Based on clinical record review and staff interview it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 13 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included dementia, fibromyalgia, and diabetes. On November 25, 2024, the physician ordered for the resident to receive the narcotic pain medication, oxycodone, every four hours as needed for severe, chronic pain. Review of Resident 8's care plan revealed that the resident had chronic pain and that the interventions were for staff to provide comfort measures with positioning, control noise levels, and other non-medication interventions. Review of Medication Administration Records revealed that the resident received the as needed narcotic (oxycodone) without documented evidence that non-pharmacological interventions were attempted prior to administration 62 times in January 2025 and 39 times in February 2025. In an interview on February 21, 2025, at 10:34 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a history of trauma for one of 14 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included anxiety and depression. Review of a psychological consultation dated March 15, 2023, revealed that the resident reported becoming anxious in the afternoon and had experienced childhood abuse and trauma which included physical, sexual, emotional, and verbal abuse. There was no assessment or care plan in Resident 14's clinical record that identified symptoms or triggers related to the history of trauma. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on April 20, 2023, at 12:19 p.m., the Director of Nursing confirmed there was no care plan developed to address Resident 14's trauma symptoms or triggers. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.11(e) Resident care plan.