**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Observation of Resident #57, on 01/07/2020 at 9:12 AM, revealed the resident had oxygen on via nasal cannula at three (3) Liters per minute (3L/min) and a BI-PAP (Bilevel Positive Airway Pressure) machine sat atop the resident's closet. Observation of Resident #57, on 01/07/2020 at 3:18 PM, revealed the resident rested in bed, eyes closed without the BI-PAP machine on for use. The equipment was atop of the bed and was not administered during the resident's naptime. Resident #57's clinical record review revealed the facility readmitted the resident, on 11/16/2019, with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction, and Chronic Obstructive Pulmonary Disease. Resident #57's Quarterly Minimum Data Set review, dated 11/22/2019, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15) determining the resident was interviewable. The resident's functional status was determined to be extensive assistance with one (1) to two (2) staff for all activities of daily living (ADL). The facility determined the resident had shortness of breath with exertion, when sitting and at rest and received oxygen therapy. Resident #57's Minimum Data Set review dated 10/14/2019, revealed the Care Area Assessment triggered care planning for Activities of Living (ADL) function, Urinary Incontinence. Section O, Special Treatment Programs which included Oxygen and BI-PAP applications, as needed during daytime naps. Resident #57's Medication Administration Record (MAR) reviewed for September, November and January revealed nursing staff had not implemented the planned care related to administration of the BI-PAP, as planned. The order for the BI-PAP was not transcribed onto the October 2019 MAR and was not received for December of 2019. Further review revealed the resident had not received his/her showers as scheduled. Resident #57's shower sheet forms review, 11/29/2019 through 01/04/2020, revealed the resident only received six (6) of the twelve scheduled showers. Interview, on 01/07/2020 at 9:12 AM, with Resident #57, revealed he/she was supposed to wear a BI-PAP; however, the resident stated the equipment was placed on top of his/her closet. The resident stated the physician ordered for him/her to wear the equipment when he/she took a nap during the daytime and at night. Resident #57 stated he/she talked to the staff nurse, the Unit Manager and the Director of Nursing, about not getting the BI-PAP during nap times. The resident further stated, he/she had filed grievances with the facility about the BI-PAP, not receiving timely brief changes and not getting his/her showers as scheduled. Resident #57 stated because of the situation and as a last resort, in order to obtain the care and services, he/she filed a complaint with the State (State Survey Agency). Interview, on 01/10/2020 at 3:47 PM with CNA #10, revealed at times a lack of staff affected the residents care needs. She stated at times she could not provide the showers, or knew who was receiving a shower because of a lack of effective communication. CNA #12 stated Resident #57 was supposed to get a bed bath; however, she was not always sure who received a shower/bed bath and there was not always enough staff to provide it. She stated the resident sat in his/her soiled and wet brief at least twice a week when she came on shift and the resident had a right to complain. CNA #12 stated when there was a lack of staff, especially on the weekends, there were more falls and residents did not get the care. The CNA stated if staff followed the care plan and the policy there would not be as many complaints. Interview, on 01/10/2020 at 4:03 PM, with LPN #2 revealed she knew Resident #57 had a PRN BI-PAP order. However, she did not follow the policy or the order. Continued interview at 4:10 PM, revealed the facility did not have enough staff and there was a lack of oversight by facility leadership with reordering medications and at times there was only on pill left in the narcotic box. She further stated there was definitely an issue with the shower schedule for CNA's who did not know which resident got a shower and on what shift the showers should be provided. She stated the ADL policy was not followed and residents complained often about this. 5. Resident #135's thirty (30) day Minimum Data Set (MDS) review, dated 09/19/2019, revealed the facility assessed Resident #135 with a Brief Interview for Mental Status score of four out of fifteen (4/15) and determined the resident was cognitively severely impaired. The resident required total assistance with one (1) staff for bed mobility and surface to surface transfers. The facility assessed the resident had two (2) or more injury falls. Resident #135's Quarterly MDS review, dated 12/26/2019, revealed the facility assessed Resident #135 with a BIMS score of five out of fifteen (5/15), determining the resident was cognitively severely impaired. The resident required extensive assistance with two (2) staff for bed mobility and surface to surface transfers. The facility determined the resident had one (1) non-injury fall during this period. Resident #135's Comprehensive Care Plan review revealed a revised goal date of 12/27/2019, and the facility determined the resident was at risk for falls related to his/her gait/balance problems, incontinence and psychoactive drug use, vision/hearing problems and impaired cognition. The goal for the resident was to be free of falls through the next review on 04/20/2020. Interventions included to encourage the resident to lay down after lunch and as needed (PRN), keep his/her remote and call light within reach and encourage him/her to use it, prompt response to all requests for assistance, appropriate footwear and non-skid socks when ambulating or mobilizing in wheel chair. In addition, the facility planned to review information on past falls and attempt to determine the cause of falls, record possible root causes and educate the resident/family/caregivers/IDT as to the causes. However, interview with the Director of Nursing (DON) on, 01/10/2020 at 12:36 PM, revealed she could not locate the fall evaluation, post fall investigation, root cause, or the Interdisciplinary Team meetings (IDT) notes for Resident #135's falls, on 08/24/2019, on 09/01/2019, 09/06/19 and 11/07/2019. Resident #135's medical record review revealed the resident was readmitted to the facility on [DATE] with diagnoses including Essential Hypertension, Diabetes Mellitus, Unspecified Cerebral Infarction, Pneumonia, Enterocolitis due to Clostridium Difficile, Sepsis due to Enterococcus, Vascular Dementia and Bradycardia. Interview, on 01/10/2020 at 3:41 PM with CNA #10, revealed Resident #135 was confused and yelled out and really did not know what he/she needed, did not always know what the call light was used for and it was hard to know at times what the resident needed. However, she stated since the resident had many falls she thought staff had not checked adequately on him/her. CNA #10 stated staff needed to check on the resident when he/she yelled out. Interview, on 01/10/2020 at 2:59 PM, with CNA #11 revealed Resident #135 understood at times, and at times he/she did not understand. She stated the resident required monitoring and supervision and he/she fell because staff had not checked on the resident often enough. Interview, on 01/11/2020 at 10:24 AM, with MDS Coordinator #1, revealed it was not normal for Resident #135 to have frequent falls. However, she stated, with the resident's cognition it was hard to prevent the resident from getting up and somebody would have to stand right by his/her bed. She stated the facility was to keep residents as safe as possible. However, the resident was one you provided care for (him/her) and two (2) minutes later the resident tried to get up. She stated the care plan was updated each time a change in the resident's care occurred; and fall interventions were in place. The MDS Coordinator stated the resident's call light and non-skid socks could help prevent a fall; but one to one (1:1) supervision, one hundred (100%) of the time, would help more. MDS Coordinator #1 stated the care plan did not have interventions related to monitoring, although the facility had tried to put interventions in place. She further stated, when a patient fell the IDT team met, and as part of the IDT team, she reviewed Nurse's Notes and the care plan and put interventions in place. However, MDS Coordinator #1 stated, the DON followed up on the root cause for falls. Interview, on 01/11/2020 at 12:24 PM, with the Director of Nursing, revealed she could not locate the Post Fall/Trauma documentation for Resident #135, the IDT Notes or the root cause of the resident's falls. She stated she was not sure that the floor-nursing staff had received any training because the forms the facility was currently using came out around November. She stated she believed the forms she had reviewed were complete; however, if she felt information was missing she reached out to staff. 6. Resident #493's Physician's Order Sheet (POS) review, dated 01/01/2020, revealed the resident had orders including Lamotringe 100 milligram (mg) Tablet, by mouth (PO), two (2) times per day (BID) as related to diagnoses of Essential Tremor and Generalized Anxiety Disorder, Topiramate Tablet, 50 mg, one (1) time a day related to a diagnosis of Essential Tremor and Xanax Tablet, 2 mg, give one (1) every eight (8) hours as needed (PRN) related to a diagnosis of Essential Tremor and an order to administer 2 Liters of oxygen per minute (2L/Min) and keep the resident's oxygen saturation > 92% PRN as related to COPD via nasal cannula. Resident #493's admission Summary Note review, dated 01/01/2020 at 3:39 PM, revealed the facility admitted the resident around 2:00 PM. The note stated at the time of admission, the resident's lungs sounds were diminished, and his/her oxygen saturation was ninety-five percent (95%) on room air. In addition, the resident appeared to get Short of Air (SOA) with ambulation and the nurse reviewed all medications with the physician. Resident #493's MDS review, dated 01/06/2020, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen (13/15) determining the resident was interviewable. Further review revealed the resident had shortness of breath with exertion and was on oxygen therapy and received antianxiety medications. Review of Resident #493's Baseline Care Plan revealed the resident received oxygen therapy and, as needed (PRN) and psychotropic medications. Review of Resident #493's Pharmacy Delivery Manifest, dated 01/02/2020 at 12:44 PM, revealed Resident #493's medications, Lamotringe 100 mg, Topiramate 50 mg and Alpazaoalm (Xanax) 2 mg, had arrived at the facility. Review of Resident #493's Progress Note, dated 01/02/2020 at 12:45 PM, revealed the resident got his/her Xanax 2 mg administered, for the first time since his/her admission, on 01/01/2020 at approximately 2:00 PM. However, the resident had remained without his/her ordered medications for twenty-two hours and twenty-five (22 hrs 25m) minutes. Interview, on 01/06/2020 at 10:57 AM, with Resident #493 revealed the physician ordered Lamictal, Xanax and Topamax and he/she had not received these medication for thirty-six (36) hours. The resident further stated he/she made this concern known to the nurse at the desk and also told LPN #11 about his/her frustration. Resident #493 stated LPN #11 informed him/her the medications should arrive in about four (4) hours. However, at 10:00 PM, the medications had not arrived from the pharmacy. The resident stated, he/she, felt extreme anxiety, as he/she suffered from Congestive Obstructive Pulmonary Disease. Interview, on 01/11/2020 at 12:29 PM with the Director of Nursing (DON) revealed she discussed with the IDT what interventions were in place at the time of the fall and, if there was a need to put any additional interventions in place. She stated, after the IDT met the MDS Coordinator revised the care plan. The DON further stated, that during the weekend she directed staff to call her with any falls and she provided staff with direction to provide the care. She stated if the care plan was not revised then residents would not receive the resident specific care. Continued interview with the DON revealed she expected the staff to provide brief changes every two to three (2-3) hours when they made rounds. She stated, she expected nursing staff to document when they provided care, such as BIPAP administration. The DON stated she had identified omissions in the medical records and was looking to identify a trend. Interview, on 01/10/2020 at 4:55 PM, with the Administrator revealed he expected interventions related to falls to be in place, root cause analysis should be conducted, and they should review medications and find out if there was a trend at a certain time of day. Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to develop/implement the care plan for six (6) of thirty-two (32) sampled residents (Residents #34, #57, #91, #101, #135, and #493). Interviews and record review revealed the facility failed to administer pain medication as ordered and care planned, implement falls prevention interventions as care planned, and provide respiratory services as care planned. Review of Resident #34's Medication Administration Record (MAR), dated December 2019, revealed Percocet 10-325 mg was not administered on 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; or 12/16/2019 at 12:00 AM. Further review of the MAR revealed staff failed to assess the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM. Further review of Resident #101's clinical record revealed a Physicians Order, dated 09/27/2019, for Oxycodone-APAP 10-325 mg give one (1) tablet by mouth every four (4) hours for pain. Review of Resident #101's MAR, dated October 2019, revealed a total of fourteen (14) missed doses of Oxycodone-APAP. Continued review of the MAR, dated November 2019, revealed a total of six (6) missed doses of Oxycodone-APAP. The findings include: Review of the facility's policy, Care Plans, Comprehensive Person - Centered, revised December 2016, revealed a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The policy stated a comprehensive care plan for each resident would be developed within seven (7) days of completion of the required comprehensive assessment (MDS- Minimum Data Set). The policy further revealed the comprehensive, person-centered care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; and incorporate risk factors associated with identified problems. The person-centered care plan included measurable objectives and timetables that met the resident's physical, psychosocial and functional needs. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process included the resident's strength and needs and culture preferences. The IDT reviewed and updated the care plan when a resident had a significant change, when the desired outcome was not met, when a resident was readmitted to the facility from a hospital stay and quarterly, in conjunction with the required Quarterly Minimum Data Set (MDS) Assessment. 1. Review of Resident 91's clinical record revealed the facility admitted the resident on 03/18/2019 with diagnoses which included Dementia without Behavioral Disturbance, Atrial Fibrillation, and Type 2 Diabetes Mellitus. Review of Resident #91's Comprehensive Care Plan for Fall Risk, initiated 10/16/2019, revealed the resident was at risk for falls related to Dementia with confusion, incontinence, poor communication/comprehension, and poor safety awareness. Continued review revealed the goal of the care plan was the resident would have a reduced risk for falls and fall related injury. Interventions included assist with transfers and encourage/assist resident to wear non skid footwear. However, there was no intervention related to side rail assessment/safety. Observation, on 01/06/2020 at 11:22 AM, revealed Resident #91's side rail was not secured to the bed and was partially resting on the floor. Further observation revealed the resident attempted to move his/her legs over the broken rail. Interview with Certified Nursing Assistant (CNA) #2, on 01/06/2020 at 11:36 AM, revealed the broken side rail was a safety issue and could cause an accident. Interview with CNA #4, on 01/08/2020 at 9:08 AM, revealed the broken rail was a fall and trip hazard. Interview with LPN (Licensed Practical Nurse) #4, on 01/06/2020 at 11:28 AM, revealed the side rail appeared to be broken. She stated Resident #91 could potentially fall out of bed. Interview with LPN #2, on 01/10/2020 at 4:54 PM, revealed the nurses were responsible for completion of the Side Rail Assessment Screen when a resident was admitted . LPN #2 stated she was not sure of the facility's protocol for utilizing side rails. Interview with Licensed Practical Nurse #12, on 01/10/2020 at 2:47 PM, revealed the purpose of the care plan was to communicate resident care needs. Interview with the MDS Coordinator #1, on 01/11/2020 at 10:24 AM, revealed she reviewed the clinical record and diagnoses to develop the initial and comprehensive care plans. The MDS Coordinator stated the care plan communicated resident care needs. Interview with the Director of Nursing (DON), on 01/10/2020 at 5:04 PM, revealed she had not initiated any audits related to care plans. 2. Review of the facility's policy Pain Management, dated October 2018, revealed a plan of care would be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. Observation, on 01/07/2020 at 10:22 AM, revealed Resident #34 neatly groomed and seated on the bedside. Interview during the observation revealed the resident went two (2) days without pain medication because the facility let it run out. Review of the clinical record revealed the facility admitted Resident #34 on 10/28/2019 with diagnoses which included Low Back Pain, Radiculopathy, and Nontraumatic Compartment Syndrome of Unspecified Lower Extremity. Review of the 5-day Minimum Data Set (MDS) Assessment, dated 11/03/2019, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) and determined the resident was interviewable. Further review of the clinical record revealed a Physicians' Order, dated 11/06/2019, for Percocet 10-325 mg (Oxycodone-Acetaminophen, pain medication) give one (1) tablet by mouth every four (4) hours related to Nontraumatic Compartment syndrome of Unspecified Lower Extremity. Review of the Care Plan for Pain, revised 11/05/2019, revealed a goal that Resident #34 would verbalize adequate relief of pain. Interventions included administering pain medications as ordered; notifying the physician of unrelieved or worsening pain; observing and reporting changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion (ROM), withdrawal or resistance to care; observing for non-verbal pain; and providing the resident and family with information about pain and options available for pain management. Review of Resident #34's Medication Administration Record (MAR), dated December 2019, revealed Percocet 10-325 mg was not administered on 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; or on 12/16/2019 at 12:00 AM. Further review of the MAR revealed staff failed to assess the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM. Review of the Progress Notes, dated 12/14/2019 at 4:49 PM, revealed Resident #34's Percocet was not available. Further review of the Progress Notes revealed staff did not assess the resident's pain level, implement non-pharmacological interventions, or notify the physician to manage the resident's pain for the two (2) days the Percocet was unavailable. Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed non-pharmacological pain interventions would include applying a cold/warm compress, offering fluids or diversional activities. LPN #11 stated she should have assessed Resident #38's pain level, implemented non-pharmacological intervention(s), and probably should have notified the physician for a one-time order for pain medication; however, she was sometimes swamped and did not document everything. LPN #11 further revealed the resident could be in a lot of pain if their pain medication was not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed non-pharmacological interventions to manage pain could include deep breathing, repositioning, and positive visualization. She further revealed pain assessments and interventions should be documented in the progress notes. According to LPN #12, Resident #34 was very upset about not having pain medication available. Interview with LPN #4, on 01/09/2020 at 10:38 AM, revealed the care plan was not implemented if the prescribed services or medications were not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the care plan communicated the resident's care needs. LPN # 12 stated Resident #34's care plan was not implemented for pain management. 3. Observation, on 01/10/2020 at 10:33 AM, revealed Resident #101 seated at the bedside. Interview during observation revealed the resident's pain medication was sometimes not available. Review of the clinical record revealed the facility readmitted the resident on 03/25/2017 with diagnoses to include Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Primary Osteoarthritis. Review of the Quarterly Minimum Data Set, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Review of the Care Plan for Pain, revised 09/20/2019, revealed a goal the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included administer analgesia as per orders; monitor/record/report to nurse resident's complaints of pain or requests for pain treatment; and notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. Further review of the clinical record revealed a Physicians Order, dated 09/27/2019, for Oxycodone-APAP 10-325 mg give one (1) tablet by mouth every four (4) hours for pain. Review of the MAR, dated October 2019, revealed a total of fourteen (14) missed doses of Oxycodone-APAP on 10/02/2019, 10/04/2019, 10/07/2019, 10/09/2019, 10/11/2019, and 10/13/2019. Review of the MAR, dated November 2019, revealed a total of six (6) missed doses of Oxycodone-APAP on 11/20/2019, 11/21/2019, and 11/26/2019. Interview with Licensed Practical Nurse (LPN) #4, on 01/09/2020 at 10:38 AM, revealed pain could affect a resident's activities of daily living (ADL). The LPN further revealed the care plan was not implemented if the prescribed pain medication was not administered. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the purpose of the care plan was to communicate resident needs. The LPN stated the care plan was not implemented if medications were not administered to manage the resident's pain.

Based on interview, record review and policy review it was determined the facility failed to revise the plan of care to include dietary supplement recommendations in order to address identified weight loss for (1) of thirty-two (32) sampled residents (Resident #107). The findings include: Review of the undated policy, Goals and Objectives, Care Plans, revealed the care plan would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The care plan goals and objectives were defined as the desired outcome for a specific resident problem. When goals and objectives were not achieved the resident's documentation in the medical record would occur as to why they were not achieved and new goals and objectives would be established. Care plans would be modified accordingly. All disciplines would have access to the information and would be able to report whether or not the desired out comes were being achieved. The goals and objectives would be reviewed and revised when the resident had a significant change in condition, when the desired outcome was not achieved, when the resident was readmitted to the facility from a hospital and at least quarterly. Review of the facility's policy for Weight Assessment and Intervention, not dated, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. Assessment information would be analyzed by the multidisciplinary team and conclusions would be made regarding resident's target weight range, approximate calorie needs and medical condition. Review of the closed record for Resident #107, revealed the facility admitted the resident on 02/09/2009, and readmitted the resident on 10/21/2019, after a hospitalization. The resident had a history of Heart Failure, Acute Myocardial Infarction (heart attack), Chronic Kidney Disease and Diabetes. Review of Resident #107's Nutrition/Dietary Note, made on 11/26/2019, revealed the resident's weight was 104.1 pounds. The Dietary Note stated the resident had a significant weight change of 10.3 percent in thirty (30) days and a 10.3 percent weight loss in the last three months and 11.8 percent in six months. Further review revealed a recommendation for eight ounces of Nepro (a supplement), every day between meals, to provide additional Kilocalories and Protein. However, the supplement did not get transferred to the plan of care, nor to the Treatment or Medication Administration Record (TAR/MAR). Further review of the Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six (6) months. Review of Resident #107's Physician's Order Set for December 2019, revealed an order for staff to provide the resident eight ounces of the supplement, Glucerna, two times a day. However, no order was provided for the Dietitian's recommended eight ounces of Nepro (a supplement), every day between meals, to provide additional Kilocalories and Protein. On 01/10/2020 at 12:20 PM, interview with Certified Medication Technician (CMT) #1, revealed she did not know Resident #107 had experienced a weight loss. CMT #1 stated if the resident had an order for supplements they would be on the MAR/TAR. She stated she could not remember administering supplements to the resident. CMT #1 stated if the staff did not revise the plan of care then the recommended supplements would not be administered to address the identified weight loss and the resident could experience a decline. Interview with Licensed Practical Nurse (LPN) #15, on 01/11/2020 at 10:38 AM and 1:03 PM, revealed Resident #107 was a diabetic and small in stature. However, due to her being agency staff, she could not remember much more about the resident. LPN #15 stated the Interdisciplinary team revised resident care plans routinely. She stated the facility did not bring it to her attention the resident had a significant weight loss or additional supplements were recommended. Continued interview revealed there was nothing was on the MAR to alert her to this either. She stated she also did not review the plan of care, she just depended on the MAR to direct her in the care of the resident. LPN #15 stated if staff did not provide the recommended supplements the resident could experience a decline. Interview on 01/11/2020 at 12:55 PM, with the Director of Nursing (DON), revealed she had not identified that Resident #107's plan of care was not revised to reflect the recommended supplement of Nepro for the resident. She stated if the facility did not revise care plans to ensure the recommended dietary supplements were placed on the plan of care, residents could experience a decline. Interview with the Administrator, on 01/11/2020 at 2:03 PM, revealed he expected staff to revise care plans with dietary recommendations after a resident was identified with weight loss. He stated he was new to his role and was still in the process of evaluating the facility's system issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were provided medications in a timely manner for one (1) of thirty-two (32) sampled residents (Resident #493). The findings include: Review of the facility's policy, Administering Medications, dated April 2019, revealed medications were to be administered in a safe and timely manner, and as prescribed. Continued review revealed medications were only to be administered by licensed persons, or as permitted by the state, to prepare, administer and document the medication administration. According to the policy, medications were administered in accordance with the prescriber's orders to include the required time frame, and for the optimal therapeutic effect of the medication. Further review revealed this was performed to honor the resident's choices and preferences, consistent with his/her care plan. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering it was to initial the Medication Administration Record (MAR) in the space provided for the drug. Review of the facility's policy, Quality of Life - Accommodation of Needs, revised August 2009, revealed the facility's environment and staff's behaviors were directed towards assisting residents in maintaining and/or achieving independent function, dignity and well-being. Review of Resident #493's clinical record revealed the facility readmitted the resident on 01/01/2019 with diagnoses including, Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease (COPD) and Generalized Anxiety Disorder, Urinary Tract Infection Site not specified and Essential Tremor. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #493 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was interviewable. Further review revealed Resident #493 was assessed to have shortness of breath with exertion and was on oxygen therapy, and received antianxiety medications. Review of Resident 493's Physician Order Sheet (POS) dated 01/01/2020, revealed the resident had orders which included the following medications: Lamotringe (an anticonvulsant) 100 milligram (mg) tablet by mouth (PO) two (2) times per day (BID) related to a diagnosis of Essential Tremor and Generalized Anxiety Disorder; Topiramate (an anticonvulsant) tablet 50 mg one (1) time a day related to a diagnosis of Essential Tremor; and Xanax (an antianxiety) tablet 2 mg one (1) every eight (8) hours as needed (PRN) for diagnosis of Essential Tremor. In addition, further review of the Physician's Order Sheet revealed an order for Oxygen (O2) to be administered at two (2) liters (L) of oxygen per minute (2L/Min) via nasal cannula as needed (PRN), to keep the resident's oxygen saturation level greater than (>) 92% related to COPD diagnosis. Review of the facility's admission Summary Note for Resident #493, dated 01/01/2020 at 3:39 PM, revealed the resident was admitted at approximately 2:00 PM to the facility. Continued review revealed at the time of admission the resident's lungs sounds were diminished and his/her O2 level was 95% on room air. Further review revealed Resident #493 appeared to have shortness of air (SOA) with ambulation at times. In addition, the admission Summary Note revealed the nurse had reviewed all the resident's medications with the Physician. Review of the Pharmacy Delivery Manifest, dated 01/02/2020 timed 12:44 PM, revealed the following medications were delivered to the facility for Resident #493: Lamotringe 100 mg, Topiramate 50 mg and Alprazolam (generic medication for Xanax) 2 mg. Review of facility's Progress Note for Resident #493, dated 01/02/2020 at 12:45 PM, revealed the resident received his/her Xanax 2 mg, for the first time since his/her admission on [DATE] at 2:00 PM. Review of the facility's Medication Administration Record (MAR) for Resident #493 revealed the Physician's Orders for Topamax, Lamotringe and Xanax had been transcribed onto the MAR on 01/02/2020 at 8:00 AM. However, record review revealed the Physician ordered all the medications on 01/01/2020. Review of the Inventory Replenishment Report, printed date of 11/13/2019 at 3:57 PM, revealed no documented evidence the facility had Resident #493's ordered Topamax, Lamotringe and Xanax medications in their stock inventory available for use for the resident. Interview with Resident #493, on 01/06/2020 at 10:57 AM, revealed he/she had been to the facility for strengthening after a hospital stay. Per interview, the resident stated he/she had not received his/her medications, Lamictal, Xanax and Topamax for about thirty-six (36) hours after admission. According to Resident #493, I asked the nurse and was told my medications would be here within four (4) hours, but then it was already 10:00 PM. After I asked several more times the nurse told me the pharmacy was located about four (4) hours away. Continued interview revealed the resident stated, I felt extreme anxiety, had not received my breathing therapy although having COPD. All I could do was to take deep breaths, inhale and exhale. Thankfully, the hospital had loaded me up with steroids. Resident #493 further stated, I had chest pains and I told myself I had to control it mentally, when in reality it was physical. I paced around and wondered when my medications would arrive. Interview with Certified Nursing Assistant (CNA) #3, on 01/10/2020 at 11:49 AM, revealed Resident #493 had been primarily concerned about all his/her medications, but mostly the as needed (PRN) medication regarding the delayed delivery. Further interview revealed CNA #3 stated some other residents had voiced the same concern to her before. Interview with Licensed Practical Nurse (LPN) #2, on 01/10/2020 at 4:03 PM, revealed the facility had an issue with medication delivery. Per interview, in respect to medication delivery, she stated medications usually got to the facility; however, the issue was nobody oversaw the reordering/ordering of medications. Interview with LPN #11, on 01/10/2020 at 12:18 PM and again at 12:27 PM, revealed the facility had ordered the medications. According to LPN #11, residents were not getting their medications on time (at the facility). She stated when the Pharmacy had staff then they sent the medications over. LPN #11 stated she believed this affected the residents. Interview with the Assistant Director of Nursing (ADON), on 01/11/2020 at 1:16 PM, revealed the facility had trouble with nurses following up on Physician's Orders. She stated she knew the nurses struggled to reorder medications, and acknowledged it had also been a struggle for her as well. Interview with the Director of Nursing (DON), on 01/11/2020 at 12:43 PM, revealed she had identified some concerns on medication reordering and educated nurses on how to follow up on medications. Interview with the Administrator, on 01/10/2020 at 5:02 PM, revealed he was not a clinician; however, the nurse should have tried to get Resident #493's medication STAT (immediately). According to the Administrator, if the medication had been available in the Emergency Drug Kit, then the nurses should have gotten it out of there. He stated not getting the medication timely made Resident #493 anxious and as a result the facility failed to provide quality of care.

Based on interview, record review and policy review it was determined the facility failed to ensure residents with an identified weight loss were monitored for further weight loss and that supplements were provided as recommended for one (1) of thirty-two (32) sampled residents (Resident #107). Review of the December 2019 Physician's Orders for Resident #107, revealed on 09/30/2019, the physician ordered the facility to weigh the resident two (2) times per week, every Monday and Thursday, related to Heart Failure. The resident also had an order for staff to provide eight (8) ounces of the supplement, Glucerna, two (2) times a day. Review of the facility's electronic Weight Log, revealed Resident #107 weighed 116 pounds on 10/03/2019, and 102 pounds, on 10/24/2019. Further review revealed this was a 14 pound weight loss. Continued review of the log revealed staff did not weight the resident per the physician's order on seventeen days between October 14, 2019 and December 31, 2019. No weights were documented for January 2020. Review of Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six months. The dietitian recommended eight ounces of Glucerna two times a day. Review of Medication Administration Record revealed the Glucerna supplement was inconsistently documented as given. The findings include: Review of the facility's policy for Weight Assessment and Intervention, not dated, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The nursing staff would measure resident weights on admission, the next day, and weekly for two (2) weeks thereafter. If no weight concerns were noted at this point, weights would be measured monthly. Weights would be recorded in each unit's Weight Record or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment would be retaken the next day for confirmation. The threshold for significant unplanned and undesired weight loss would be based on the following criteria. For a one month time frame a 5% weight loss was significant and a greater than 5% weight loss was severe. For a three month time frame a 7.5% weight loss was significant and a greater than 7.5% weigh loss was severe. During a six months time frame a 10% weight loss was significant and greater than 10% was severe. Assessment information would be analyzed by the multidisciplinary team and conclusions would be made regarding resident's target weight range, approximate calorie needs, and medical condition etc. The team and the physician would identify conditions and medications that may be causing weight loss. Review of Resident #107's closed record revealed the facility initially admitted the resident on 02/09/2009, and readmitted the resident on 10/21/2019, after a hospitalization. The resident had a history of Heart Failure, Acute Myocardial Infarction (heart attack), Chronic Kidney Disease and Diabetes. Review of the December 2019 Physician's Orders for Resident #107, revealed on 09/30/2019, the physician wrote orders for the facility to weigh the resident two (2) times per week, every Monday and Thursday, related to Heart Failure. The resident also had an order for staff to provide eight (8) ounces of the supplement, Glucerna, two (2) times a day. Review of the facility's electronic Weight Log, revealed Resident #107 weighed 116 pounds on 10/03/2019, and was 102 pounds, on 10/24/2019; which was a 14 pound weight loss. Continued review of the log revealed staff did not weight the resident per the physician order on 10/14/2019, 10/17/2019, 10/28/2019, 10/31/2019, 11/04/2019, 11/07/2019, 11/14/2019, 11/18/2019, 11/22/2019, 11/25/2019, 12/02/2019, 12/05/2019, 12/09/2019, 12/16/2019, 12/23/2019, 12/26/2019, or 12/30/2019. No weights were documented for January 2020. Review of the Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six months. The resident's diet was a mechanical soft modified diabetic diet with thin liquids. The Dietitian recommended eight ounces of Glucerna two times a day. Review of the Medication Administration Record revealed the Glucerna supplement was inconsistently documented as given. Review of Resident #107's Nutrition/Dietary Note, made on 11/26/2019, revealed the resident's weight was 104.1 pounds. The Dietary Note stated the resident had a significant weight change of 10.3 percent in thirty days; a 10.3 percent weight loss in the last three months; a 11.8 percent in the six months and recommendations were made for eight ounces of Nepro (a supplement), every day between meals, to provide additional Kilocalories and Protein. However, the supplement did not get transferred to the plan of care nor to the Treatment or Medication Administration Record (MAR/TAR). Interview with Certified Medication Technician (CMT) #1, on 01/10/2020 at 12:20 PM, revealed she was agency staff and did not know Resident #107 had experienced a weight loss. She stated her role as a CMT was to remind the Certified Nursing Assistants (CNA) to weigh residents. She stated she did not document resident's weights because the nurse documented the weights obtained. CMT #1 also stated if the resident had orders for supplements they would be on the MAR/TAR. She stated she could not remember administering supplements to the resident. CMT #1 stated if the staff did not monitor residents' weights or administer supplements per the physician's order they could experience a decline. Interview, on 01/11/2020 at 10:38 AM and 1:03 PM, with Licensed Practical Nurse (LPN) #15, revealed Resident #107 was diabetic, small in stature and sat in a wheelchair. However, due to her being agency staff, she could not remember much more about the resident. She stated the facility did not bring it to her attention the resident had a significant weight loss or that the resident was not being weighed as ordered. LPN #15 stated nothing was on the MAR to alert her to this either. She stated she believed the leadership team discussed residents with identified weight loss in the morning meetings, which she did not attend. LPN #15 stated she also did not review the plan of care, she just depended on the MAR to direct her in the care of the resident. She stated if staff did not weigh the resident or provide supplements as ordered they could contribute to a decline. Interview with the Director of Nursing (DON), on 01/11/2020 at 12:55 PM, revealed she had identified staff were not routinely obtaining weights as ordered. The DON stated she recently assumed her role and had not yet fixed the system issues related to monitoring residents with identified weight loss. She stated the facility tried to pull staff aside at the time they identified non-compliance with physician orders or when staff did not follow policy. The DON stated she had not identified Resident #107's weight loss, nor did she remember a discussion in the morning meeting about the staff not weighing the resident or providing the supplements as ordered. She stated if the facility did not assess or monitor residents for weight loss, residents could experience a decline. Interview with the Administrator, on 01/11/2020 at 2:03 PM, revealed he expected staff to follow facility policy and physician orders related to obtaining resident's weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure effective pain management for two (2) of thirty-two (32) sampled residents (Residents #34 and #101). The facility failed to have an effective system to ensure pain medications were available when needed. A total of nine (9) missed doses of pain medication for the resident experiencing chronic pain. The findings include: Review of the facility's policy, Pain Management, dated October 2018, revealed the purpose of the policy was for each resident to be assessed for pain, and to maintain the resident as free from pain as possible. The policy revealed the physician would be notified of unrelieved or worsening pain in a resident. According to the policy, residents receiving routine pain medication were to be assessed each shift by the Charge Nurse during rounds and/or during medication pass. Per the policy, the reason for administration, and effectiveness of the pain medication were to be documented on the Medication Administration Record (MAR), or on the facility's specific Pain Management Flow Sheet. 1. Observation on 01/07/2019 at 10:22 AM, revealed Resident #34 neatly groomed and seated on the bedside in no apparent distress. Interview during the observation revealed Resident #34 stated he/she needed pain medication for his/her back and neck pain. According to the resident, he/she had been without his/her pain medication for two (2) days because the facility let it run out. Review of the clinical record for Resident #34 revealed the facility admitted the resident on 10/28/2019 with diagnoses which included Low Back Pain, Radiculopathy (disease of a nerve root), and Nontraumatic Compartment Syndrome of Unspecified Lower Extremity (a painful condition occurring when pressure levels in a muscle builds up to a dangerous level). Review of the facility's Minimum Data Set (MDS) Assessment, dated 11/03/2019, revealed the facility assessed Resident #34 with a Brief Interview for Mental Status (BIMS) total score of twelve (12) out of fifteen (15), indicating the resident was not severely cognitively impaired and therefore was interviewable. Review of Resident #34's History & Physical (H&P) dated 10/24/2019, revealed a Chief Complaint of Intractable Back Pain (severe, constant, relentless and debilitating pain that is not curable). Further review of the H&P revealed an Magnetic Resonance Imaging (MRI), performed prior to admission, showed significant disc disease of the resident's lumbar spine. Review of the facility's Physician's Orders revealed an order dated 11/06/2018, for Percocet 10-325 mg (Oxycodone-Acetaminophen) give one (1) tablet by mouth (PO) every four (4) hours related to the diagnosis of Nontraumatic Compartment Syndrome of Unspecified Lower Extremity. Review of the facility's MAR for Resident #34 dated December 2019, revealed no documented evidence the resident's Percocet 10-325 mg was administered on the following dates: 12/14/2019 at 4:00 PM and 8:00 PM; 12/15/2019 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; and 12/16/2019 at 12:00 AM. A total of nine (9) missed doses of pain medication for the resident experiencing chronic pain. Further review of the MAR revealed no documented evidence staff had assessed the resident's pain level from 12/14/2019 at 4:00 PM until 12/16/2019 at 4:00 AM, a period of thirty-six (36) hours. Review of the facility's Progress Note dated 12/14/2019 at 4:49 PM, revealed Resident #34's Percocet pain medication was not available to administer. The Note stated the nurse had notified the Pharmacy and would continue to monitor the resident. Review of the Progress Note dated 12/15/2019 at 4:02 PM,{twenty-four (24) hours after the medication was documented to have been unavailable for administration}, revealed the nurse had notified the Physician to get a prescription for Resident #34's Percocet pain medication. Review of Progress Note, dated 12/16/2019 at 3:39 AM{approximately thirty-six (36) hours after the medication had not been available for administration}, revealed the nurse had obtained a one-time order to administer Percocet to Resident #34 from the facility's Emergency Drug Kit (EDK) box. Further review of the Progress Notes revealed no documented evidence staff had assessed Resident #34's pain level, implemented any non-pharmacological interventions, or had notified the Physician in order to manage the resident's pain for the thirty-six (36) hours his/her prescribed Percocet had been unavailable. Interview with Licensed Practical Nurse (LPN) #2 on 01/08/2020 at 10:02 AM, revealed the facility had problems getting medications from the pharmacy and stated there were lots of issues getting residents' narcotic pain medication ever since the facility switched pharmacies. She further revealed there were also issues with delivery of stat medication orders. LPN #2 stated the pharmacy was located out of town and sometimes a resident could miss two (2) doses before the medication was delivered to the facility. According to LPN #2, Oxycodone was not available in the emergency drug kit (EDK). Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed the facility had issues with timely delivery of medications since the pharmacy changed in September 2019. LPN #11 stated the nurse was responsible for notifying the physician if a medication was not available and request a one-time order to pull the controlled pain medication from the EDK as needed; however, she did not know why she did not notify Resident #34's physician. The nurse did not contact the physician to pull from the EDK until the medication arrived from the pharmacy. According to LPN #11, non-pharmacological pain interventions would include applying a cold/warm compress, offering fluids or diversional activities. Continued interview revealed LPN #11 should have assessed Resident #34's pain level, and implemented some non-pharmacological intervention(s). Per interview, she probably should have notified the Physician for a one-time order for pain medication as the resident was out of medication. However, she was sometimes swamped and did not document everything. Further interview revealed a resident could have been in a lot of pain if their pain medication was not administered accordingly. Interview with LPN #10, on 01/09/2020 at 11:07 AM, revealed nurses were responsible for ordering medication in the facility's electronic MAR (eMAR) and for notifying the physician for a new prescription for controlled medications. She further stated the nurse was responsible for obtaining a Physician's Order as needed to administer a narcotic from the EDK. LPN #10 stated she was not aware of any issues related to the availability of Resident #34's pain medication. Interview with LPN #12 on 01/10/2020 at 2:47 PM, revealed the facility had problems receiving medication orders from the Pharmacy. According to LPN #12, the pharmacy did not notify the facility whenever a new prescription was needed for refills. The LPN stated nurses were responsible for pulling medications from the EDK and/or notifying the Physician for a prescription if a medication was not available. Continued interview with LPN #12 revealed non-pharmacological interventions to use for residents' pain management could include deep breathing, repositioning, and positive visualization. She further stated pain assessments and interventions should be documented in the Progress Notes. According to LPN #12, Resident #34's was very upset about not having pain medication available. 2. Observation, on 01/10/2020 at 10:33 AM, revealed Resident #101 seated at the bedside. Interview during observation revealed the resident sometimes went without pain medication for days because it was not available. Review of the clinical record revealed the facility readmitted the resident on 03/25/2017 with diagnoses to include Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Primary Osteoarthritis. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Further review of the clinical record revealed a Physician's Order, dated 09/27/2019, for Oxycodone-APAP 10-325 mg give one (1) tablet by mouth every four (4) hours for pain. Review of the MAR, dated October 2019, revealed a total of fourteen (14) missed doses of Oxycodone-APAP on 10/02/2019, 10/04/2019, 10/07/2019, 10/09/2019, 10/11/2019, and 10/13/2019. Review of the MAR, dated November 2019, revealed a total of six (6) missed doses of Oxycodone-APAP on 11/20/2019, 11/21/2019, and 11/26/2019. Interview with Licensed Practical Nurse (LPN) #4, on 01/09/2020 at 10:38 AM, revealed the facility had issues getting medication delivered from the pharmacy. She stated sometimes the pharmacy needed a new prescription and Resident #101 would run out of pain medication. According to LPN #4, nurses were responsible for notifying the physician and pulling the narcotic from the Emergency Drug Kit (EDK) as needed. The nurse stated pain could affect a resident's activities of daily living (ADL). Interview with LPN #11, on 01/10/2020 at 11:52 AM, revealed there were constant issues with delivery of medications and stated she reported the issues to the former Administrator and the pharmacy representative. Interview with LPN #12, on 01/10/2020 at 2:47 PM, revealed the facility had problems with delivery of medications. She stated staff were not aware the pharmacy needed a new prescription until they called to find out why the medication was not delivered. Interview with LPN #15, on 01/11/2020 at 10:34 AM, revealed nurses were responsible for notifying the physician to request a one-time order to remove a narcotic from the EDK if a pain medication was not available. She stated it was important to manage pain because pain could affect the resident's mood, behavior, socialization, and mobility. Interview with the Regional Director of Customer Success for the pharmacy used by the facility, on 01/11/2020 at 12:52 PM, revealed he was not aware of any recent issues related to orders or delivery of medications. Interview, on 01/11/2020 at 12:29 PM with the Director of Nursing (DON) revealed she had recently assumed the role as DON and had identified omissions in the medical records and was evaluating to identify a trend to put a corrective action plan in place. Interview, on 01/10/2020 at 4:55 PM, with the Administrator revealed he expected medications to be administered as ordered and the facility was still in the process of finding out if there was a trend at a certain time of day related to medication administration and availability issues. Interview with the Medical Director, on 01/11/2020 on 2:42 PM, revealed he was working with the pharmacy to resolve an issue with faxed prescriptions. The Medical Director stated he was not aware of any persistent issues with delivery of medications.