Based on observation, interview, and record review it was determined the facility failed to provide appropriate pain management for 2 of 2 sampled residents (#s 33 and 39) reviewed for pain management. This failure resulted in Resident 39 not receiving her/his scheduled narcotic pain medications for three days which caused the resident to suffer from narcotic withdrawal, increased pain, and an avoidable hospitalization. This placed residents at risk for narcotic withdrawal and increased pain. Findings include: 1. Resident 39 admitted to the facility in 10/2024 with diagnoses including heart disease and kidney disease. Resident 39's 4/14/25 Quarterly MDS indicated the resident was cognitively intact. Resident 39 received scheduled pain medication and PRN pain medications. Resident 39 had frequent pain, which occasionally affected her/his sleep and ADLs. On 4/23/25 Resident 39 was admitted to hospice. On 6/23/25 at 11:25 AM, and 6/27/25 at 9:15 AM, Resident 39 stated two weeks ago, the facility ran out of her/his prescribed morphine. Resident 39 reported being informed by multiple staff members her/his medication had not been reordered. As a result, she/he went several days without receiving her/his pain medication. Resident 39 stated she/he had been taking morphine for an extended period of time and believed she/he should have been gradually titrated off the medication, rather than cut off. Resident 39 reported experiencing nausea, vomiting, and diarrhea, which led to her/him being sent to the hospital. When asked about her/his pain level when the medication was not available she/he stated The pain I can take, it was the diarrhea that I could not tolerate. The resident indicated her/his pain was unmanaged and she/he was also concerned about her/his blood sugars being all over the place. A 4/23/25 Hospice Physician Order instructed staff to administer morphine sulfate (narcotic pain medication) 0.75 ml three times a day for pain and give 0.75 ml every hour PRN for pain and shortness of breath. Review of a 6/8/25 Progress Note indicated Resident 39 experienced symptoms of opiod withdrawl including: elevated blood pressure, nausea, diarrhea, general malaise, cold sweats, and dizziness. Staff reported the facility ran out of Resident 39's prescribed morphine on 6/7/25 in the morning and were unable to administer the resident's pain medication. Resident 39 experienced symptoms consistent with opioid withdrawal. Staff called the on-call provider to request a medication refill, but they did not respond. Resident 39 was transferred to the hospital for further evaluation and treatment. A 6/2025 MAR revealed the following: -morphine was not administered on 6/7/25 at 3:00 PM and 11:00 PM. -morphine was not administered on 6/8/25 at 700 AM, 3:00 PM, and 11:00 PM. -hydralazine 25 mg was administered on 6/8/25 for elevated blood pressure. -morphine was not administered on 6/9/20 at 7:00 AM, and 3:00 PM. A 6/8/25 Emergency Department Provider Note indicated Resident 39 admitted to the emergency department with fatigue, nausea, vomiting, diarrhea, cold chills and sweats. Resident 39 stated her/his symptoms had been ongoing for the last 24 hours. Resident 39 stated she/he took morphine due to pain related to lower extremity amputations. The resident stated the nursing facility ran out of her/his morphine two days ago. Resident 39's nurse called and confirmed the situation. It appeared completely feasible that the resident was experiencing opioid withdrawals since the last dose was approximately 48 hours prior. Resident 39 was provided an order for oxycodone 5 mg because the facility did not have morphine available. A 6/8/25 Progress Note indicated Resident 39 returned from the hospital with an order for oxycodone 5 mg to be administered every four hours PRN for pain. Resident 39's Pain Level Summary indicated the following on 6/9/25: -12:55 AM, pain level 8/10. -9:45 AM, pain level 8/10. -12:13 PM, pain level 6/10. -3:56 PM, pain level 9/10. -11:22 PM, pain level 3/10. On 6/24/25 at 3:50 PM, Staff 20 (LPN) stated the facility ran out of resident 39's morphine on 6/7/25. She informed the oncoming nurse and assumed the refill would be requested. The next day, she noticed the medication was not reordered and believed the resident was experiencing opioid withdrawal symptoms, including cold sweats, elevated blood pressure, and elevated blood sugar levels. Staff 20 reported leaving three messages for the on-call provider, but did not receive a response. She stated it was typical for the on-call provider not to respond to messages. Staff 20 stated the morphine was typically stocked in the back up medication stock, but administration required approval, which she described as difficult to obtain. Staff 20 added that on 6/8/25 she contacted the hospital, informed them the facility was out of Resident 39's morphine and asked if they could write a short-term prescription. On 6/24/25 at 4:13 PM, Staff 22 (LPN) stated 6/6/25, was when she first noticed Resident 39 was running low on her/his morphine. She reported that no specific staff member was designated to re-order medications and the facility frequently ran out of medications over the weekend. On 6/7/25 during shift change Staff 22 was informed Resident 39 experienced symptoms consistent with opioid withdrawal and was transferred to the hospital. Upon the resident's return, Staff 22 noted the resident was prescribed oxycodone, but not morphine. She stated Resident 39 appeared withdrawn and was not at her/his baseline. Staff 22 further stated the resident's medication was not refilled in a timely manner and acknowledged that it just fell through the cracks. On 6/25/25 at 2:45 PM, Staff 25 (Prescribing Technician) confirmed the facility called the pharmacy on 6/8/25 to request a refill of Resident 39's morphine prescription. On 6/25/25 at 3:18 PM, Staff 23 (Prescribing Technician) and Staff 21 (Pharmacist) stated on 6/9/25 at 8:17 AM, the facility requested a refill for Resident 39's morphine and the medication was delivered to the facility the evening of 6/9/25. On 6/26/25 at 1:20 PM, Staff 2 (DNS) and Staff 24 (Regional Nurse Consultant) reviewed Resident 39's 6/2025 MAR and narcotic log. Staff 2 and Staff 24 confirmed the facility failed to administer seven doses of resident 39's morphine. Documentation indicated the medication was unavailable or not administered. Staff 2 stated the facility's expectation was for nurses to follow the established medication reordering process. Staff 2 acknowledged multiple staff failed to reorder Resident 39's medication in a timely manner. Staff 2 acknowledged Resident 39's hospitalization could have been avoided if the facility had provided timely pain management. Staff 2 confirmed the facility had ongoing issues with communication from the on-call provider and this caused a delay in residents obtaining medication refills. 2. Resident 33 was admitted to the facility in 11/2023 with diagnoses including polyosteoarthritis (osteoarthritis that affects five or more joints in the body simultaneously). A public complaint was received on 3/25/25 which alleged Resident 33 did not receive her/his scheduled pain medication from 3/21/25 through 3/23/25. A review of Physician Orders revealed a 2/22/24 order for Lyrica (a pain medication) twice a day in the morning and in the evening. The 2/2025 MAR revealed Resident 33 did not receive Lyrica starting 3/21/25 evening dose through 3/24/25 morning dose. Medication Administration Notes from 3/21/25 through 3/24/25 revealed Resident 33 was out of Lyrica. A 3/23/25 Progress Note revealed Resident 33 needed a new script for Lyrica and an order refill request was placed in the provider's binder on 3/23/25. A review of the pain monitor from 3/21/25 through 3/24/25 revealed Resident 33's pain level varied from 0/10 to 10/10. A review of the 3/2025 CNA Pain Task documentation revealed Resident 33 experienced pain from 3/21/25 through 3/24/25 which was unchanged with non-pharmacological interventions. On 6/23/25 at 8:23 AM, Resident 33 stated she/he had constant pain in her/his shoulders and lower back. Resident 33 stated the facility ran out of her/his medications often and she/he would go without pain medications until the pharmacy delivered the pain medications. Resident 33 stated without pain medications, her/his pain level gets to 10/10. On 6/25/25 at 1:39 PM, Staff 17 (LPN) stated medications should be ordered when there was a week left so the resident did not run out of medications. Staff 17 stated the facility did not always have an effective system for ordering medications. On 6/26/25 at 10:51 AM, Staff 2 (DNS) stated Resident 33's Lyrica was not available starting the evening dose on 3/21/25 through the morning dose on 3/24/25. Staff 2 stated during this time Resident 33's pain level got up to 9-10/10 but no new orders for pain control were obtained and Resident 33's as needed Tylenol was not administered. Staff 2 stated the CNA task documentation showed non-pharmacological pain control interventions were tried including distraction, repositioning, and rest, but the non-pharmacological pain interventions were not effective. Staff 2 stated her expectation would be the nurse should call the provider for a temporary order in the interim until the Lyrica arrived.

Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer, failed to ensure accurate and completed wound assessments, failed to care plan the pressure ulcer and failed to demonstrate the resident's clinical condition made the development of a pressure ulcer unavoidable for 1 of 1 sampled resident (#35) reviewed for pressure ulcers. This resulted in Resident 35 developing an unstageable (full thickness skin preventing view of the depth of the wound) pressure ulcer. Findings include: Resident 35 was admitted to the facility in 10/2022 with diagnoses including heart failure and malnutrition. The 10/17/22 Significant Change CAA indicated Resident 35 was at risk for pressure ulcers related to incontinence of bowel and bladder and needed assistance with ADLs. Resident 35 had a Stage 3 (full thickness skin loss) pressure ulcer. The 10/5/22 care plan indicated the resident had bladder incontinence. The resident will remain free from skin breakdown due to incontinence and brief use A Progress Note dated 10/7/22 indicated Resident 35 had an unblanchable area to her/his coccyx (tailbone). This was not identified as a Stage 1 pressure ulcer (unblanchable area). A Skin and Wound Assessment sheet dated 10/31/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage, description, measurements or if the physician was notified. A Skin and Wound Assessment sheet dated 11/15/22 indicated the resident had a pressure ulcer. There was no documentation of the site, stage or description of the pressure ulcer. A Skin and Wound Assessment sheet dated 11/17/22 indicated the resident had an unstageable pressure ulcer. A review of Resident 35's 10/5/22 through 11/14/22 electronic record revealed no indication staff educated the resident regarding the risks and benefits of repositioning while in bed or the resident's non-compliance with repositioning prior to the development of the unstageable pressure ulcer. Random observations from 11/14/22 through 11/18/22 on day and evening shifts revealed Resident 35 lying flat on her/his back. On 11/15/22 at 4:53 Staff 6 (CNA) stated Resident 35 refused to change positions while in bed. On 11/16/22 at 12:30 PM Staff 25 (CNA) stated Resident 35 refused to reposition while in bed and staff reported this to nursing. On 11/16/22 at 12:40 PM Staff 26 (CNA) stated Resident 35 refused to reposition while in bed and nursing was aware. On 11/16/22 at 2:47 PM Staff 15 (LPN/RCM) stated she was aware the resident refused to reposition while in bed but this was not documented in the electronic record. Staff 15 stated she provided staff education multiple times on the importance of repositioning residents every two hours to avoid pressure ulcers and to document refusals but they did not comply. Staff 15 stated Resident 35 refused repositioning and acknowledged staff did not document the resident's refusals to reposition while in bed. On 11/17/22 at 1:31 PM Staff 2 (DNS) acknowledged on 10/7/22 Resident 35 had a Stage 1 pressure ulcer and a skin sheet should have been completed. Staff 2 further stated Resident 35's pressure ulcer worsened to a Stage 3 and was now unstageable. Staff 2 acknowledged the Skin and Wound Assessment sheets were inaccurate and incomplete and Resident 35's care plan did not have information related to the resident's pressure ulcer.