**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatments and services to promote healthy healing by failing to follow orders for antibiotics for one resident (Resident #1). Additionally, the facility failed to complete wound treatments, failed to complete skin assessments upon admission, re-admission and weekly and failed to complete weekly wound assessments for two residents (Residents #1 and #26). The sample size was three. The census was 51. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure. Review of the facility's pressure injury prevention and management policy, revised on 3/3/22, showed: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or removed underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate; -Licensed nurses will conduct full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record; -Assessments of pressure injures will be performed by a licensed nurse and documented in the medical record. Review of the facility's wound treatment management policy, revised on 9/1/22, showed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician order; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progress of healing; Changes in characteristics of the wound (location, pressure ulcer stage, size, drainage, pain, presence of infection, condition of issue in wound bed, condition of peri-wound); and changes in the resident's goals and preferences. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/12/23, showed: -Cognitively intact; -Rejection of care behavior not exhibited; -Impairment on both side of lower extremities; -Total dependence for toilet use; -Required substantial assistance for dressing, bed mobility and transfers; -Always incontinent of bladder; -Bowel not rated, resident has a colostomy (a piece of the colon is diverted through an artificial opening in the abdominal wall and stool passes through the colon through the abdominal wall into a bag located on the outside of the body to collect stool); -At risk for pressure ulcers; -One Stage IV unhealed pressure ulcer (PU) present upon admission; -Two unstageable PUs present upon admission; -Diagnoses included Stage IV PU of sacrum (sacral, triangular bone located above the coccyx (tailbone)), elevated blood cell count (showing infection) and anemia (iron poor blood). Review of the resident's medical record, showed: -An order, dated 10/11/23, for the specialty wound management to evaluate and treat as indicated; -An order, dated 10/11/23, discontinued 10/15/23, to cleanse wound to the sacrum area, apply wet to moist to wound bed, cover with abdominal pad (abd pad, absorbent pad) and tape, every day; Review of the resident's specialty wound management report, dated 10/12/23; showed: -Rounded with Wound Nurse. Extensive wound with exposed bone, necrotic muscle and necrotic fat. Wound culture and sensitivity test ordered; -Stage IV pressure ulcer at sacrum; measured 33 centimeters (cm) by 21 cm by 2.1 cm; necrotic muscle, bone and necrotic adipose (fat) were exposed; moderate amount of serosanguinous (composed of serum and blood) drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound (area around wound) presents with signs and symptoms of infection; -Stage III pressure ulcer at left hip, measured 3.9 cm by 5 cm by 0.3 cm with scant amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -A note, dated 10/12/23 at 2:47 P.M., the resident was seen by specialty Wound Nurse Practitioner (NP) for initial visit. Sacral wound was evaluated with bone evident, drainage and pain. Sacral wound orders include cleansing, Santyl (ointment to debride wounds) alginate (absorbent dressing) and abd pad. Hip order was to cleanse, apply Santyl, alginate and foam dressing; -An order, dated 10/13/23, to perform skin assessments every day shift on Fridays; -An order, dated 10/13/23, discontinued on 10/18/23, to cleanse, apply Santyl, alginate and abd pad, once a day for wound care. There was no location noted; -An order, dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day for wound care; -There was no documentation found that the resident's wound culture and sensitivity test had resulted and a new order was received from the Wound NP; -An order, dated 10/14/23 discontinued on 10/16/23, for Meropenem (antibiotic) intravenously (IV, administered into a vein), give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacrum for 5 days; -A note, dated 10/14/23 at 6:39 P.M., Meropenem was not administered because it did not arrive from the pharmacy. There was no documentation the pharmacy was contacted to follow up, the PCP was notified, or the nursing supervising team was notified; -A note, dated 10/14/23 at 9:41 P.M., Meropenem was not administered because it did not arrive from the pharmacy. There was no documentation the pharmacy was contacted to follow up, the PCP was notified, or the nursing supervising team was notified; -A note, dated 10/15/23 at 7:37 A.M., Meropenem was not administered because the resident did not have a peripherally interested central catheter (PICC, thin long tube inserted into vein in arm, leg or neck). There was no documentation found the PCP or nursing supervising team was notified; -A note, dated 10/15/23 at 10:46 A.M., the nurse attempted to insert an IV into the resident's arm and failed twice. The Director of Nursing (DON) was notified; -A note, dated 10/15/23 at 6:43 P.M., the nurse attempted to insert an IV into the resident's arm and failed; -A note, dated 10/16/23 at 1:09 P.M., the resident had new orders to go out to the hospital to get a PICC line placed; -A note, dated 10/16/23 at 2:23 P.M., the resident left for the hospital; -A note, dated 10/16/23 at 11:04 P.M., the resident returned from the hospital with a PICC line in his/her right arm; -An order dated 10/16/23, discontinued on 10/20/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer at sacrum for 5 days; -A note, dated 10/19/23 at 12:17 P.M., Wound NP to see the resident. The resident's Stage IV sacral PU measured 39 cm by 29 cm by 2.1 cm. Santyl with Calcium alginate. The resident's Stage III pressure ulcer measured 5 cm by 3 cm by 0.3 cm. Cleanse and apply border foam. The resident was his/her own responsible party. Review of the resident's specialty wound management report, dated 10/19/23; showed: -On 10/14/23, the results of wound culture showed positive for multiple strands bacteria; Meropenem (antibiotic) intravenous (IV, give through the vein) for five days ordered; -Stage IV PU at sacrum; measured 39 cm by 29 cm by 2.1 cm; necrotic muscle, bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III PU at left hip, measured 5 cm by 3 cm by 0.3 cm with scant amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day; -A note, dated 10/20/23 at 4:39 P.M., nurse unable to complete resident's treatments as wound nurse was not on shift. There was no documentation found the PCP or nursing supervisory team was notified; -A note, dated 10/23/23 at 4:49 P.M., the resident was sent to the hospital due to infiltration of the IV line; -A note, dated 10/23/23 at 10:54 P.M., the resident returned to the facility at or around 10:15 P.M. The resident's PICC line was in place and functioning properly; -A note, dated 10/24/23, at 5:58 P.M., the resident was sent to the hospital to receive a blood transfusion due to a low hemoglobin level (protein contained in red blood cells that is responsible for delivery of oxygen to the tissues). The ambulance was called and transported the resident to the hospital. Review of the resident's electronic Treatment Administration Record (eTAR), dated October 2023, showed: -An order, dated 10/11/23, discontinued 10/15/23, to cleanse wound to the sacrum area, apply wet to moist to wound bed, cover with abd pad and tape, every day, was documented as blank (showing not administered) on 10/15/23; -An order, dated 10/13/23, for weekly skin assessments, every Friday, was documented as completed on 10/13/23; -An order, dated 10/13/23, discontinued 10/18/23, to cleanse, apply Santyl, alginate and abd pad, once a day for wound care (no location specified) was documented as not given due to out to hospital on [DATE]; -An order dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day, was documented as resident refused on 10/14/23, not given due to out to hospital on [DATE], not completed due to wound nurse not on shift on 10/20/23 and not done due to resident out at hospital on [DATE]; -An order, dated 10/14/23 discontinued on 10/16/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacral region for 5 days was documented as not given due to medication not available at 2:00 P.M. and at 10:00 P.M. on 10/14/23, not given due to no PICC line at 8:00 A.M. on 10/15/23 and not given due to no IV access at 2:00 P.M. on 10/15/23, documentation was blank at 10:00 P.M. on 10/15/23 and at 8:00 A.M. on 10/16/23; -An order dated 10/16/23, discontinued on 10/20/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacral region for 5 days was documented as blank at 10:00 P.M. on 10/16/23 and blank at 8:00 A.M. on 10/17/23; -An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day, was documented as not done due to wound nurse not on shift on 10/20/23. Review of the resident's medical record showed: -There was no documentation the resident returned to the facility from the hospital; -There was no skin assessment completed after the resident was re-admitted from the hospital; -A note, dated 11/2/23 at 12:57 P.M., where the Wound NP visited the resident. The resident's Stage IV sacral PU measured 39 cm by 32 cm by 1.9 cm, a terminal (a wound that will not heal) wound, Santyl and calcium alginate. The resident's left hip wound measured 16 cm by 15.5 cm by 1.2 cm, a terminal wound, Santyl and calcium alginate. The resident was his/her own responsible party and aware. Review of the resident's specialty wound management report, dated 11/2/23; showed: -Stage IV PU at sacrum; measured 39 cm by 32 cm by 1.9 cm; necrotic muscle, bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III PU at left hip, measured 16 cm by 15.5 cm by 1.2 cm with small amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -There was no documentation the resident refused wound treatments on 11/2/23; -An order, dated 11/2/23, Meropenem IV, give 1 gram every 8 hours for bacterial infection until 11/28/23 at 10:47 A.M.; -There was no documentation why Meropenem was not given at 10:00 P.M. on 11/2/23; -A note, dated 11/3/23 at 5:14 A.M., Meropenem was not administered because there was no IV pump in the room; -A note, dated 11/3/23 at 3:14 P.M., Meropenem was not administered because it was not delivered by the pharmacy. There was no documentation the pharmacy was called to follow up on the order, the PCP was notified, or the nursing supervising team was notified; -A note, dated 11/5/23 at 5:23 A.M., Meropenem dose was missed; caught after 2:00 A.M. Next dose due at 6:00 A.M.; -On 11/7/23, at 1:42 P.M., there was no documentation of a base line care plan or a care plan was started or completed; -Review of the skin assessment, dated 11/7/23, no new wounds identified during the skin check. There was no documentation found regarding any existing wounds; -There were no other weekly skin assessments documented; -There was no order found to complete weekly wound assessments; -There were no weekly wound assessments found documenting all characteristics of the wounds; -A note, dated 11/9/23 at 10:47 A.M., Wound NP saw resident today. The resident's sacral wound measured 38.5 cm by 31 cm by 1.7 cm. Order changed. Resident's left hip wound measured 13 cm by 10 cm by 0.4 cm. Order changed. The resident was his/her own responsible party and aware. Review of the resident's specialty wound management report, dated 11/9/23; showed: -Stage IV pressure ulcer at sacrum; measured 38.5 cm by 31 cm by 1.7 cm; necrotic muscle, necrotic bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III pressure ulcer at left hip, measured 13 cm by 10 cm by 0.4 cm. with moderate amount of serosanguinous drainage noted; 1% to 25% granulation , 1% to 25% slough and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -A PCP progress note, dated 11/10/23, showing on 11/7/23, requesting hospice consult due to terminal wounds and overall decline. The resident was currently treated with IV antibiotics and receiving wound care, both would have to stop if brought into hospice; -An order, dated 11/10/23, for sacral wound; Cleanse entire area with normal saline (NS), mix collagen powder (stimulates new tissue growth) with hydrogel (keeps wounds moist and apply to entire area every day shift; -An order, dated 11/10/23, for left hip wound, cleanse area with NS, mix collagen powder with hydrogel and apply, cover with abd pad, every day shift; -There was no documentation why the resident did not receive treatments on 11/11/23 or 11/12/23. Review of the resident's eTAR, dated November 2023, showed: -An order, dated 10/13/23, for weekly skin assessments every day shift on Fridays, was documented as no on 11/3/23, and blank on 11/10/23; -An order dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day, was documented as blank on 11/1/23, resident refused on 11/2/23, and blank on 11/4/23; - An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day, was documented as blank on 11/1/23, 2 on 11/3/23, blank on 11/3/23 and blank on 11/4/23; -An order, dated 11/2/23 at 2:00 P.M., for Meropenem IV, 1 gram every 8 hours, was documented as blank at 2:00 P.M. and see progress notes at 10:00 P.M. on 11/2/23, as see progress notes at 8:00 A.M. and 2:00 P.M. on 11/3/23, as blank at 11:00 P.M. on 11/5/23, and as blank at 8:00 A.M., on 11/6/23; -An order, dated 11/10/23, for sacral wound, administer collagen powder with hydrogel, every day, was documented as blank on 11/10/23, see progress notes on 11/11/23, blank on 11/12/23, and blank on 11/14/23; -An order, dated 11/10/23, for left hip wound, administer collagen powder with hydrogel, cover with abd pad, every day, was documented as blank on 11/10/23, see progress notes on 11/11/23, blank on 11/12/23, and blank on 11/14/23. During an interview on 11/13/23 at 10:40 A.M., the resident said his/her wound treatments had not been changed in days. He/She did not always receive his/her antibiotics or dressing changes as ordered. Observation on 11/13/23, at 10:41 A.M., showed the resident lay in his/her bed on his/her back. The absorbent pad which was placed underneath the resident's waist to mid-thigh was visibly drenched with a foul smelling substance. The pad had dark brown and yellow rings extending from beneath the resident towards the edges of the pad. Licensed Practical Nurse (LPN) N and Certified Nurse Assistant (CNA) J turned the resident to his/her side, exposing the resident's sacrum. The bandage, dated 11/9/23, located at the resident's sacrum was soaked through with brown, yellowish drainage with a strong, foul odor. The bandage was soaking wet with foul drainage, it slipped off the resident's body. During an interview on 11/13/23 at 10:56 A.M. and at 12:55 P.M., CNA J said he/she was assigned to the resident that day. He/She worked with the resident regularly, if not almost daily. He/She had never experienced the resident refusing care. He/She had never seen the resident's treatment or bed as soaking wet with drainage as it was today. The resident's wounds did weep, but if the treatments were changed regularly, the wetness was not as bad and did not come through the dressing. Review of the PCP progress note, dated 11/13/23, showed: -History: The resident was laying in his/her bed, sleeping and barley able to wake up to talk to the PCP. A change of consciousness from the last visit was noted. The resident was not answering questions appropriately and had numerous wounds on his/her body and has been on IV antibiotics. There has been some mention of hospice care. PCP will go ahead and order a hospice consult and may have to contact the power of attorney (POA, legal authorization for a designated person to make decisions about another person's property, finances, or medical care) for this patient if he/she has one because of his new change in mental status; -Plan: -Gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection): Resident has numerous wounds and has been receiving IV antibiotics, continue IV antibiotics; -Decubitus ulcer of sacral region, unstageable: Continue present care at this moment resident unable to tell PCP one way or the other if he/she wants hospice care; -Acute alteration in mental status: Resident is probably a candidate for hospice at this time he/she could not answer questions appropriately and may need to contact next of care guardian, hospice consult initiated; -Overall Plan: 1. Reviewed current medications continue all medications, 2. Referral for hospice care may also need to contact this resident's guardian as he/she was unable to answer questions for the PCP on the day the PCP saw him/her. During an interview on 11/14/23, at 12:35 P.M., the Wound NP said: -She ordered Meropenem IV for 5 days on 10/14/23 after the wound culture resulted on that same day with multiple strains of bacteria; -She was not aware the resident did not receive the antibiotic as ordered. During an interview on 11/16/23 at 7:54 A.M., CNA J said if he/she noticed a dressing was soiled he/she would report it to the Charge Nurse. CNA J said seeing soiled dressings happens so often, he/she cannot remember who he/she has reported it to. CNA J said he/she has seen soiled dressings at least every other day. CNA J said the resident acted like his/her normal self on 11/13/23 while he/she was working day shift. When the resident returned from the hospital on [DATE], the resident was doing better, eating well, communicating well. It really surprised CNA J the resident passed away on 11/15/23. During an interview on 11/20/2023 at 2:21 PM, the Wound Nurse Practitioner (NP), said she described the photo of the resident's coccyx wound, taken upon admission, dated 10/6/23, as having 60% granulation, 30% slough and 10% necrotic tissue present in the wound base, with scant sero-sanguineous drainage present. She assessed the resident's coccyx wound in person on 10/12/23 and noted the wound had increased slough and potentially increased necrotic tissue in the wound bed as well as increased drainage compared to the wound picture taken on 10/6/23. The quality of the wound tissue declined, wound margins appeared to have expanded distally and proximally from initial wound size in the admission photo. 2. Review of Resident #27's admission MDS, dated [DATE], showed: -Cognitively intact; -No behaviors noted; -Impairments on both sides of lower body; -Required total assistance for toileting, bathing, personal hygiene and transfers; -Required substantial assistance for dressing and bed mobility; -Used a wheelchair for mobility; -Used a catheter (tube inserted into bladder to drain urine) for bladder; -Was always incontinent of bowel; -Diagnoses included kidney disease, heart failure, diabetes mellitus, osteomyelitis (bone infection) and atrial fibrillation (irregular heartbeat; -At risk for pressure ulcers; -Had one, unhealed Stage III pressure ulcer upon admission; -Had three un-stageable pressure ulcers present upon admission; -Received dialysis (treatment for kidney disease) while a resident. Review of the resident's care plan, dated 9/7/23, showed: -The resident had actual impairment to his/her skin integrity; -Interventions included monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Medical Director (MD); Weekly skin assessments done by nurse; Weekly treatment documentation to include measure of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the resident's medical record, showed: -A skin assessment, dated 9/27/23, the resident had unstageable pressure ulcers located at his/her right and left heels. There was no other documentation found describing the characteristics of the wound; -An order, dated 9/28/23, discontinued on 10/10/23, to apply Santyl to right heel, cover with calcium alginate, abdominal pad and wrap with kling (flexible, rolled gauze dressing) every day; -An order, dated 9/29/23, discontinued on 10/5/23, for skin prep (forms protective barrier) to left heel, cover with abd pad and cover with kling wrap, every day; -A note, dated 10/5/23 at 12:27 P.M., the resident was sent to the hospital for evaluation due to excessive swelling in upper arms and knees. Review of the resident's specialty wound management report, dated 10/5/23; showed: -An unstageable PU, at left heel present; measured 3.5 cm by 3.0 cm by 3.1 cm with 76% to 100% eschar tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 3.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 1% to 25% granulation, 26% to 50% slough and 1% to 25% eschar tissue present at wound base. Review of the resident's medical record, showed: -A note, dated 10/12/23 at 6:55 P.M., the resident returned back from the hospital. There was no documentation regarding the resident's skin integrity; -There was no skin assessment completed after the resident was re-admitted on [DATE]; -A note, dated 10/16/23 at 7:56 A.M., the resident was sent to the hospital; -A note, dated 10/18/23 at 6:18 P.M., the resident was re-admitted to the facility. There was no documentation regarding the resident's skin integrity; -There was no skin assessment completed after the resident was re-admitted on [DATE]. Review of the resident's specialty wound management report, dated 10/19/23; showed: -An unstageable PU, at left heel present; measured 2.4 cm by 1.2 cm by 0.2 cm; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 2.8 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 1% to 25% granulation, 1% to 25% slough and 26% to 50% eschar tissue present at wound base. Review of the resident's medical record, showed: -A note, dated 10/19/23 at 10:48 A.M., the resident was seen by the Wound NP via video. The resident's wound located at his/her left heel measured 2.4 cm by 1.2 cm by 0.2 cm and the resident's wound located at his/her right heel measured 1.5 cm by 2.8 cm by 0.2 cm; -An order, dated 10/19/23, complete weekly skin assessments every Thursday. If there are any skin issues, identify on skin assessment; -An order, dated 10/20/23, to apply Santyl to right heel, cover calcium alginate, abd pad, and kling wrap, every day; -An order, dated 10/20/23, to apply Santyl to left heel, cover calcium alginate, abd pad, and kling wrap, every day; -There were no orders found for specialty wound management team to evaluate and treat the resident's wounds; -There were no orders found for weekly skin assessments for the time period from 9/22/23 through 10/18/23; -There was no documentation found that skin assessments were completed from 10/4/23 through 10/18/23 by a nurse; -A skin assessment, dated 10/25/23, the resident had a Stage III PU at his/her right heel, measuring 1.5 cm by 2.8 cm by 0.2 cm and an un-stageable PU located at his/her left heel measuring 2.4 cm by 1.2 cm. Review of the resident's specialty wound management report, dated 10/26/23; showed: -A Stage III PU, at left heel present; measured 3.5 cm by 2.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 2.4 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present at wound base. Review of the resident's electronic medication administration record (eMAR), dated October 2023, showed: -An order, dated 9/28/23, discontinued on 10/10/12, for treatment to right heel, every day, was documented blank (showing not completed as ordered) on 10/2/23 and 10/3/23; -An order, dated 9/29/23 and discontinued on 10/5/23, for treatment to the left heel was documented as blank on 10/1/23 and 10/2/23; - An order, dated 10/20/23, for treatment to left heel every day, was documented as not administered due to wound nurse not present on 10/20/23, not administered on 10/23/23 or on 10/27/23 due to resident out to dialysis or 10/30/23 because resident was absent; -An order, dated 10/20/23, for treatment to right heel, every day, was documented as not administered due to wound nurse not present on 10/20/23, not administered on 10/23/23 or on 10/27/23 due to resident out to dialysis or 10/30/23 because resident was absent. Review of the resident's specialty wound management report, dated 11/02/23, showed: -Stage III PU, at left heel present; measured 1.7 cm by 1.5 cm by 0.2 cm with small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed; -Stage III PU, at right heel present; measured 1.2 cm by 2.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed. Review of the resident's medical record, showed: -A note, dated 11/9/23 at 11:14 A.M., showed the Wound NP saw the resident. The wound at the resident's left heel measured 1.9 cm by 1.4 cm by 0.2 and the wound at the resident's right heel measured 1.2 cm by 2.0 cm by 0.4 cm; -There were no orders for weekly wound assessments; -There were no weekly wound a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered, failed to document the reason the residents missed doses and failed to document the measures they took to obtain the medication, for four of 28 sampled residents (Residents #6, #27, #21 and #1). Resident #6 experienced pain resulting in the resident crying out and rocking back and forth and calling family members crying. Resident #27 was unable to get out of bed because he/she was in so much pain he/she could not sit up in his/her wheelchair. Resident #21 described their pain as excruciating. The facility also failed to administer pain medications to Resident #1 prior to completing wound care. The resident described their pain as an eight out of ten, aching and steady to the areas where he/she had wounds. The census was 51. Review of the facility's Medication Reordering policy, revised 4/7/22, showed: -Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident; -Policy Explanation and Compliance Guidelines: --The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident; --Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; --In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the medical provider; --For STAT (immediate) medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy. The STAT medication can be stored in a portable, but sealed emergency box or container, or may be stored in an electronic dispensing system. Review of the facility's Pain Management Policy, revised 9/1/21, showed: -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; -In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility shall: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs; c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences; -Facility staff shall be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: *Hurting or aching; *Throbbing; *Burning: *Numbness, tingling, shooting or radiating; *Soreness, tenderness, discomfort; -Pain assessment: The facility shall utilize a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Pain Management and Treatment: Based upon the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, and monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -Pharmacological interventions shall follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team shall develop a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: *Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain; *Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. 1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/28/23, showed: -Unclear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain presence, yes; -Diagnoses included Parkinson's disease (a progressive disorder that affects the nervous system), acute and chronic respiratory failure, heart failure, pain and diabetes. Review of the resident's care plan, dated 10/13/23, showed: -Focus: Resident has impaired cognitive function/dementia or impaired thought processes; -Interventions: Administer medications as ordered, Monitor/document for side effects and effectiveness; -Focus: Resident has alteration in comfort due to pain; -Interventions: Administer analgesia as ordered. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review of compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor for side effects of pain medication. Observe for new onset of increased agitation, restlessness, confusion, hallucinations. Report occurrences to the physician. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. Review of grievances filed by the resident, showed: -On 8/28/23: -Were you able to report the concern to a staff member: Yes; -If yes, please provide staff member's name: Administrator's name; -Please describe the concern in detail: Resident says he/she is not getting his/her medicine as he/she should. He/She has to wait too long for his/her medicine; -On 9/20/23, a customer and concern feedback form, showed: -Were you able to report the comment/concern to a staff member? Yes; -If yes, please provide staff member name: The Administrator and Director of Nursing (DON)'s name; -Describe in detail the comment or concern: States night shift staff refused to give him/her pain medication every fours hours as needed; -Investigation findings: The resident's order is for every four hours as needed. Resident was educated he/she would have to ask for the medications, as they are not scheduled. Review of the resident's progress notes on 9/20/23 at 8:31 P.M., showed the staff received a call from the resident's physician's office. The physician did not approve the resident's Norco to every 4 hours as needed. The staff member explained to the physician's office the resident and his/her family member complained of the every four hours not being administered. The office contacted the physician who gave a new order for the Norco every 6 hours scheduled. Review of the resident's electronic physician order sheet (ePOS), showed: -Order, dated 8/2/23, for acetaminophen (used to relieve mild to moderate pain) oral tablet 500 milligrams (mg), give two tablets by mouth three times a day for mild pain; -Order, dated 9/7/23, for baclofen (muscle relaxer), 10 mg, give one tablet every eight hours related to pain; -Order, dated 10/13/23, for hydrocodone-acetaminophen tablet (Norco) 5-300 mg (opiate pain medication), give one tablet by mouth every six hours for pain. Review of the resident's medication administration record (MAR), showed: -On 10/14/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded. At 8:00 P.M., staff documented the resident's pain level at a six (pain level 0 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain). Two tablets of acetaminophen 500 mg were administered; -On 10/18/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/19/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/26/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/27/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/28/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/29/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/3/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Staff did not document the acetaminophen 500 mg or baclofen as administered; -On 11/6/23 at 6:00 A.M. and 6:00 P.M., staff did not document the resident's pain level. There was no documentation of Norco administered. At 6:00 A.M., there was no documentation of Acetaminophen 500 mg or baclofen administered; -Chart codes: 9 = Other/See progress notes. Review of the resident's progress notes, showed: -On 10/14/23, no documentation about 6:00 P.M. Norco; -On 10/18/23 at 1:19 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the Norco medication or why the medication was not administered; -On 10/19/23 at 1:53 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of medication or why the medication was not administered; -On 10/25/23 at 11:27 P.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of medication or why the medication was not administered; -On 10/27/23 at 12:06 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the medication or why the medication was not administered; -On 10/28/23 at 3:49 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the medication or why the medication was not administered. Review of the resident's controlled drug receipt forms, showed: -On 10/22/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next Norco signed out on 10/23/23 at 4:00 A.M. (missed 12:00 A.M. dosage); -On 10/25/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/26/23 at 6:00 A.M. (missed 12:00 A.M. dosage); -On 10/26/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/27/23 at 5:00 A.M. (missed 12:00 A.M. dosage); -On 10/27/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/28/23 at 6:00 A.M. (missed 12:00 A.M. dosage); -On 10/30/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/31/23 at 5:30 A.M. (missed 12:00 A.M. dosage); -On 11/3/23, hydrocodone-acetaminophen signed out at 11:25 A.M., next hydrocodone-acetaminophen signed out on 11/4/23 at 12:00 A.M. (missed 6:00 P.M. dosage); -No documentation of why the missed medication was not administered. During an interview on 11/1/23 at 8:10 A.M., the resident said he/she was in pain all of the time. It was especially bad at night. He/She put his/her light on and it will take a long time for the staff to respond, and sometimes they will not respond at all. He/She was confused, so sometimes he/she could not always remember when he/she last got his/her medication. The staff will come and turn his/her light off and tell him/her they will be back, and then they will not come back, and he/she will be in pain all night. During an interview on 11/1/23 at 2:00 P.M., the resident's family member said he/she complained to administration in September about the staff not responding to the resident's pain at night. The resident will be due for his/her medication, and he/she will ask the staff about it and will be told the resident will get the medication when the staff can get to him/her. After he/she complained, the resident's physician changed his/her medication from as needed every four hours to routinely every six hours, but the resident was still not always getting it. The resident will call the family member crying and say he/she is in pain, and the staff will not bring him/her the pain medication. Review of Resident #22's admission MDS dated [DATE], showed: -Adequate hearing and vision; -Cognitively intact. During an interview on 11/7/23 at 12:40 P.M., Resident #22 said Resident #6 stays in the room next to him/her. He/She could sometimes hear Resident #6 cry out in pain in the mornings. This often happens between 4:00 A.M. and 5:00 A.M., and it wakes him/her up. Resident #6 will call out for the nurse and this will go on for a long time sometimes. Resident #22 could hear Resident #6 yelling for his/her pain medication. Resident #22 has gotten out of bed a couple of times to find staff to get assistance for Resident #6. During an interview on 11/2/23 at 11:48 A.M. Registered Nurse (RN) P said if he/she was working and noticed a resident was running low on pain medication, he/she would go to the resident summary in the electronic (e)MAR and hit reorder. If that did not work, he/she would call the pharmacy and ask them to reorder the medication. He/She would make sure to give the pain medication before he/she left. For Norco, staff should reorder seven days before the prescription runs out because they need to call the physician and the pharmacy to get the order refilled. The staff have to call the physician to sign the Norco script to send to the pharmacy or have the pharmacy call the physician to get the script approved. Staff should not be waiting until the last day to get the order filled in case they need to do all of this. They can get an order for a Norco out of the emergency medication system (e-kit) in an emergency. Observation and interview on 11/7/23 at 4:45 P.M., showed Resident #6's call light on. The resident said he/she was in pain. He/She was crying and rocking back and forth. He/She said he/she had asked the staff for pain medication several times already. He/She did not remember getting a pain pill earlier in the day. At 5:35 P.M., Certified Nurse's Aide (CNA) C entered the room, spoke to the resident, turned off the resident's light and left the room. At 5:45 P.M., the resident turned his/her light back on. During an interview on 11/7/23 at 5:50 P.M., CNA C said the resident had turned on his/her light to complain about being in pain. He/She had asked for a pain pill earlier and the CNA reported this to the Certified Medication Technician (CMT) on duty. Review of the resident's MAR dated 11/7/23, showed: -At 12:00 A.M., Norco administered; pain level assessed at a 3 ; -At 6:00 A.M., Norco administered; pain level assessed at a 6; -At 12:00 P.M., no documentation for pain level or Norco administration; -At 2:00 P.M., staff recorded a pain level of 0 and administered two tablets of acetaminophen; -At 6:00 P.M., Norco administered; pain level assessed at a 10. Review of the resident's drug receipt form, showed: -On 11/6/23, Norco signed out at 12:24 P.M., next Norco signed out on 11/7/23 at 12:00 A.M. (missed 6:00 P.M. dosage). This was listed as the last Norco in the prescription; -On 11/7/23 at 6:00 A.M., a Norco signed out with no information regarding where the medication was obtained. Review of a medication re-order form dated 11/7/23, showed an order sent to the pharmacy for the resident's Norco at 6:28 A.M., that morning. Review of the resident's progress notes dated 11/7/23, showed no documentation of the resident's complaints of pain, steps taken to alleviate the pain, the unavailability of the narcotic medication, where the Norco was obtained or if obtained for the 6:00 A.M. administration, or actions taken to obtain the medication from the pharmacy. During an interview on 11/8/23 at 7:00 A.M., CMT K said the resident was supposed to be administered pain medication at midnight but never woke up asking for it. It probably should not be ordered for every six hours. If it was not administered, there should be documentation why it was not administered. If the resident was not needing it at night, staff should contact the physician to see about getting the order changed. During an interview on 11/7/23 at 6:10 P.M., CMT E said he/she knew the resident was in pain, but they had run out of his/her Norco the day before, and the refill had not arrived from the pharmacy yet. He/She had let both nurses know the resident was out of medication that morning. CMT E had given the resident 1000 mg of acetaminophen earlier. CMT E did not know why staff had not reordered the medication until after it had run out. They were supposed to order the medication when it got to the last line on the card, usually three to five days before the medication ran out, so residents would not be without their medication. The CMTs could do this by reordering it on the computer, faxing or calling the order into the pharmacy. If the medication was a Norco, then they would let the nurse know because this usually required a script and the nurse would have to notify the physician to get the script sent to the pharmacy. They had called the pharmacy earlier that day about the medication, and it was on order but would not arrive until after midnight. He/she had not administered any Norco to the resident earlier that day and had not notified the nurse to pull the medication from the e-kit. During an interview on 11/7/23 at 5:55 P.M., Licensed Practical Nurse (LPN) N said the CMT should have notified the nurse on duty about the resident being out of his/her pain medication so he/she could have called the pharmacy to get a code to pull the medication from the e-kit. The staff should be ordering the medication prior to it running out. Narcotics require a script from the physician and sometimes the facility or the pharmacy must contact the physician to get this, and it can hold the medication from being filled. The staff should be contacting the resident's physician if they could not get the script filled to find out if there was anything else they could give the resident for pain. Review of the resident's MAR, showed: -On 11/9/23 at 2:00 P.M., baclofen not documented as administered; a 9 was recorded; -On 11/10/23 at 6:00 A.M. and at 10:00 P.M., baclofen not documented as administered; a 9 was recorded; -On 11/10/23 at 12:00 A.M., staff did not document the resident's pain level. Norco was not documented as administered; a 9 was recorded. During an interview on 11/7/23 at 10:30 A.M., the Director of Nursing said it depended on the resident or resident's family if staff would wake them up in the middle of the night to administer pain medication. If the resident was sleeping, staff should document why the medication was not administered. If the resident continued to sleep through that medication time, then staff should contact the physician and get the order changed to omit that medication time. The resident occasionally asked for his/her pain medications at night. He/she requested them during the day and evening. He/She had Parkinson's Disease and experienced anxiety more than pain. The staff had to work with him/her to try and avoid the anxiety as much as possible. He/She complained of pain a lot. The staff should be ordering the medication seven days prior to it running out. If it is a nurse that notices the medication, he/she should contact the physician to get a script from the physician to send to the pharmacy. If it is a CMT that notices the medication is down to seven days, then he/she should notify the nurse to make the notifications. If the resident has completely run out, then the nurse could call the pharmacy to get an access code to access the e-kit to get the medication from the e-kit. A resident should not have to go for three days without a pain pill. 2. Review of Resident #27's admission MDS, dated [DATE], showed: -Clear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain presence, yes; -Pain intensity: Moderate; -Diagnoses included fracture of the left shoulder, multiple fractures of the ribs, paraplegia (paralysis), spinal stenosis (narrowing of the spine) and unspecified fractures of the T-5 and T-6 vertebrae (T-5 thoracic spinal cord injuries primarily affect the muscles in the upper chest, upper back, and inner arms. T-6 spinal cord injuries can affect balance, walking, and bowel and bladder functions). Review of the resident's care plan, dated 10/13/23, showed no documentation of the resident's pain or interventions for pain. Review of the resident's ePOS, showed: -Order, dated 9/18/23, for acetaminophen, 325 mg, give two tablets by mouth as needed for pain. Give with oxycodone; -Order, dated 10/9/23, for oxycodone HCL (a pain medication) oral tablet 10 mg, give one tablet by mouth every four hours. Review of the resident's MAR, showed: -On 10/13/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/14/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/21/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/22/23 at 8:00 A.M., staff recorded the the resident's pain level as a 1. Oxycodone was not documented as administered; a 9 was recorded. At 10:00 A.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded. At 2:00 P.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded. At 6:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 10:00 P.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded; -On 10/23/23 at 6:00 A.M., staff did not document the resident's pain level or administration of oxycodone. At 10:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 2:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 6:00 P.M., staff documented a 0 for the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 11/2/23 at 6:00 P.M., staff did not document the resident's pain level or administration of oxycodone; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered. At 6:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered. At 10:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 11/6/23 at 6:00 A.M., staff did not document the resident's pain level or administration of oxycodone; -On 11/15/23 at 6:00 P.M., oxycodone was not documented as administered; a 9 was recorded. At 10:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. Review of the resident's progress notes, showed: -On 10/21/23 at 6:26 A.M., the resident only had one remaining pain pill. He/She was not given the 2:00 A.M., dose and instead, given the 6:00 A.M. dose. Medication was faxed to pharmacy for refill. Waiting for medication to arrive at facility. Staff explained this to the resident and resident verbalized his/her understanding. At 11:17 A.M., oxycodone, not available. At 3:12 P.M., medication not available. At 7:32 P.M., medication not available -On 10/22/23 at 6:36 A.M., oxycodone, medication on order. At 3:59 P.M., medication not available. At 6:38 P.M., medication not available; -On 10/23/23 at 11:41 A.M., oxycodone medication unavailable, called pharmacy, waiting on script. At 12:03 P.M., nurse faxed script for oxycodone refill to the physician's office. At 2:19 P.M., oxycodone 10 mg, medication unavailable; -On 10/24/23 at 7:35 A.M., resident voiced complaint over no pain medications over the weekends; -On 10/25/23 at 5:16 A.M., physician's progress note- Will continue physical and pain control. Patient is at high risk for functional impairment without therapy and adequate pain control. Patient has a high risk for developing contractures, pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), poor healing if not receiving adequate therapy and pain control. Observation and interview on 11/2/23 at 11:20 A.M., showed the resident seated in a wheelchair. The resident said he/she was shot in the shoulder in September and has chronic pain. He/She has run out of his/her pain medication a couple of times since being admitted and the last time it took a few days to get it refilled. He/She takes oxycodone for the pain and was without it from a Saturday morning until Monday night. He/She actually started going through withdrawals by the time he/she was able to get the medication. The only thing the staff offered him/her was Tylenol (acetaminophen), which does nothing to help ease the pain. During an interview on 11/2/23 at 12:40 A.M., CMT E said the resident ran out of his/her oxycodone last month, and he/she told the nurse. The resident never complained to him/her about the pain. He/She would just say he/she was going to flip out. The nurse would pull the pain medication from the e-kit but could only pull one pill a day. The resident has his/her pain medication now. During an interview on 11/2/23 at 11:15 P.M., LPN O said sometimes when a resident's prescription for a narcotic runs out, the pharmacy will not fill it unless the physician sends a new script. They were unable to get in contact with the resident's physician that weekend in October to get the script renewed and had to wait until Monday before they could get it filled. Sometimes if a resident comes in from the hospital without a script over the weekend, they will have to wait 72 hours or more for the physician to sign the script. The pharmacy will not send the medication without a script and the primary care physician will not give them the medication unless the hospital sends a script with them. The physician has said he/she has 72 hours to sign the script, so the resident will go days without their pain medication. If a resident is in extreme pain, the physician says to send them to the hospital, but the nurses have to get permission from the DON to send a resident to the hospital, and the staff have not always been able to reach her. Medications should be ordered seven days before the resident runs out. The CMT orders it unless it is a narcotic, then the nurse would call the physician to get a prescription sent to the pharmacy. They call the pharmacy for an access code to the e-kit. They cannot get a code to the e-kit unless there is a script for that medication. They can only pull a limited supply of a medication from the e-kit, and there is a limited supply of medications in the e-kit. If it is a narcotic, they can only pull one medication for a resident in a 24 hour period. They do not keep a list of what is in the e-kit. Further review of the resident's progress notes on 11/15/23 at 5:53 A.M., showed a eMAR note if oxycodone 10 mg, medication on order. At 11:04 A.M., medication unavailable. At 1:17 P.M., the nurse placed a call out out to the pharmacy to inquire about the resident's pain medication. The person the nurse spoke with informed him/her it would be sent out on the next medication run. The nurse requested a code for the e-kit and it was received. At 5:15 P.M., the medication was unavailable. At 8:00 P.M., the medication was on order; not in from the pharmacy. Review of the facility's card count medication sign off, dated 11/15/23, showed staff signed off as receiving 12 oxycodone pills between 7:00 P.M. and 7:00 A.M. During an interview on 11/16/23 at 8:35 A.M., LPN C said the resident was out of medication on 11/15/23 because they needed a new signed prescription from the physician. He/She pulled one from the e-kit for one dose the day before, and the pharmacy sent the new cards either last night or that morning. He/She talked to the resident's physician to request an order for more than nine days of medication since it requires a script each time it is renewed. Further review of the resident's MAR on 11/26/23 at 2:00 P.M., showed staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. Further review of the resident's progress notes, showed: -On 11/26/23 at 5:12 P.M., showed staff placed a call to the pharmacy regarding the oxycodone being out of stock. The pharmacist said they will stat (should be prioritized first as it's needed urgently) out an order. Staff notified the resident and he/she is thankful for the follow up; -On 12/4/23 at 3:52 P.M., the resident's physician in to see the resident with the following order change made: Increase oxycodone to 15 mg, one tablet by mouth every four hours scheduled; -On 12/5/23 at 5:59 P.M., eMAR note, only 10 mg of oxycodone available. Staff informed resident and he/she agreed to take what is available; -On 12/6/23 at 1:24 P.M., the nurse placed a call to the pharmacy and inquired about the pain med. The pharmacy informed the nurse they were waiting for the script to be signed by the physician; -On 12/7/23 at 5:57 A.M., eMAR note, oxycodone 15 mg, not available waiting for MD to sign script. At 6:50 A.M., staff informed the resident he/she was out of his/her oxycodone. The resident became loud and agitated, and would not allow the staff to explain they were waiting on a script from the physician. Staff called the pharmacy and requested they call the physician's office but the person who answered the phone at the on call physician's office could not sign for the medication. Staff would pass this information on to the morning nurse. At 8:08 A.M., staff spoke to someone at the resident's physician's office who requested the pharmacy send over a [TRUNCATED]