the Physicians to ensure residents' medications were available for new admissions. Continued interview revealed it was also important for the nurses to ensure refills for controlled pain medications such as Percocet were reordered timely and a prescription obtained in order for the resident not to go without their pain medications. The Medical Director stated Physicians could send a prescription by phone application or write a prescription and fax it to pharmacy if a new prescription was needed for a controlled medication. Further, there was the Nexsys system for emergency medications that could be utilized and this system did include controlled pain medications. Per interview, the facility did have a challenge, with the new computer system and new pharmacy; however, the facility should have ensured Resident #207 had pain medications available for administration as needed. 3. Review of Resident #32's clinical record revealed the facility admitted the resident on 09/01/18 and readmitted the resident on 04/23/19 with diagnoses to include Atrial Fibrillation; Secondary Parkinsonism; Cognitive Communication Deficit, and Anxiety. Review of the Update to Care Plan, Hospice, dated 09/11/19, revealed Resident #32 had become a Hospice patient, with a goal that the resident, resident's family, nursing facility staff and Hospice staff and volunteers would work together to assure that the resident had quality end of life care. The interventions included the resident's medication was to be obtained from the facility; nursing facility staff to notify the Hospice Nurse with changes in the resident's level of comfort, be it pain or other symptoms; nursing staff from both agencies to communicate with each other to manage the pain and other symptoms in a timely manner; and if any questions arise, a Hospice Nurse can be contacted. Observation of Resident #32, on 10/01/19 at 12:44 PM, revealed the resident was in bed with his/her eyes closed and the resident's spouse was at the bedside. Interview with the resident's spouse during this observation revealed the resident did not receive his/her morning Ativan medication and the spouse was told pharmacy had not delivered the medication. Resident #32's spouse further stated the resident did get restless at times. Review of Resident #32's Order Summary Report, revealed active Physician's Orders dated 09/26/19, for Ativan Tablet 0.5 mg (Lorazepam) (anti-anxiety medication) give one (1) tablet every four (4) hours for anxiety. Review of Resident #32's September 2019 Medication Administration Record (MAR), revealed Ativan Tablet 0.5 mg, give one (1) tablet every four (4) hours for anxiety was scheduled at 3:00 AM, 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, and 11:00 PM. Continued review of the MAR, revealed the last dose of Ativan was administered on 09/30/19 at 7:00 PM, by LPN #1. Further review of the MAR, revealed no documented evidence Resident #32 received the scheduled Ativan dose at 11:00 PM on 09/30/19. According to the Controlled Drug Record (CDR), the Ativan 0.5 mg was last administered on 09/30/19 at 7:00 PM, and there was no Ativan available after this dose. Review of Resident #32's October 2019 MAR, revealed Ativan Tablet 0.5 mg, one (1) tablet every four (4) hours for anxiety was scheduled at 3:00 AM, 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, and 11:00 PM. However, review of the MAR, revealed no documented evidence the resident received the scheduled Ativan dose on 10/01/19 at 3:00 AM or 7:00 AM. Review of the Controlled Drug Record, revealed the resident received Ativan 0.5 mg on 10/01/19 at 12:00 Noon. Thus, the resident missed three (3) consecutive scheduled doses of Ativan 0.5 mg, as doses were not administered on 09/30/19 at 11:00 PM, and on 10/01/19 at 3:00 AM and 7:00 AM. Review of Resident #32's Progress Note, dated 10/01/19 at 3:37 AM, revealed the resident's Ativan medication had not arrived from pharmacy, and pharmacy stated they were waiting on a prescription. Further review of the Note, revealed a call was placed to the Physician on call, who stated she would send the prescription. Interview with Resident #32's Hospice Nurse, on 10/01/19 at 12:54 PM, revealed facility staff informed her today, Resident #32 missed Ativan medication due to pharmacy didn't deliver the medication. Additional interview revealed the facility had the medication in the emergency box Nexsys system, but couldn't obtain the medication because the facility had to have a code from pharmacy, and needed a prescription in order to get the code. Further, during her visit with Resident #32, the resident was pulling at his/her blanket and had a grimace on his/her face, and didn't look comfortable. The Hospice Nurse stated if she had known the resident did not have Ativan available for administration, she would taken measures to ensure the resident received the medication. Additional interview with the Hospice Nurse, on 10/02/19 at 12:08 PM, and 10/03/19 at 10:10 AM, revealed she contacted the Physician herself and obtained Resident #32's Ativan medication from a local pharmacy in time for the 11:00 AM dose on 10/01/19. She further stated it was a concern Resident #32 did not receive scheduled doses of Ativan for his/her anxiety. Interview on 10/04/19 at 11:12 AM, with LPN #1, revealed she reviewed Resident #32's MARs and identified she administered the last two (2) doses of Ativan to Resident #32 on 09/30/19. Further, she did not reorder the medication, but told another nurse (could not recall which nurse) the resident received the last two (2) pills of Ativan. LPN #1 further stated when she arrived at the facility the following day, on 10/01/19, at 2:00 PM, she was informed Hospice had brought in a bottle of Ativan for the resident. Further interview with LPN #1, revealed she was not assigned to the resident when he/she missed the doses of Ativan, and she did not know how many doses the resident missed. LPN #1 stated medications were re-ordered through the point click care computerized system and the order was automatically electronically transmitted to pharmacy. She further stated if a refill was needed for a controlled drug such as Ativan, there would need to be a new prescription, but she did not know if the Hospice Physician or the facility Physician was responsible for sending the prescription for the Ativan for Resident #32 who was a Hospice resident. Phone interview with the Pharmacist, on 10/04/19 at 9:18 AM, revealed a request for Resident #32's Ativan was received on 10/01/19 at 2:28 AM, and the pharmacy called the facility back at 3:32 AM, and advised a script was needed. The Pharmacist further stated there were no prior refill requests for the medication. The Pharmacist stated the Ativan medication was delivered to the facility on [DATE] at 12:56 AM. Additional interview revealed if the resident was routinely taking Ativan medication, the resident could become more anxious if the medication was missed. Interview with the Director of Nursing (DON), on 10/04/19 at 8:42 AM, revealed it was her expectation the facility nurses reorder medications and obtain prescriptions for medications in a timely manner for Hospice residents. Per interview, the process for reordering medications for Hospice residents was the same as ordering the medication for other residents. Further, she stated the Ativan medication for this resident could have been obtained from the Nexsys system once pharmacy received a prescription, or staff could have informed Hospice the medication was unavailable. Additional interview revealed review of Resident #32's MAR, indicated the resident missed the scheduled Ativan 0.5 mg dose on 09/30/19 11:00 PM dose, and also missed the 10/01/19 doses at 3:00 AM and at 7:00 AM. She stated this revealed the resident missed three (3) consecutive doses of Ativan which could cause an increase in anxiety and discomfort for this Hospice resident. Per interview, staff should have communicated with Hospice related to the resident not receiving the medication as scheduled. Further, the DON stated Resident #32's Attending Physician was out of the country and unable to be interviewed. Interview with the Medical Director, on 10/04/19 at 1:00 PM, revealed Resident #32 was a Hospice resident and was prescribed Ativan every four (4) hours scheduled. Per interview, missing doses of the medication could be a problem if the resident exhibited symptoms of anxiety. Continued interview revealed there was an emergency box (Nexsys) which could be utilized to obtain Ativan medication that had not been delivered from pharmacy, and also staff could utilize Hospice to ensure medications were obtained. Interview with the Administrator, on 10/04/19 at 7:44 PM, revealed it was her expectation the facility have an effective process in place to ensure medications were available to administer as ordered including routine and as needed medication. Per interview, it was uncomfortable and possibly psychologically harmful for Resident #207 to not have pain medications available upon request and as ordered. Further, Resident #32 should have received the scheduled Ativan as ordered for anxiety.