**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 Record review of the ADL care plan for Resident #17 revealed the resident had an ADL self-care performance deficit related to activity intolerance, dementia, impaired balance, and stroke. Interventions included the resident requires substantial assistance by two (2) staff with personal hygiene. On 5/28/2024 at 11:06 AM, an observation revealed Resident #17 sitting in a wheelchair in the day room with one-fourth (1/4) inch of gray facial hair observed to the sides of his face and above his lip. On 5/29/2024 at 1:44 PM, an observation and interview with the Director of Nursing (DON) confirmed Resident #17 had long facial hair. An interview with the Director of Nursing (DON) on 5/30/2024 at 10:25 AM revealed the purpose of the care plan was to have a guide to follow for resident care and confirmed the care plan for personal hygiene was not followed. Record review of the admission Record revealed the facility admitted Resident #17 on 11/14/2023 with a medical diagnosis of unspecified dementia. Based on observation, staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for a resident exhibiting nonverbal signs of pain and a care plan to address ADL (activities of daily living) of a resident for two (2) of 19 resident care plans reviewed. Resident #29 and Resident #17. Findings Include: Review of the facility policy titled, Comprehensive Care Plans with no revision date revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #29 Record review of Resident #29's care plans revealed a care plan regarding Elder is at risk for pain with a goal of; The elder will verbalize pain reduction or relief with each intervention. Interventions included administer pain medications as ordered and monitor for effectiveness, observe for need for pain medications prior to any care and observe for verbal/nonverbal indications of discomfort. An observation on 05/28/24 at 11:03 AM revealed that two staff members were leaving Resident #29's room with a bag of garbage and the resident was moaning loud enough to be heard in the hallway. Upon entry into the resident's room, the resident was sitting up in her wheelchair, dressed in personal clothes and continued making loud moaning noises with her mouth open at all times, her eyebrows were furrowed, and a single tear fell from her right eye. The resident was unable to be interviewed and could not answer questions at this time. An interview on 5/28/24 at 11:20 AM with Licensed Practical Nurse (LPN) #2 revealed the aides were getting Resident #29 up out of bed when they were observed leaving the room around 11:00 AM. During an interview on 5/29/24 at 10:45 AM, with Certified Nurse Assistant (CNA) #2 confirmed that Resident #29 moans most of the time, but when they get her up or move her, she moans loader. She stated that the resident's care plans are to let the staff know what care the resident needs and we should have let her nurse know she was moaning out and they could give her pain medication. During an interview on 5/29/24 at 12:00 PM with Registered Nurse (RN)/Minimum Data Set (MDS) Nurse confirmed that Resident #29 had a diagnosis of Multiple Myeloma and movement probably increases the resident's pain. She stated that the only way to know for sure that the resident is in pain is if her moaning increased, but there would be no way to tell what the pain level was on a scale of 1-10, because the resident is unable to verbalize that information. She revealed that the residents care plan provides the care needed for the residents. She confirmed that she put in the resident's pain care plan and the care plan goal of the resident verbalizing pain relief would be difficult to for her to achieve. On 5/29/24 at 3:30 PM, an interview with the Director of Nurses (DON) confirmed that it would be impossible for Resident #29 to give them a pain scale of 1-10 or let them know if she is relieved from the pain medication. She confirmed that the care plan needed some changing to apply more to this resident and was not being implemented to the best of its ability due to not providing as needed (PRN) pain medication or offering every 4 hours as ordered. Record review of Resident #29's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnosis that included Multiple Myeloma not having achieved remission and Secondary Malignant Neoplasm of Bone. Record review of Resident #29's physicians orders revealed an order dated 3/15/24 for Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) by (via) PEG (Percutaneous Endoscopic Gastrostomy Tube) every 4 hours as needed for pain. Record review of Resident #29's Electronic Medication Administration Record (EMAR) revealed the resident has received nine (9) PRN (as needed) Hydrocodone pills in the last 29 days with the last administration being 5/27/24 at 1:47 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident representative interviews, record review and facility policy review, the facility failed to ensure a resident was free from pain after exhibiting nonverbal signs of excruciating pain for one (1) or 16 residents sampled. Resident #29 Findings Include: Review of the facility policy titled, Pain Management with no revision date revealed under the Policy .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences This review revealed under Policy Explanation and Compliance Guidelines .The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain .k. Sighing, groaning, crying, breathing heavily; under Pain Assessment: e. Determining factors that make the pain better or worse; and under Monitoring: 1. Reassess patients with pain regularly based on the facility's established intervals. On 05/28/24 at 11:03 AM, an observation revealed two staff members were leaving Resident #29's room with a bag of garbage and the resident was moaning loud enough that it could be heard from the hallway outside of her room. Upon entering the resident's room, the resident was sitting up in her wheelchair, dressed in personal clothes and continued making loud moaning noises with her mouth open at all times, her eyebrows were furrowed, and a single tear fell from her right eye. The resident was unable to be interviewed and could not answer questions. On 5/28/24 at 11:20 AM, an interview with Licensed Practical Nurse (LPN) #2 revealed the aides were just in there getting Resident #29 up out of bed and the LPN stated that they were observed leaving the room around 11:00 AM. Record review of Resident #29's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnosis that included Multiple Myeloma not having achieved remission and Secondary Malignant Neoplasm of Bone. An observation on 5/28/24 at 1:00 PM, revealed the resident sitting up in her wheelchair in the resident's room with continuous moaning that could be heard in the hallway and continued to have furrowed brows and facial grimacing. Record review of Resident #29's physicians orders revealed an order dated 3/15/24 for Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) by (via) PEG (Percutaneous Endoscopic Gastrostomy Tube) every 4 (four) hours as needed for pain. Record review of Resident #29's May 2024 Electronic Medication Administration Record (EMAR) revealed the resident has received 9 (nine) Hydrocodone pills as needed in the last 29 days with the last administration being 5/27/24 at 1:47 AM. An interview on 5/29/24 at 10:20 AM, with Resident #29's husband who is her representative revealed it is hard to tell when she is hurting so they just give her pain medicine sometimes. He stated she has Multiple Myeloma that deteriorates the resident's bones, so it hurts her when they have to move her. An interview on 5/29/24 at 10:45 AM, with Certified Nurse Assistant (CNA) #2 confirmed that Resident #29 moans most of the time, but when they get her up or move her, she moans even louder. She stated that she has told the nurses before that she thinks the resident is hurting, but she has not told them that every time they get her up or move her that she moans out like this. An interview on 5/29/24 at 11:00 AM, with LPN #2 and Registered Nurse (RN) #1 confirmed that Resident #29 moaned all of the time, but they give her pain medicine when her moaning increased or has gotten louder because that was how they could tell when she was hurting. They confirmed that the resident had a cancer that affected her bones, so it probably did hurt when she was moved or transferred. They revealed that the resident did not get pain medicine with transfers but could see how that would be a good idea. An interview on 5/29/24 at 11:15 AM, with CNA #3 confirmed that Resident #29's moaning would increase when they got her up or moved her and she was sure it was because of pain. An interview on 5/29/24 at 12:00 PM, with RN/Minimum Data Set (MDS) Nurse confirmed that Resident #29 had a diagnosis of Multiple Myeloma and movement probably increased the resident's pain. She revealed she did the pain assessment for Resident #29's Minimum Data Set (MDS) assessments and confirmed that the resident moans a lot. She stated that the only way to know for sure the resident is in pain is if her moaning increased, but there would be no way to tell what the pain level was on a scale of 1-10, because the resident is unable to verbalize that information. She stated that receiving a pain pill 9 times in the last 29 days was probably not enough for this resident. She stated that she feels like the resident is to a point where she could use a more continuous type of pain medication. An interview on 5/29/24 at 1:55 PM, with Nurse Practitioner (NP) confirmed that Resident #29 had Multiple Myeloma that more than likely caused pain with movement. She revealed that on the resident's initial assessment in 3/2024, she discovered the resident had spasticity in her right posterior neck with pain and she started her on a muscle relaxer. She confirmed that the resident had PRN pain pills ordered, but it was hard to tell with this resident if she was in pain except that her moaning would change. She stated that maybe they should consider changing her order of PRN pain pills to be given before transfer or scheduled. An interview on 5/29/24 at 3:30 PM, with the Director of Nurses (DON) confirmed that Resident #29 probably needs something scheduled for pain with a diagnosis of Multiple Myeloma. She confirmed that the resident moans almost all of the time, but her moaning does get a different pitch to it when they think she is in pain. She confirmed that it would be impossible for the resident to give them a pain scale of 1-10 or let them know if she is relieved from the pain medication. She stated that a resident with Multiple Myeloma probably needs more than 9 pain pills in 29 days for pain control. Review of Resident #29's MDS with an Assessment Reference Date (ARD) of 3/18/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely cognitively impaired and in Section J that the resident had pain that is indicated with nonverbal sounds.