**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) identify and address a severe weight loss of 7.6 pounds (lbs.) and 5.3% in one week from 9/15/22 through 9/22/22, and obtain a reweight for 1 of 4 residents, (Resident #97), b.) ensure that a resident identified as at risk for malnutrition or malnourished was comprehensively evaluated and assessed for 2 of 4 residents, (Resident #38 and #97), and c.) provide the recommended supplements to residents that experienced weight loss for 3 of 4 residents, (Resident #33, #38 and #97) reviewed for nutrition. The evidence was as follows: 1. On 3/2/23 at 11:25 AM, the surveyor observed Resident # 97 awake and seated in a wheelchair in front of the North nursing unit. At that time, the resident stated that he/she was aware of his/her weight loss. The surveyor reviewed the electronic and paper medical record for Resident # 97. Review of the admission Record (an admission summary), included that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), hemiplegia and hemiparesis (weakness of one side of the body) following cerebral infarction affecting the right dominant side, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/13/22, included a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated that the resident had an intact cognition. Review of the March 2023 Order Summary Report (OSR) indicated a physician order (PO) dated 8/15/22, for a Regular diet *Regular texture, Thin consistency. Review of the August 2022 through March 2023, electronic Medication Administration Record (eMAR) reflected the above corresponding PO. Review of the resident's weights included the following: 9/15/22 145.6 lbs. 9/22/22 138 lbs. Review of Nutrition Assessment -V2 dated 8/22/22, indicated that the Registered Dietitian (RD) #1 observed the resident consume > 50% of the breakfast meal. It further indicated that the resident's food preferences, diet, and weight history were obtained. It also included nutritional interventions for a super cereal (a nutritionally fortified hot cereal) at breakfast and a four ounce (oz) mighty shake for breakfast, lunch, and dinner to provide 200 calories and 6 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid (electronic and paper) medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the resident's progress notes from the hybrid medical records from 9/22/22 through 2/22/23, reflected no documented evidence that the resident's severe weight loss was identified and addressed by the RD, Nursing, Attending Physician (AP) or the Nurse Practitioner (NP). Review of the Mini Nutritional assessment dated [DATE] which was completed by RD #2, indicated that the resident was identified as Malnourished, had a moderate decrease in food intake, and had a weight loss greater than 6.6 lbs. There was no documented evidence that RD #2 reassessed the resident and recommended nutritional interventions. Review of the resident's comprehensive care plan (CP), a nutrition CP initiated on 8/29/22 included interventions for .supplements as rx'd [prescribed]; monitor weight, labs, skin integrity, hydration status; honor food preferences; meds as rx'd. There was no documented evidence of a revised CP that addressed the severe weight loss. Review of the resident's meal tickets (documentation of what was provided on a meal tray for breakfast, lunch, and dinner) provided to the surveyor by the Food Service Director (FSD), in the presence of the Regional FSD on 3/2/23 at 10:08AM, did not reflect the RDs recommended nutritional supplements. Review of the Nursing Quality Assurance Performance Improvement Plan Monthly Review (NQAPIPMR) forms dated 9/22/22, 10/20/22, 11/28/22, and 1/26/23, included a Weight Variance Report that addressed residents who experienced weight losses. Resident #97 was not included. On 3/2/23 at 11:36 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN). She stated that the DON, RD, and UMs conducted monthly weight meetings and discussed those residents who experienced weight loss. She stated that the DON retained the weight meeting documentation records. She acknowledged that she was aware of the resident's severe weight loss and recently discussed this with the RD. The UM/LPN stated that the RD told her that maybe the original weight documentation was incorrect, but she was not sure if this was documented in the resident's medical record. On 3/2/23 at 11:52 AM, the surveyor interviewed the Certified Nursing Aide (CNA) #1 who was familiar with the resident. She stated that residents were weighed by CNAs monthly or sometimes twice weekly. She was not aware of the Resident #97's weight loss. The CNA could not speak to whether the resident received nutritional supplements on his/her meal trays. On 3/2/23 at 12:20 PM, the surveyor interviewed the DON who stated that she, the RD, and UMs conducted monthly meetings to discuss residents who experienced weight loss. She further stated that the content of the meetings were documented on the NQAPIPMR forms. The DON provided copies to the surveyor. On 3/2/23 at 1:04 PM, the surveyor reviewed the NQAPIPMR forms which indicated a list of residents and their calculated weight loss. The report indicated whether the weight loss was desired, undesired, planned or unplanned. It further included nutritional interventions and the date the CPs were revised. Resident #97 was not included. On 3/2/23 at 1:24 PM, the surveyor interviewed the DON in the presence of the survey team. She stated that RD #1 worked from November 2021 through December 31, 2022, RD #2 was employed from January 2023 through February 10, 2023, and RD #3 would be working as an interim from February 11, 2023, to present. On 3/2/23 at 2:04 PM, the surveyor interviewed RD #3 in the presence of the survey team. RD #3 confirmed the above statement from the DON regarding her employment timeline in the facility. She stated that she documented comprehensive nutritional assessments for new admissions and then initiated a comprehensive nutrition care plan and provided dietary recommendations. Furthermore, RD #3 also stated that she revised care plans quarterly, annually and on an as needed basis. She stated that we always update the care plans. RD #3 further stated that if she recommended nutritional supplements, she would complete a Dietitian Recommendations communication form. She stated that she then presented the form to the nurse who signed it and relayed the information to the physician. She stated that a copy went to the FSD, and a copy remained in the chart. She stated that the form was utilized to communicate initiation or discontinuation of nutritional supplements. She acknowledged that the RD and AP should have been notified of a resident's 5% or more weight loss in one week and that weekly weight monitoring should have been conducted. During the interview, RD #3 stated that the RDs reviewed residents' weekly or monthly weights depending on the status. She further stated that after she reviewed the weights, she conducts a nutritional assessment which would be documented in the medical record. She acknowledged that if a resident had a significant weight loss, she would request a re-weight to confirm the weight loss. She stated that if a significant weight loss was confirmed, she would conduct a root cause analysis to determine whether the weight loss was intentional or unintentional, make nutritional recommendations, and revise the care plan, all of which would be documented in the resident's medical record. On 3/3/23 at 10:25 AM, the surveyor had a follow up interview with Resident #97. The resident stated that he/she had not received mighty shake supplements. The resident further stated that he/she was just recently offered a vanilla mighty shake, but he/she refused it and stated it was too sweet. Resident #97 informed the surveyor that he/she never liked any kind of cereal, and the staff were aware of his/her food preferences. The resident also stated that the staff did not offer him/her other alternatives to choose from. On 3/3/23 at 10:33 AM, the surveyor conducted a follow up interview with the UM/LPN in the presence of a second surveyor. The UM/LPN informed the surveyor that the residents were weighed monthly by the CNAs. She stated that she would review the weights for discrepancies to confirm significant weight loss. She further stated that if a significant weight loss was confirmed, she or the nurse would document this in the resident's electronic medical records, and she would notify the RD. She stated that the RD would document a nutritional assessment and then communicate recommendations with the Dietician Recommendations form. The UM/LPN stated that she would sign the recommendation form in acknowledgement, then the RD would alert the kitchen of the nutritional supplements that needed to be provided to the resident. She further stated that the RD also notified her for any discontinuation of nutritional supplements and that the RD would directly speak to the kitchen staff to communicate the discontinued recommendations. During the interview, the UM/LPN stated that she would notify the AP and that the AP usually agreed to the RD recommendations. The UM/LPN stated that she only documented in the resident's medical records when the AP disagreed with the recommendations. The UM/LPN acknowledged that the resident received mighty shakes and super cereal on his/her meal trays in the past. She further acknowledged that the resident did not prefer the nutritional supplements and that the RD was notified of this. However, the UM/LPN could not speak to whether the RD reassessed the resident, updated his/her preferences and made new recommendations. The UM/LPN stated that she relied on the RD for weight calculation to determine weight loss. She further stated that she expected the RD to identify and address significant weight loss and provide nutritional interventions. On 3/3/23 at 12:55 PM, the LNHA and DON met with the survey team. The DON acknowledged that the CNAs obtained weights. She stated if there was a weight discrepancy, a re-weight should be obtained to confirm significant weight loss. She further stated that she expected the nurse to notify the RD of the confirmed weight loss, and that the RD should have addressed the weight loss with a nutritional assessment, revised CP, and provided nutritional interventions which may include supplements. Furthermore, the DON stated that nutritional supplements were provided with the resident's meal and acknowledged that there was no documented evidence to account for the administration and recorded consumption of the mighty shakes and super cereal. On 3/6/23 at 9:41 AM, the surveyor attempted to call the resident's AP in the presence of the survey team, but the AP was not available at that time. The AP's office manager (OM) informed the surveyor that the AP would be in the office at 3:00 PM. On 3/6/23 at 10:33 AM, the surveyor interviewed the DON in the presence of the survey team. She stated that she reviewed Resident #97's paper medical records and acknowledged that there was no documented evidence from the AP and RD that addressed the residents severe weight loss, and she stated, I did not see any. On 3/6/23 at 12:20 PM, the LNHA, LNHA in training, and DON met with the survey team. The DON acknowledged that the resident's AP was aware of the resident's significant weight loss but did not address it. She further acknowledged that the RD was also aware of the resident significant weight loss, but the RD failed to document this in the resident's medical records. The DON stated that the resident had resolved edema which could have contributed to the resident's weight loss, and then acknowledged that there was no documented evidence related to when that occurred. The DON acknowledged that she was unable to correlate the resolved edema and the weight loss. During the interview the DON stated that the Mini Nutritional Assessment form was utilized to assess whether a resident was malnourished or at risk for malnutrition. The DON stated that she expected the RD to act upon when a resident was identified as malnourished or at risk with a documented comprehensive nutritional assessment and a revised CP to include dietary interventions. The DON informed the survey team that the Mini Nutritional Assessment was new to them, and she had never seen that form prior to surveyor inquiry. On that same date at 3:36 PM, the surveyor reattempted to conduct a telephone interview with the AP, but the OM stated that the AP was unavailable to speak to the surveyor. 3. On 2/22/23 at 12:13 PM, the surveyor observed Resident #33 in his/her room seated in a wheelchair in front of the lunch tray on an overbed table. The resident stated that he/she had not eaten lunch yet and the plate was covered with a domed lid. There was no mighty shake observed on the tray. On 2/24/23 at 12:53 PM and on 3/2/23 at 1:15 PM, the surveyor observed the resident in his/her room seated in a wheelchair in front of the lunch tray on an overbed table. There was no mighty shake observed on the tray. The surveyor reviewed the electronic and paper medical record for Resident #33. Review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to; dysphagia (difficulty swallowing) and Alzheimer's disease, unspecified. Review of the admission MDS dated [DATE], reflected that the resident had a BIMS score of 12 out of 15, which indicated that the resident had a slightly impaired cognition. It further reflected that the resident was holding food in mouth/cheeks or residual food in mouth after meals, was 65 inches tall, weighed 125 lbs., experienced a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and Yes, not on a physician-prescribed weight-loss regimen, and was on a mechanically altered diet-require change in texture of food or liquid . Review of the March 2023 OSR indicated a PO dated 11/7/22, for a Mechanical Soft Chopped meats texture. Review of the November 2022 through March 2023 eMAR, reflected the above corresponding PO. Review of the resident's weights included the following: 9/29/22 139 lbs. 11/2/22 125 lbs. Review of the Nutrition Assessment -V2 dated 11/7/22, included that the resident experienced a 10% weight loss x 60 days and that RD #1 observed the resident consumed > 50% of the lunch meal. It further indicated that the RD initiated a care plan. The RD further documented nutritional interventions which included a four oz mighty shake twice a day at lunch and dinner to provide 200 calories and 6 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the CP did not reflect documented evidence of a nutritional status CP that included the resident's weight loss, nutritional goals or interventions. Review of the resident's paper chart did not include Dietitian Recommendations forms. Review of the resident's meal tickets provided to the surveyor by the FSD, in the presence of the Regional FSD on 3/2/23 at 10:08AM, did not include a mighty shake for lunch or dinner. On 3/03/23 at 10:18 AM, the surveyor interviewed Resident #33, who stated that he/she had never received a mighty shake on the lunch or dinner tray. The resident stated that they came yesterday to ask about it. On 3/03/23 at 11:02 AM, the surveyor interviewed the residents regularly assigned CNA #3 who stated that she had not observed a mighty shake on the resident's lunch tray. On 3/03/23 at 1:20 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. She stated that when the RD assessed a resident and made recommendations, she assumed the RD would follow up. On 3/03/23 at 1:44 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. The DON acknowledged that there was no documented evidence that mighty shakes were provided to the resident. She further stated that if the RD discontinued the mighty shakes there should have been follow up documentation with a rationale. On 3/06/23 at 12:00 PM, the surveyor interviewed the LNHA in the presence of the DON, the LNHA in training and the survey team. The LNHA stated that RD #1 worked consistently throughout the entire year of 2022. On 3/06/23 at 12:53 PM, the surveyor conducted a phone interview with RD #3. She stated that the Mini Nutritional Assessment form was a screening tool used to identify a resident as malnourished or at risk for malnutrition. She stated that this tool was not considered a comprehensive nutrition assessment. She further stated that the RD should have completed a comprehensive follow up evaluation and assessment, and even if supplementation was not indicated, there should have been supporting documentation. RD #3 also stated that if the RD discontinued nutritional supplements, there should have been supporting documentation as well. On 3/6/23 at 1:34 PM, the survey team met with the LNHA, LNHA in training, and DON. There was no additional information provided. Review of the facility policy Weight Taking and Recording with a revised date of 5/2022, reflected that the policy was to . strive to prevent, monitor, and intervene for undesirable weight loss for our residents. In addition, it included to . to monitor weight changes. It also included the following: The dietitian will review the weight and will make recommendations as necessary . Any weight change of 5 lbs. +/- or more since the last weight assessment will be taken for confirmation with the license nurse. If the weight is verified the dietitian will be notified . The Unit Manager and the Dietitian will review the completed monthly weights . The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 1 month - 5% weight loss is significant; greater that 5% is severe . The dietitian will review the weekly weight and will make necessary recommendations as necessary. Review of the facility policy Nutritional Management with a revised date of 10/22/22, included the following: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status . Acceptable parameters of nutritional status refer to factors that reflect that an individual's nutritional status is adequate . such as weight, food/fluid intake, and pertinent laboratory values . A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors, b. Evaluating/analyzing the assessment information, c. Developing and consistently implementing pertinent approaches, d. Monitor the effectiveness of interventions and revising them as necessary . A comprehensive nutritional assessment will be completed by a dietitian on all admission, annual, and upon significant change in condition . The assessment shall clarify the resident's current nutritional status and individual risk factors . The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient and fluid needs and whether intake is adequate to meet those needs . Care plan implementation: a. The residents' goals and preferences regarding nutrition will be reflected in the resident's plan of care. b) Interventions will be individualized to address the specific needs of the resident . Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis . The care plan will be updated as needed, such as when a resident's condition changes . interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified . The physician will be notified of significant changes in weight, intake, or nutritional status . The comprehensive care plan should describe any interventions offered but declined by the resident or resident's representative. NJAC 8:39-11.2(e)(2) (i), 17.1(c), 17.4(a)(3), 27.1(a) 2. On 2/22/23 at 10:15 AM, the surveyor observed Resident #38 seated in a wheelchair and listening to the radio. The resident appeared thin and did not respond to surveyor inquiries. On 2/27/23 at 12:15 PM, the surveyor observed the resident eating lunch independently. The resident meal consisted of a sweet potato, roasted pork and Brussel Sprouts. There was also a dessert and a low-fat milk on the tray. The resident stated that he/she consumed most of the roasted pork and sweet potatoes, and few of the Brussel sprouts. On 2/27/23 at 12:39 PM, the surveyor observed both the CNA #2 and an LPN in the resident's room encouraging the resident to consume more food. The surveyor observed that the resident consumed 0% of the lemon meringue pie dessert. In addition, there was no mighty shake or magic cup (supplements) observed on the resident's lunch tray or on the overbed table. The surveyor reviewed the electronic and paper medical record for Resident #38. Review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to; malignant neoplasm of prostate (prostate cancer), major depressive disorder (mood disorder that causes a persistent feeling of sadness and a loss of interest), neutropenia (condition of few neutrophils, a type of white blood cell that fights infection), and anemia (condition that causes a lack of healthy red blood cells to carry adequate oxygen to body tissues). Review of the quarterly MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. Review of the March 2023 OSR POs indicated a PO for a Regular diet, Regular texture, and thin consistency with a start date of 3/5/21. It also included a PO dated 8/6/22, for Remeron 15 milligrams (mg) one tablet by mouth at bedtime as an appetite stimulant. Review of the September 2022 through March 2023 eMAR, reflected the above corresponding PO. Review of the resident's weights included the following: 8/11/22 96 lbs. 9/5/22 93 lbs. 10/3/22 97 lbs. 11/10/22 95 lbs. 12/9/22 95 lbs. 1/6/23 94 lbs. 2/1/23 92.6 lbs. Review of the resident's progress notes from the hybrid medical record from 9/1/22 through 02/22/23, included the following documentation related to the resident's nutritional status: Review of the nutritional progress note dated 9/8/22, indicated that the resident experienced a 9.7% weight loss over the last 90 days. It also indicated that the resident had a mildly depleted albumin (protein in the blood) level of 3.4 dated 7/8/22. RD #1 documented that she observed the resident consume less than 50% of breakfast that day and added the following supplements: a four oz mighty shake at lunch and dinner, which provided an additional 200 calories and six grams of protein per four oz portion, and a four oz magic cup at lunch and dinner, which provided an additional 290 calories and 9 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the Mini Nutritional Assessment completed by RD #2 and dated 1/9/23, identified Resident #38 as being at risk for malnutrition. There was no further documented evidence of a comprehensive nutrition assessment or revised nutritional interventions to address the risk for malnutrition, prior to surveyor inquiry. Review of the nursing progress notes from 9/1/22 until 2/22/23, did not include documented evidence that the resident received or refused the mighty shake and magic cups at lunch and dinner. Review of the resident's paper chart did not include Dietitian Recommendations (the communication form utilized by the RD to inform the nursing staff, the physician and the Food Service Department for the recommended nutritional supplements) forms. Review of the CP date initiated 9/8/22, included the following interventions, Diet, supplements, snacks, fortified foods as rx'd [prescribed]; honor food preferences; meds as rx'd; weight, labs, hydration status, diet counseling/education as needed. The CP did not include that the resident was at risk for malnutrition and there was no evidence of revisions, or additional interventions related to the identification of risk for malnutrition dated on or after 1/9/23, until to surveyor inquiry. Review of the resident's meal tickets provided to the surveyor by the FSD, in the presence of the Regional FSD on 2/27/23 at 10:00AM, did not include a mighty shake or magic cup for lunch or dinner. On 3/6/23 at 12:30 PM, the surveyor interviewed the DON, in the presence of the LNHA and the survey team. She acknowledged that the 1/9/23, Mini Nutritional Assessment identified the resident at risk for malnutrition. She further stated that the RD should have documented a follow up comprehensive nutritional assessment and revised the care plan.

Based on observation, interview and record review, it was determined that the facility failed to: a.) administer breakthrough pain medication in a timely manner when a resident visually and verbally exhibited signs of unmanaged pain during movement, b.) ensure the same resident was appropriately assessed and pre-medicated for breakthrough pain prior to performing wound care and activities of daily living, and c.) place a pressure-relieving gel seat cushion to the chair when out of bed to offload pressure and reduce pain associated with the resident's full thickness tissue loss pressure ulcer. This deficient practice was identified for 1 of 3 residents reviewed for pain management (Resident #25). The evidence was as follows: On 3/2/21 from 11:28 AM to 11:57 AM, the surveyor observed that Resident #25 was in bed on an air mattress. The resident's eye's were closed and the room was darkened. The surveyor interviewed the resident's roommate who stated that Resident #25 was very sick. The surveyor asked the roommate how he/she knew Resident #25 was very sick and he/she replied that Resident #25 would shout out but the roommate was unable to elaborate further. The surveyor reviewed the medical record for Resident #25. A review of the admission Record face sheet (an admission summary) reflected that the resident had diagnoses which included altered mental status, abnormalities of gait and mobility, atrophy (muscle wasting due to a lack of physical activity), abdominal aortic aneurysm, multiple sites of idiopathic gout (arthritis characterized by severe pain, redness, and tenderness in the joints with an unknown cause), edema (swelling), and anxiety. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/22/20 reflected that the resident had a brief interview for mental status score of 11 out of 15 indicating an intact cognition with moderate forgetfulness. The MDS assessment included that the resident had no behaviors in the last seven days of rejecting care, or physical or verbal behaviors. It further included that the resident required an extensive two person physical assist for bed mobility and personal hygiene, and only transferred out of bed 1-2 times in the last seven days. The assessment indicated that the resident had a functional limitation in range of motion affecting one side of the upper extremity and one side of the lower extremity. The resident's pain was further assessed at that time to reflect that he/she had occasional pain level of 5 out of 10 on a pain scale, a moderately distressing pain, that did not impact sleep or day to day activities. The MDS reflected that the resident received a scheduled opioid pain medication 7 out of the last 7 days, and in addition received pain medication as needed (PRN). A review of the resident's individualized comprehensive care plan initiated on 9/20/19 reflected that the resident needed pain management due to multiple conditions including but not limited to degenerative disc disease of the lumbar spine, gout, episodes of on and pain to the left lower abdomen related to an aortic aneurysm, a history of hemorrhoidal pain, osteoporosis (a condition that causes weak and brittle bones), neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), and a history of a surgical incision on the inguinal area. The goal indicated that the resident will maintain an adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. Interventions included to Administer medication as ordered .Evaluated characteristics and frequency/pattern of pain .evaluate what makes the patient's pain worse .monitor swelling/pain of joints and Notify MD [Medical Doctor]. The care plan initiated on 8/19/20 further reflected that the resident had acute/chronic pain from his/her medical conditions and that he/she had range of motion limitations due to immobility. The goal for managing the resident's pain was revised on 2/20/21 and included that the resident will have an acceptable pain level one hour after intervention was initiated with a goal date of 6/20/21. Interventions included to: Avoid pressure on the areas of pain; Complete pain assessment; Distracting activities; Evaluate the effectiveness of pain medications, Give pain medications; Re-position for comfort. (The care plan addressed neither the resident's acceptable numeric level of pain nor any precipitating factors that were known to cause him/her increased pain). Further review of the resident's individualized comprehensive care plan dated 10/26/2020 revealed that the resident had a behavior sometimes of refuses to get OOB [out of bed] but it did not specify why the resident refused to get out of bed. A review of the Certified Nursing Aide Kardex for Resident #25 included to complete pain assessment as needed .ROHO Cushion to wheelchair when OOB [out of bed]. A review of the most recent Wound Consult report dated 3/3/21 reflected that Resident #25 also had a Stage III (full thickness tissue loss) pressure ulcer to the sacrum that was improving. The wound measured 2 centimeters (cm) x 1.5 cm x 0.3 cm and was draining a moderate amount of serous (clear) drainage. The Wound Consult report indicated that the wound bed was covered in 30% slough (yellowing dead tissue), which was debrided (removed the dead tissue) using a blade and Benzocaine 20% spray (a topical anesthetic) without complications. The Wound Consultant/Advanced Practice Nurse (WC/APN) recommended to perform a wound dressing change daily to the sacral ulcer by applying Santyl (a debriding agent) in a nickel-thick amount to the wound, apply collagen powder and calcium alginate cut to fit the size of the wound base and cover the wound with a bordered foam dressing. An additional Order included to avoiding position directing pressure to Wound site .continue use of ROHO cushion (a seat cushion to relieve pressure and allows for more comfort while sitting for longer periods of time). The resident's care plan initiated on 9/20/19 did not specifically address that the resident had a Stage III pressure ulcer to the sacrum. Interventions in the care plan for Impaired Skin Integrity dated 8/20/20 only included vague descriptions of the resident's skin including that the resident had a skin issue, open areas, area monitored but it did not specify a sacral ulcer or the implications of pain related to a Stage III pressure ulcer to the sacrum. An intervention dated 12/9/2020 included to use a ROHO cushion to wheelchair when out of bed. Interventions did not address assessing or pre-medicating the resident prophlyactically for pain prior to daily wound treatments. A review of the physician's Order Recap Report for March 2021 and the electronic Medication Administration Record (eMAR) for March 2021 included the following physician's orders (PO) to assess the resident's pain score every shift as of 9/30/20 and to address the resident's pain as follows: 1.) a PO dated 11/25/20 for a narcotic analgesic, Oxycodone Hydrochloride (HCl). The order specified to administer one tablet of 5-milligrams (mg) by mouth every eight (8) hours around the clock for pain management. The eMAR was plotted for the Oxycodone HCl to be administered at 6 AM, 2 PM and 10 PM. 2.) a PO dated 9/30/20 for Tylenol 325 mg (an analgesic that treats minor aches and pains). The order specified to administer two tablets to equal 650 mg every four (4) hours as needed for mild pain (numeric pain scale of 1-3). The eMAR was plotted for the Tylenol to have a Pain Level numeric assessment documented with the PRN dose. 3.) a PO dated 10/22/20 to administer the schedule-IV controlled opioid analgesic, Tramadol HCl tablet. The order specified to administer 100 mg by mouth every eight (8) hours as needed for moderate to severe pain with numeric levels of 4-10 on a pain scale of 0 to 10. The eMAR was plotted to be administered PRN. 4.) a PO dated 12/9/20 to apply Lidocaine Ointment (a topical numbing cream) 5% to the sacral area topically every 24 hours as needed for numbing prior to the wound treatment, and that it may be used less than or equal to four times daily. The eMAR was plotted for the ointment to be applied PRN. The Order Recap Report for March 2021 further reflected a PO dated 9/30/20 for Pramoxine Cream 1-2.5% for rectal inflammation to be applied topically every 6 hours PRN, and a PO dated 11/14/20 for a daily scheduled medication used to treat gout (Allopurinol 100 mg). There were no other physician orders used to medicinally manage the resident's pain. The surveyor continued to observe and conduct interviews with facility staff. The following was revealed: On 3/9/21 at 10:40 AM, the surveyor observed Resident #25 in bed on an air mattress. The resident was awake and the resident's assigned Certified Nursing Aide (CNA) was in the resident's room. The CNA stated that she had finished providing morning care to Resident #25. The surveyor asked the resident in the presence of the CNA if he/she could show the surveyor their hands from under the blanket, and the resident just stared at the surveyor. At that time, the CNA slowly removed the resident's blanket that was covering his/her body and began to gently touch and open the resident's right and left hand. There was no visible acute swelling to either the left or right arm. As the CNA opened the resident's left hand, the surveyor observed the resident quickly pulled back the left arm and make a facial grimace as though he/she had pain. The CNA acknowledged the resident's discomfort in moving his/her upper left extremity. The CNA then showed the surveyor the resident's feet from under the blanket. The surveyor observed that both legs were elevated on a single pillow and the left leg had more swelling that the right leg. The resident's left foot was in a plantar flexion (when the top of the foot points away from the leg) and the left leg was laterally rotated. The resident's left heel was in direct contact with the resident's lateral right ankle. There was no positioning devices in place. The CNA separated the resident's left and right leg from touching, and the resident immediately flinched and grimaced. The CNA then covered the feet with a blanket. At that time, the resident's cell phone rang and the CNA assisted the resident with the phone call by holding the phone to the resident's ear. The surveyor observed that the resident was not verbally communicating back with the caller. After the CNA terminated the call after several minutes of the resident not verbally engaging, the surveyor interviewed the CNA. The CNA stated that Resident #25 was alert and oriented and in the past could usually make his/her needs known without an issue, but in the last two months the resident has had a decline in cognition and function. The CNA confirmed that the resident was not verbally responding to the caller and that his/her cognition and ability to communicate would wax and wane. The CNA continued that she now had to anticipate all of the resident's needs because he/she was dependent on staff for all activities of daily living and required at least two people to provide care because the resident was unable to turn in bed or hold a phone to the ear anymore. The CNA elaborated that the resident would wear specialized boots when out of bed, but that Resident #25 would often refuse to get up or accept showers on shower days anymore. The surveyor asked the CNA why the resident refused to get out of bed or allow for showers anymore, and the CNA stated that it may be because [he/she] had pain. The CNA added that she thought it was because of pain because the resident cries when I wash him/her. The CNA acknowledged that on gentle touch or movement of the left arm and leg in the presence of the surveyor, the resident exhibited signs of discomfort. The CNA stated that movement would often increased the resident's pain, so when the resident would cry during care, she would immediately stop and get the nurse and the nurse would administer pain medication to the resident. She stated that she would return to finish care after about 30 minutes so the medication could take effect. The CNA stated that the resident could usually say if he/she was in pain or if he/she didn't want to eat, but it depended on the day. The CNA stated that the resident had a little open wound on the buttock that the nurse puts a treatment on everyday. The CNA stated that she thought the resident developed the wound in the hospital. The CNA wasn't sure if the resident received pain medication prior to care, adding that the surveyor would have to ask the nurse that question. On the same day 3/9/21 at 11:03 AM, the surveyor interviewed the resident's assigned Licensed Practical Nurse (LPN). The LPN stated that this was her first day with Resident #25 because she was an agency nurse. The LPN stated that she was orienting with a Registered Nurse (RN) but the RN was also new and had only been working at the facility for about three to four weeks herself. She stated that she couldn't speak to much about the resident. The surveyor asked what information she received on the shift to shift report about Resident #25, and neither the LPN nor RN could speak to the information they received on report about Resident #25. The LPN stated that she did just finish a wound treatment with the RN for Resident #25 around between 9:30 AM and 10:00 AM this morning. The surveyor asked the LPN about how the resident tolerated the wound dressing change, and the LPN stated that the resident didn't complain of any pain in the moment. The surveyor inquired about the pain assessment done prior to the wound care, and the LPN stated that the resident did not give her a numeric pain scale number, so she didn't need the pain meds at the time. The LPN stated that she did not pre-medicate the resident for any pain because the resident did not complain of pain. The surveyor asked how she assesses for pain and she stated that she asks for a numeric number and depending on the number she will medicate for pain. She added that I typically give pain meds before a dressing change but that she did not do it today. The LPN stated that she did the wound care with the RN today. At 11:15 AM, the surveyor interviewed the RN who stated that the resident had a pressure ulcer to the sacrum about the size of a nickel and that it was not draining. The surveyor asked the RN if she had conducted a pain assessment prior to the wound care, and the RN stated that she asked the resident are you in pain? and the resident reported that the pain was a 2-3 out of 10, but she didn't need to give the resident any medication because the resident had already received a dose of Oxycodone HCl at 6 AM. The RN confirmed that a wound treatment performed between 9:30 AM and 10:00 AM was between 3 to 3.5 hours since the last dose. The RN did not speak to the administration of Tylenol for mild pain of 1-3, or the order for the Lidocaine cream to be applied PRN prior to wound care. At 11:21 AM, the LPN/Unit Manager (LPN/UM) overheard the surveyor interviewing the LPN and the RN, and the LPN/UM stated that she was there also during the wound treatment this morning with the resident because the resident needs assistance with turning and the resident was new to the nurses. The LPN/UM stated that the resident didn't say a word and that the resident was not moaning. The LPN/UM stated that had she seen the resident flinch in pain, moan or scream, she would stop or have the nurses stop and medicate the resident for pain and return. The surveyor asked why they would wait until the resident was in pain to medicate him/her, instead of offering a prescribed medication (Tylenol, Tramadol, or Lidocaine as ordered by the physician) prophlyactically to prevent any pain. The LPN/UM acknowledged that it was easier to prevent pain than to treat pain, but kept insisting that the resident did not even flinch in pain. The surveyor asked the LPN/UM about the resident's pain management, and the LPN/UM stated that the resident has a history of generalized pain mostly to the lower extremities and that he/she would sometimes just lay in bed and scream. She added that when the resident gets out of bed he/she screams also and therapy was working with the resident. She stated that medications were adjusted and whatever [he/she] is getting now is effective. The surveyor asked the LPN/UM what makes the pain worse for Resident #25, and she stated that if someone goes to change the resident just touching him/her the resident will yell Oww! Oww! as though in pain. She elaborated that repositioning makes the pain worse, and because the resident will sometimes scream without anyone even touching him/her, it's more of a behavior and not necessarily pain. The LPN/UM continued to state that despite the resident's history of flinching when changing him/her, or touching and repositioning causing the resident to report signs of pain, that this did not occur during the wound treatment that morning. The LPN/UM confirmed that the resident did not get pre-medicated prior to the wound treatments. The surveyor reviewed the resident's eMAR for March 2021 together with the LPN, the RN and the LPN/UM who confirmed that there was no record of administration of any pain medication administered including the Tylenol, Tramadol, or the Lidocaine numbing ointment given prior to the wound care in accordance with the physician's order. The surveyor reviewed the Individual Patient Controlled Drug Records for the Oxycodone 5 mg and the Tramadol 100 mg order in the presence of the LPN, the RN, and the LPN/UM. The declining inventory record revealed that the last dose of Oxycodone 5 mg was removed from inventory on 3/9/21 at 6 AM that morning and the last dose of Tramadol was removed on 3/2/21 at 9:42 AM. At 11:30 AM, the RN stated to the surveyor that it was a standard of practice to give a pain medication prior to treatment. The RN stated that because the pain medication doses were PRN and not routinely scheduled, and because it didn't look like the resident was in any pain, it wasn't needed. The LPN and RN both stated that they would only chart by exception that if a resident exhibited pain during a wound treatment than they would document how the resident tolerated the procedure, but otherwise they wouldn't need to document how he/she tolerated the dressing change. The LPN/UM further expressed that the resident had a psychiatric consult on 2/19/21 for evaluation of a gradual dose reduction of his/her psychotropic medications, and the psychotropic medications were subsequently discontinued. The LPN/UM stated that the resident's calling out in pain was sometimes behavioral and we had to determine if the resident was really in pain or if it was a behavior. She stated that they thought it might be behavioral because the resident would receive pain medication and after it was effective, the resident would continue exhibit signs of pain. The surveyor asked how she knew the pain medication given was effective if the resident was showing or verbalizing pain, and the LPN/UM stated that it was because the resident was already medicated. The LPN/UM confirmed that it could also mean that the medication was not effective if the resident continued to exhibit signs of pain. She acknowledged that pain was subjective and tolerance to pain can vary between individuals. She was not aware of the resident's numeric acceptable pain level. The surveyor asked to see any Psychiatric consults, Physiatrist Consults or any other Physician notes that addressed the resident's verbalizations of pain as being a behavior. The LPN/UM stated that she would get back to the surveyor. On 3/9/21 at 11:54 AM, the surveyor and the LPN entered the room of Resident #25 who was in bed with eyes closed. The LPN attempted to move the resident's left leg and the resident pulled back the leg and grimaced. The LPN stated that this was indicative of pain and that he/she could receive pain medication now. She stated that the resident appears comfortable until moving him/her. She confirmed that avoiding movement can be an alleviating factor for pain, and assessment for pain involves more than just looking at a resident. She confirmed pain assessment should include how the resident responds to normal activities of daily living, repositioning, touching and other visual cues of pain, and not just when looking at a resident at rest. She could not speak to if the resident responded in the same way during the wound treatment that morning between 9:30 AM and 10:00 AM. The LPN stated that she would give the resident pain medication now. A review of the eMAR's for February 2021 and March 2021 did not reflect documented evidence that the resident received the PRN Lidocaine ointment to the sacrum prior the dressing change. The eMAR's were also blank to reflect the resident did not receive any doses of Tylenol PRN for mild to moderate pain of 1-3 out of 10 on the pain scale. The eMAR for February 2021 further reflected that the resident only got Tramadol 100 mg on 2/5/21 at 9:35 AM for a pain of 5 out of 10 on the pain scale; on 2/12/21 at 9:10 PM for a pain of 4 out of 10 on the pain scale; 2/19/21 at 9:36 AM for a pain of 5 out of 10 on the pain scale; and on 2/20/21 at 11:00 AM for a pain of 7 out of 10 on the pain scale. The Tramadol was documented as effective on those dates. There was no documented evidence that these doses of Tramadol were given prophlyactically prior to wound care of the Stage III pressure ulcer to the sacrum. A review of the eMAR for March 2021 conducted on 3/9/21 reflected that the resident received Tramadol on 3/1 at 11:30 AM for a pain of 5 out of 10 on the pain scale which was effective; on 3/2/21 at 9:43 AM for a pain of 4 out of 10 on the pain scale which was effective, and on 3/9/21 at 12:00 PM for a pain of 4 out of 10 on the pain scale. On 3/9/21 as of 1:32 PM, there was no documented evidence that the resident had been re-evaluated for the effectiveness of the 12:00 PM dose of Tramadol given on 3/9/21. Further, there was no documented evidence that these doses of Tramadol were given prophlyactically prior to wound care of the Stage III pressure ulcer to the sacrum. A review of the Physical Medicine and Rehabilitation Follow up notes dated 10/26/20 reflected that the resident had good pain control status post right knee injection during the last visit. Extremities were noted to have gross edema .not tenderness to the right knee at this time, continues to have left knee tenderness to palpation with no swelling . The Plan was to use Tylenol PRN and Tramadol PRN . the MD performed a steroid injection to the left knee. A review of the most recent Physical Medicine and Rehabilitation Follow up note dated 12/3/20 reflected that the resident was seen for a chief complaint of generalized weakness and muscle atrophy and denies any acute issues at that time. Range of Motion assessment revealed right lower extremity was impaired at the knee. The left lower extremity was impaired at the hip, the right upper extremity was impaired at the shoulder and elbow, and the left upper extremity was within functional limits. The Plan for pain included Tylenol PRN and Tramadol PRN, and otherwise as per eMAR, and to monitor for side effects and efficacy. Medical team to follow up. The next day on 3/10/21 at 8:38 AM, the surveyor observed Resident #25 awake in bed on an air mattress. The surveyor attempted to interview the resident about his/her pain and the resident verbally responded to the surveyor. The resident stated that he/she had pain in the back-side. The resident was only able to elaborate on the location of the pain, and not the type, severity, duration or other possible causes of the pain. The resident stated that he/she got pain medication that morning, and when asked if the medication was effective at relieving the pain, the resident replied, No. The resident continued to state that not only did he/she have pain to the back-side but also had pain that also went up higher and the resident kept repeating that the pain was across the shoulders, too. At 8:43 AM, while the surveyor was interviewing Resident #25, the Licensed Practical Nurse (LPN) assigned to care for Resident #25 entered the resident's room. The LPN was not the same LPN as assigned to the resident on 3/9/21. The surveyor observed that the LPN was holding a medicine cup filled with apple sauce. The LPN stated that a Certified Nursing Aide (CNA #2) had reported to her that Resident #25 was experiencing pain during morning care. The LPN stated that the Tylenol that she gave that morning around 7 AM was not effective and therefore she was going to administer a PRN dose of Tramadol for breakthrough pain. The surveyor observed the LPN put two whole tablets of the Tramadol into the resident's mouth at one time using a cup of apple sauce, and gave the resident a cup of water with a straw. The resident did not drink through the straw, so the LPN used the teaspoon from the apple sauce to collect water from the drinking cup and attempted to give the resident water using a spoon-feeding method with two teaspoons of water. The LPN encouraged the resident to swallow the medication, but the resident pocketed it and then spit out both of the tablets and the remaining applesauce from his/her mouth. At that time the LPN confirmed that the resident spit out the two tablets of Tramadol, and she accessed a brown paper towel and wiped the resident's mouth with the paper towel. The surveyor observed the LPN roll up the two whole Tramadol tablets into the paper towel, and crumpled it into a ball. She then removed her gloves over the brown paper towel with the Tramadol tablets inside it and threw it all in the resident's regular trash can at the door. The LPN exited the resident's room and stated that she was going to get another dose of Tramadol and crush it up this time, so the LPN returned to the medication cart. The surveyor observed the LPN open the Narcotic book and access the resident's Individual Patient's Controlled Drug Record (a declining inventory sheet used for the accountability of controlled drugs) for the Tramadol tablets. The drug record reflected the Tramadol tablets were white oblong in color and shape. The LPN turned to the back of the drug record which was used for signing Destroyed/Wasted Medication Doses. The LPN filled out the form reflecting that tablets number 16 and 17 had been wasted because resident spit out. The LPN signed for the destruction of the Tramadol. The LPN then signed out two additional tablets (Tablet 14 and 15) of Tramadol from the resident's Individual Patient's Controlled Drug Record, removed the two tablets from the the medication card, and proceeded to crush them into fine granules and put it into a cup of applesauce for ease of swallowing. At approximately 8:57 AM, the LPN spoon fed the two tablets of crushed Tramadol into the resident's mouth, and upon the medication sitting in the resident's mouth, the resident began to grimace and repeating, I don't like that, I don't like that. At 8:59 AM, the resident stated that he/she was going to throw up and the resident began to spit out the crushed up Tramadol tablets in the presence of a Registered Nurse (RN) and the surveyor. The LPN stated that the resident was not able to take the Tramadol after two attempts, so she collected the crushed Tramadol granules that the resident spit out, put it back into the medicine cup and brought it to the medication cart. She then opened the Narcotic book and returned to the resident's Individual Patient Controlled Drug Record for the Tramadol, and on the back of the form she began to fill out the destruction/wasting of Tramadol dose 14 and 15, but she didn't fully record a reason for why the tablets were not given. At 9:01 AM, the LPN informed the surveyor that because the two attempts to administer Tramadol was ineffective and that he/she spit them both out, that she was going to call the Medical Doctor (MD) to get an order for a pain medication that can be taken by an alternate route that didn't require swallowing such as a sublingual tablet (which can dissolve under the tongue) or an analgesic suppository. The LPN stated that the resident looked comfortable and that because the RN was in the resident's room that she had time to call the MD and get the order for a new pain medication. On the same day on 3/10/21 at 9:15 AM, the LPN showed the surveyor the Lidocaine 5% ointment from the treatment cart. The ointment tube was designated for Resident #25 and had a delivery date of the day before on 3/9/21 and an open date of 3/10/21, and the tube appeared to have been used. The LPN confirmed that the Lidocaine was delivered yesterday or last night. She could not speak to if they had the Lidocaine had been available prior to yesterday or if there was any housestock. She stated that the Wound Consultant had made rounds at approximately 6:30 AM that morning and that she had done the wound treatment for Resident #25 and had used the Lidocaine numbing ointment. On 3/10/21 at 9:17 AM, the surveyor interviewed the Rehab Director/Physical Therapist (PT). The PT stated that the resident received Occupational Therapy (OT) services from 10/1/2020 until 11/20/2020, and Physical Therapy services form 10/1/2020 until 12/4/2020. She stated that she had worked with the resident on and off during his/her time receiving Physical Therapy. She stated that the resident had been hospitalized in September 2020, and was readmitted to the facility with weakness and required a maximum assistance for bed mobility and transfers. She stated that the resident was also evaluated for the use of positioning boots because of identified plantar flexion of the foot, and that the boots were necessary to stabilize and prevent further contractures of the feet. She stated that the resident was tolerating the multipodus boots for up to three hours while in bed upon discharge from rehab services. The surveyor asked the PT about the resident's pain during rehab services, and the PT stated that the therapists performed active range of motion exercises with the resident during therapy services and used positioning wedges for the left leg due to the left hip that was rotated causing the resident pain. She stated that the resident would say no at times to things such as sitting up in the chair because he/she could not tolerate it due to discomfort. At the time the resident was able to articulate any pain the exercises or plan for the day were adjusted to meet the resident's needs and tolerance levels. She added that the resident was not able to tolerate sitting in a chair and that the rehab team offered the resident maximum encouragement but the resident would sometimes clearly say no. She stated that the rehab team would make sure the resident was pre-medicated for pain prior to therapy in order to prevent pain. She confirmed that pain would be voiced during movement specifically with the left leg due to hip flexion, foot drop and formation of contractures (shortening of muscles and soft tissues caused by immobility) to the left hip and ankle. The PT could not speak to if the resident had a decline in the bilateral lower extremities, since she had not seen the resident for services since 12/4/20. The surveyor requested a copy of all in-service records provided by the PT regarding caregiver training for Resident #25. The PT stated that she would have to get back to the surveyor because it was filed and not e[TRUNCATED]