Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and 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 16 sampled residents. (Resident 18) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included dementia, anxiety, and diabetes. There were physician's orders dated July 14, 2022, for staff to administer the narcotic pain medication, oxycodone, every four hours as needed for very severe pain, rating nine to 10 only. Review of Resident 18's care plan revealed the resident had chronic pain with interventions for staff to evaluate if interventions were effective, notify the physician if interventions were unsuccessful, and offer non-pharmacological interventions. In an interview on January 10, 2024, at 9:30 a.m., Resident 18 stated she was in pain. Review of the Medication Administration Records for December 2023, and January 2024, revealed that the resident received the as needed narcotic (oxycodone) on December 9 and 29, 2023, and January 6 and 10, 2024 for a pain rating less than the ordered nine to 10 parameter. The Resident received the as needed narcotic twice on December 29, 2023, and on January 2 and 6, 2024, without documented evidence that non-pharmacological interventions were attempted prior to administration. In addition, on December 9 and 29, 2023, and January 6 and 10, 2024, staff documented that the medication was ineffective or unknown. There was no documented evidence that the physician was notified. During an interview on January 11, 2024, at 12:58 p.m., the Director of Nursing confirmed that the oxycodone was given outside parameters and 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 or that the physician was notified of the unsuccessful interventions. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of incident reports, and staff interview, it was determined that the facility failed to provide adequate supervision for a resident who exhibited behaviors and failed to ensure that an assessed safety intervention was in place in order to prevent falls for one of eight sampled residents who were at risk for falls. (Resident 120) Findings include: Clinical record review revealed that Resident 120 was admitted to the facility on [DATE], with diagnoses that included dementia with behavioral disturbance, psychosis, insomnia, restlessness, and agitation. Review of the current care plan identified the resident was at risk for falls due to dementia and poor safety awareness. There was an intervention since admission for staff to ensure that the resident had a chair and bed silent mobility detector (device to alert staff of unassisted transfers and ambulation) in place at all times. Review of the fall risk evaluation from admission revealed that the resident had a history of falling, had a weak gait (was weak when walking) and that he overestimated or forgot the limits of his own ability to ambulate safely which placed him at a high risk for falling. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, had delusions, exhibited both verbal and physical behaviors over the last four to six days and that the behaviors interfered with the resident's care. In addition, the assessment indicated that the resident required supervision for transfers and walking, was not steady when he was walking, required assistance with toileting and had a history of falls. Review of nursing documentation revealed that on March 3, 2022, the resident exhibited aggression towards staff. On March 5, 2022, at 1:30 p.m., the resident was found on the floor near his bed. On March 6, 2022, at 2:34 a.m., the resident was noted as restless and was hollering out. On March 11, 2022, the resident was refusing his medications and was resistive to care. On March 13, 2022, at 10:05 a.m., the resident was noted as wandering on the unit and was agitated. On March 15, 2022, at 3:24 a.m., the resident was noted as restless and wandering on the unit. The resident was getting up and down in his chair and was unable to sit for very long. On the same day at 5:13 a.m., he was again noted with increased behaviors and was extremely restless. Again on the same day at 1:41 p.m., the resident was noted as refusing his medications. Review of an incident report dated March 15, 2022, at 7:40 p.m., revealed that the resident was found on the floor in his room with his head beside the dresser. The resident had taken himself to the bathroom and when walking back from the bathroom he fell and struck his head on the dresser drawer when he fell. It was noted that the chair alarm pad was in place but that it was not connected to the alarm box and therefore, the alarm did not sound to alert staff of the unassisted transfer out of the chair. Review of a witness statement revealed that before the fall, a staff member had assisted him to his chair after he had been wandering in the hallway. The statement indicated that the staff member forgot to plug the alarm from the bed to his chair and had left the room. Subsequently, the resident transferred himself out of the chair, walked to the bathroom, and fell on the way back from the bathroom. The facility failed to provide adequate supervision to a resident who had exhibited restless and wandering behaviors and failed to ensure that the assessed safety intervention (silent mobility chair alarm) had been in place at the time of the fall. In an interview on March 24, 2022, at 9:34 a.m., the Administrator stated that the assessed safety intervention had not been in place properly in order to activate the alarm at the time of the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services. .