Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a person-centered comprehensive care plan for a resident with chronic pain (Resident #39) and a resident dependent on staff for nail care (Resident # 22) for two (2) of 16 care plans reviewed. Resident #22 and #39 Findings Include: Review of the facility policy titled Care Plans-Comprehensive revealed under, Policy Statement: An individual (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Resident #22 Record review of Resident #22's Care Plan Report revealed that he required assistance with his ADL's (Activities of Daily Living) related to confusion and cognitive impairment and had interventions initiated on 10/24/22 that included, Nail care as needed or scheduled. An observation on 4/14/25 at 2:43 PM revealed Resident #22 sitting up in his wheelchair in the room and his fingernails on both hands were long. They were approximately one-half to three-fourths inch long and there was a brown substance underneath them. An observation and interview on 4/15/25 at 9:20 AM with Licensed Practical Nurse (LPN) #1, confirmed that Resident #22 had long, dirty fingernails and she revealed that they should have been taken care of. An interview on 4/15/25 at 2:50 PM with the Minimum Data Set (MDS) Coordinator revealed that they developed a patient specific personalized care plan, so the staff knew how to care for the individualized needs of the residents. She confirmed that Resident #22's ADL care plan which includes his nail care was not followed. Record review of Resident #22's admission Record revealed an admission date of 10/17/22 and that he had diagnoses that included Unspecified Dementia, Age-Related Physical Debility, and Unspecified Depression Resident #39 Record review of the Care Plan Report for Resident #39 revealed under, Focus: Resident has intermittent episodes of chronic pain . and listed under, Goals: Resident will verbalize full relief from pain with interventions provided by staff . Also revealed under, Interventions: Monitor for worsening pain symptoms and report to physician if indicated. Date initiated 4/3/25. An observation and interview on 4/14/25 at 2:48 PM with Resident #39 revealed she was sitting in a chair in her room and she stated that she was newly admitted to the facility and explained that she had been out of her pain medication (Lyrica) for almost a week. The resident revealed she came into the facility taking it for neuropathy pain for her lower legs and feet. She stated, I cannot even walk due to the leg pain. The resident explained that she had Tylenol that she could take, but it was not effective for her nerve pain in her legs and feet. Record review of the Pain Assessment dated 4/08/25 revealed Resident #39 frequently experienced pain in the last 5 days with a pain intensity scale rated 7 on a scale of 1-10. An interview with Licensed Practical Nurse (LPN) #1 on 4/15/25 at 2:10 PM, while in the room with Resident #39, confirmed that the resident was currently reporting pain in her feet and legs and rated the pain 8 on a scale from 1 to 10 with 10 being the worst pain. The resident stated, It hurts to even touch my feet and to stand. She revealed that Lyrica helped with her nerve pain and explained that without the medication, the pain was constant and intense with the faintest touch. An interview with the MDS Nurse on 4/16/25 at 10:29 AM revealed the purpose of the care plan was to develop a plan of care for the direct care staff to follow so they can provide the best care needed. She then confirmed that the pain care plan was not followed because the staff had failed to administer medications to relieve the resident's pain. An interview with the Physical Therapy Assistant (PTA) on 4/16/25 at 8:55 AM revealed occupational therapy (OT), and she had been working with Resident #39 to build strength and endurance, but that they had to modify her therapy because she was in pain during therapy sessions. Record review of the Order Listing for Resident #39 revealed an order dated 4/02/25, Lyrica (nerve pain) Oral Capsule 200 MG (milligrams) (Pregabalin) Give 1 (one) capsule by mouth three times a day related to other chronic pain, with a discontinued date of 4/10/25. Record review of the admission Record revealed the facility admitted Resident #39 on 4/02/25 with medical diagnoses that include Chronic Pain, Anxiety Disorder, Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Record review of the MDS with an Assessment Reference Date (ARD) of 4/08/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #39 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy review, and record review, the facility failed to ensure effective pain management for one (1) of sixteen (16) sampled residents (Resident #39), when staff failed to provide continued access to prescribed pain medication (Lyrica) and failed to implement appropriate interventions. This resulted in the resident experiencing uncontrolled neuropathic pain, impaired mobility, disruption in therapy services, and a decline in quality of life. Findings Include: Review of the facility policy titled Pain Assessment/Management with a revision date of 9/10 revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents at risk for acute and chronic pain. Each residents pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications. On 4/14/25 at 2:48 PM an observation and interview with Resident #39 revealed that she was newly admitted to the facility and explained that she had been out of her pain medication (Lyrica) for almost a week. The resident revealed she came into the facility taking it for neuropathy pain in her lower legs and feet. She explained that staff told her that they contacted the facility doctor, but he would not refill it for her. She stated that she has an upcoming appointment with her pain specialist this Thursday, but she would rather not wait that long and stated, I cannot walk anymore due to the leg pain. The resident explained that she had Tylenol that she could take, but it was not effective for her nerve pain in her legs and feet. An interview with the Director of Nursing (DON) on 4/14/25 at 3:10 PM revealed Resident #39 was a new admission to the facility on [DATE] and had a contract with the pain clinic and could not get pain medication prescribed by anyone besides with them. She explained that the resident has an appointment to have a drug screen on 4/17/25 and will have a telehealth visit through the pain clinic after the drug test to get her refills. She confirmed that the resident was admitted to the facility on Lyrica for pain management and revealed that the order was discontinued after the facility medical director was contacted about refilling it. The DON explained that he refused to refill the medication and told them that the resident must get her pain medications refilled by her pain management physician. She stated, If he was not willing to refill the Lyrica, that was the physician's order from him to discontinue the medicine. Record review of the Order Listing for Resident #39 revealed an order dated 4/02/25, Lyrica (nerve pain) Oral Capsule 200 MG (milligrams) (Pregabalin) Give 1 (one) capsule by mouth three times a day related to other chronic pain, with a discontinued date of 4/10/25. Record review of the April 2025 Medication Administration Record (MAR) revealed Resident #39 last received a dose of Lyrica 200 mg on 4/10/25 at 1400 (2:00 PM), and the order was discontinued. Record review of the Pain Assessment dated 4/08/25 revealed Resident #39 frequently experienced pain in the last 5 days with a pain intensity scale rated 7 on a scale of 1-10. An interview with Licensed Practical Nurse (LPN) #1 on 4/15/25 at 2:10 PM, while in the room with Resident #39, confirmed the resident had been out of the Lyrica. She revealed that the resident was currently reporting pain in her feet and legs and rated the pain 8 on a scale from 1 to 10 with 10 being the worst pain. LPN #1 revealed stopping the medication abruptly could cause a recurrence of pain symptoms and withdrawal side effects. The resident stated, It hurts to even touch my feet and to stand. She revealed that Lyrica helped with her nerve pain and explained that without the medication, the pain was constant and intense with the faintest touch. The resident explained that the facility's Medical Director saw her last week and told her he could not prescribe pain medications to her because it would void her contract with the pain clinic. She stated, I don't know what to do. An interview with the Director of Nursing (DON) on 4/15/25 at 2:19 PM revealed the staff had contacted Resident #39's pain clinic for the Lyrica refill, but they were told the resident must come in. She explained there was nothing they could do since the medical director would not refill it. A telephone interview with the facility Medical Director (MD) on 4/15/25 at 2:35 PM revealed Resident #39 has chronic pain and currently has rib fractures due to a fall at home. He confirmed he saw the resident last week in the facility, and revealed the staff did not tell him the resident was out of Lyrica. He explained that the staff did ask him about refilling her medications, and he told them that she would need to get it refilled by her pain specialist. The MD stated, There was a misunderstanding because I was never told that she was out of the medicine. He further elaborated, It was not my intention for her to go without. He acknowledged that he had no problem with giving the resident enough medication until she got back in with the pain clinic, but would not want to do it on a long-term basis. The MD confirmed this medication should not be abruptly stopped and would cause a recurrence of pain for the resident. An interview with the Administrator on 4/15/25 at 2:55 PM revealed Resident #39 should not be in pain and confirmed the facility was responsible for ensuring the resident had the medications available to manage her pain. She revealed her expectations were for the Medical Director to provide the medication until the resident was able to see her pain specialist. An interview with the Physical Therapy Assistant (PTA) on 4/16/25 at 8:55 AM revealed occupational therapy (OT), and she had been working with Resident #39 to build strength and endurance. She revealed they had previously been walking and doing exercises, but explained that the resident complained of pain in her feet yesterday and could not stand and we had to modify her therapy treatment plan to adapt due to the pain. Record review of the PT (Physical Therapist) Flowsheet revealed the following entries: Dated 4/14/25 . Pt (patient) reported not feeling well and needing to sit with c/o (complaints of) rib pain and foot nerve pain. PTA transitioned activity to dynamic sitting activity . Dated 4/15/25 . dynamic sitting balance activity requiring pt to reach across midline to challenge trunk stability needed for daily tasks. Pt reported not feeling well with LE (lower extremity) pain. No standing on this day date related to pain. Record review of Resident #39's April 2025 Medication Administration Record revealed under, Pain scale-evaluate pain per pain scale (0-10) Q (every) shift and PRN (as needed). If pain is present document interventions and follow up on effects. Notify MD of persistent pain unrelieved by intervention with zeros (0) documented on all shifts from 4/10/25 until 4/16/25 indicating the resident had no pain. An interview with LPN #1 on 4/16/25 at 9:45 AM confirmed that she did not document Resident #39's pain level correctly on her shift. She revealed the resident complained of pain in both feet rated 8/10 and explained that she gave the resident two (2) Tylenol 325 milligrams (MG) at 245 PM yesterday, and upon follow-up the resident stated, It helped a little bit but not much. She confirmed that she failed to document the pain or that Tylenol was given because she forgot. LPN #1 confirmed that the resident had told her that her pain was an 8 on a scale of 1-10. Record review of the admission Record revealed the facility admitted Resident #39 on 4/02/25 with medical diagnoses that include Chronic Pain, Anxiety Disorder, Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/08/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #39 was cognitively intact.