**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a resident's Activities of Daily Living (ADL) care and a resident's pain medication management for two (2) of 18 resident care plans reviewed. Resident #14 and Resident #53 Findings include: Record review of facility policy titled, Care Plan Process, dated 8/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The policy also revealed, The Physician Orders, Medication Administration Record, and Treatment Administration Record are part of the Comprehensive Care Plan. Resident #14 A record review of Resident #14's comprehensive care plan revealed the resident needs assistance with ADL's. Approaches: Assist with ADLs as needed. On 6/17/24 at 12:59 PM, observation and interview with Resident #14 revealed facial hair approximately one-half (1/2) inch to the sides of his cheeks, above his lip, and on his chin and neck. Resident #14's fingernails on bilateral hands were approximately ½ inch long and jagged with a brown substance under his nails. The resident stated it's been a long time since he was shaved, and he would like to be shaved and have his nails cut. An interview on 6/18/24 at 3:05 PM, the Assistant Director of Nurses (ADON) confirmed that male residents should be shaven, and all residents' nails cleaned and trimmed. The ADON confirmed Resident #14 care plan was not being followed regarding his ADL care. During an interview on 6/19/24 at 10:25 AM the Minimum Data Set (MDS) nurse revealed she and the MDS Assessment nurses are responsible for developing the resident's care plans and they are developed so the staff will know the resident's needs and how they are to be taken care of. She revealed personal hygiene includes shaving and nail care and it is a standard practice and the Certified Nursing Assistants (CNA) know that. She confirmed if Resident #14 was not shaved, and his nails were not taken care of then the plan of care for his ADL's was not followed. Record review of Resident #14's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Shortness of breath and Muscle Weakness. Resident #53 Record review of Resident #53's Care Plan revealed a problem/need dated 5/1/24 Resident is at risk for pain. The goal listed for this problem was Resident will have a decrease in pain through next review. Intervention listed as Administer meds as ordered. During an interview on 6/17/24 at 11:55 AM, Resident #53 revealed he had back and joint pain and took prescription pain medication two times a day for comfort and pain relief. He revealed a few weeks ago, the facility was out of his pain medications and he was given an over the counter pain medication which did not help relieve pain as well as the prescribed pain medication. During an interview on 6/19/24 at 9:10 AM, the Director of Nursing (DON) confirmed care plans are developed to guide the staff of the needed care for each resident. She confirmed Resident #53's pain care plan was not followed since the prescription medication for pain relief was not available to be given as ordered. She confirmed there was a documented pain level of ten (10) on the vital sign record dated 5/29/24 at 7:29 AM, and no interventions were documented as given. She confirmed that by the facility not having ordered pain medication, it was not readily available for this resident. She stated the facility failed to follow his developed comprehensive care plan concerning pain management. During an interview on 6/19/24 at 10:19 AM, the MDS Nurse confirmed the facility failed to follow Resident #53's comprehensive care plan for pain management. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Pain. Record review of MDS with Assessment Reference Date (ARD) of 4/30/24, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident was free of pain for one (1) of three (3) residents reviewed for pain. Resident #53 Findings include: Record review of facility policy titled, Pain Screen and Management, dated 12/23 revealed, All residents have the right to treatment for pain. Resident preferences are respected when deciding on methods to be used for pain management. Family members are involved when appropriate. The resident's statements are the most valid measurement of pain. Record review of facility policy titled, Medication Ordering, Reordering and Receiving Procedures, dated 12/19, revealed, Reordering Medications . On the established medication check day, the 11-7 (10-6) nurse will check all medications, not just punch cards, and reorder any medications that need to be re-filled. At the end of the shift, after all medications have been checked, the reorder will be faxed to the appropriate pharmacy. A form will be retained in the medication order/reorder binder with the fax confirmation. Checking in Medication Received from the pharmacy via courier. 1. Using the Medication Order/Re-Order Form for re-orders and New Medication Reconciliation form for new orders, compare each medication received to what was ordered, ensuring the resident name, medication, dose, route and frequency are correct. As each medication is checked, nurse places initials and amount received in the column to verify the reconciliation. The pharmacy is to be notified for discrepancies. During interviews with Resident #53 on 6/17/24 at 11:55 AM, and 6/18/24 at 3:30 PM, he stated he had back and joint pain and received prescription pain medication each morning and night to control his pain. He stated several weeks ago the facility did not have his prescription pain medication available, so he was given over the counter medication for his pain control, but that did not completely ease his pain. During an interview on 6/18/24 at 9:45 AM, the Director of Nursing (DON) confirmed the facility ran out of Resident #53's prescription pain medication. She stated the facility's procedure when the resident was running low on pain medication, was to place the reorder sticker from the medication card to the pharmacy form and it would be scanned to the pharmacy. At that point, the pharmacy would review the information and decide if a prescription was needed, and notify the facility or the provider to obtain a prescription. She stated for Resident #53's pain medication, there was a failure in this process and the scanned request was not followed up on by the facility. She stated the resident was given over the counter pain medication and it was documented that it was effective for his pain control. She stated for situations like this, the nurse should notify the on call provider for a now dose order, and obtain the medication from the facility's emergency kit to administer to the resident for pain relief and this was not done. She stated if notified, the provider would send a prescription to the pharmacy and pharmacy would have delivered the medication day or night, but this was also not done. She stated the resident was out of his medication from the evening of 5/27/24 until evening of 5/30/24, when she returned to work and identified the concern. The Nurse Practitioner was notified, a prescription was obtained, and the medication was delivered right away. An interview on 6/18/24 at 1:30 PM, with the Nurse Practitioner (NP) revealed he was notified on 5/29/24 of Resident #53's complaints of pain and withdrawal type symptoms from not receiving his pain medication. When he assessed the resident, he stated his pain was well controlled and clinically, the resident did not exhibit any signs or symptoms of withdrawal. The NP stated that Resident #53 had received Tylenol and it was documented that the medication was effective, and the resident did not verbalize otherwise. He confirmed by his oversight, he failed to provide a prescription to obtain an ordered medication needed for the resident's pain control. During a phone interview on 6/18/24 at 2:15 PM, Licensed Practical Nurse (LPN) #3 revealed the resident's pain medication had been requested but was not delivered to the facility from the pharmacy so he did not have this medication available when needed. She stated she was uncertain of the date but she worked that night and the resident slept well and that next morning he complained of pain and requested his pain medication. She revealed the resident had an order for a prescription pain medication that he could take every eight hours if needed for pain and he would always take one in the morning and one in the evening for his pain management. Since that was unavailable she gave him an over the counter medication to help with his pain but he was not very happy that he did not receive his prescription medication. She stated the resident was concerned about withdrawals and she assessed the resident and he did not have a tremor, vomiting, or any other symptoms of withdrawal. She stated this occurred during the morning shift change and she notified the oncoming nurse to get his meds from the pharmacy when they opened so he would have them available when needed. She stated she did not notify the provider. During a phone interview on 6/18/24 at 4:40 PM, the Registered Pharmacist stated the pharmacy received the faxed medication request from the facility on 5/23/24. This was somehow overlooked, so the pharmacy staff did not follow-up with the provider or the facility. She confirmed it was the responsibility of both the pharmacy and facility to ensure the requests are addressed and since the provider was in the facility almost daily, the prescription should have been obtained from the facility and faxed to the pharmacy. She stated the facility did not notify the pharmacy until 5/30/24 when the prescription was received by the pharmacy and was filled that day and sent out for delivery that evening. She confirmed the oversight led to a delay in resident receiving his medication. An interview with the DON on 6/19/24 at 9:10 AM, revealed the facility failed to have an ordered as-needed (PRN) pain medication available for a resident that experienced frequent pain. She confirmed there was a documented pain level of nine (9) on the vital signs record dated 5/28/24 at 7:38 AM and Acetaminophen was given and documented as effective. She confirmed there was a documented pain level of ten (10) on the vital sign record dated 5/29/24 at 7:29 AM, and no interventions were documented as given. She confirmed the facility failed to administer medication or additional interventions to assist this resident with his pain management. She confirmed the facility failed to ensure his ordered medications were available. She confirmed the facility failed to provided adequate pain management care to a resident with frequent complaints of pain. Record review of Physician Orders revealed orders dated 4/24/24 for Hydrocodone 5 mg (milligrams) - Acetaminophen 325 mg tablet: Give one tablet orally every 8 hours as needed and Acetaminophen 325 mg tablet: Give 2 tablets orally (650 mg total dose) every 6 hours as needed. Record review of Resident #53's Electronic Medication Administration Record (EMAR) revealed on 5/28/24 at 7:39 AM Acetaminophen 325 mg (milligram) tablet - 2 tablets were given for a pain level of 9. The EMAR follow up note for Acetaminophen dated 5/28/24 at 9:20 AM, revealed, Medication was effective. Record review of the Vital Signs Grid for resident revealed on 5/28/24 at 7:38 AM Resident #53 was noted to have a verbal pain scale of 9. Review revealed on 5/29/24 at 7:29 AM, the verbal pain scale was listed as 10. Record review of Medication Reorders form dated 5/23/24, revealed Resident #53's reorder for prescription pain medication was sent to the pharmacy. Record review of a prescription for the pain medication Hydrocodone-APAP 5-325 mg tablet for Resident #53 was faxed to the pharmacy on 5/30/24. Record review of Progress Note dated 5/29/24 at 7:33 AM by LPN #3 revealed, Resident is out of Norco which he requests twice a day for joint pain since 5/27/24 at bedtime. He told CNA that he needed saltine crackers to counter act withdrawal. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Pain. Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/30/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.