**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician's order for medication administration for 1 resident (Resident #56) of 6 residents reviewed for medications. The findings include: Review of the facility's policy titled, Administration of Medications, reviewed on 8/25/2022, showed .The facility will ensure medications are administered safely and appropriately per physician order . Resident #56 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, and Dorsalgia (back pain). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #56 was cognitively intact and received scheduled and as needed pain medication. The resident received Opioids (narcotic pain relieving medication) on all 7 days of the look back period. Review of the Medication Administration Record (MAR) dated 10/1/2022-10/31/2022 showed an order dated 9/28/2022 for .Lidocaine Patch [an over the counter medication used to relieve mild pain] 4% [percent] .Apply to lower back topically [medication applied to a particular place on the body] one time a day for back pain .apply 2 patches and remove per schedule . The Lidocaine Patch was not administered as ordered on 10/1/2022, 10/2/2022, 10/3/2022, 10/6/2022, 10/8/2022, 10/9/2022, 10/12/2022, 10/13/2022, 10/18/2022, 10/21/2022. Registered Nurse (RN) #1 documented the 10/1/2022, 10/2/2022, and 10/3/2022 doses as not administered. Licensed Practical Nurse (LPN) #1 documented the 10/6/2022 dose as not administered and LPN #2 documented the 10/8/2022, 10/9/2022, 10/12/2022, 10/13/2022, 10/18/2022, and 10/21/2022 as not administered. Review of the Orders - Administration Note dated 10/1/2022 at 11:32 PM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .No patch to remove . Review of the Orders - Administration Note dated 10/2/2022 at 10:41 PM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .No patch found to remove . Review of the Orders - Administration Note dated 10/6/2022 at 10:05 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/8/2022 at 8:22 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/9/2022 at 8:11 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/12/2022 at 8:50 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/13/2022 at 9:03 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/18/2022 at 8:34 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/21/2022 at 8:44 AM, showed .Lidocaine Patch 4% .Apply to lower back topically one time a day for back pain apply 2 patches and remove per schedule .Waiting on Pharmacy . Observation and interview with Resident #56 on 12/13/2022 at 4:04 PM, in the resident's room, showed the resident lying in bed eating a snack and watching TV with no signs of distress observed. Resident #56 stated he had chronic neck and back pain. Pain control interventions included medications, therapy, and repositioning. Resident #56 stated the pain control interventions .help . his pain but did not .cure it . Resident #56 denied any changes or worsening in his pain. During a telephone interview on 12/13/2022 at 4:46 PM, the Director of Nursing (DON) and the Medical Director stated Resident #56 had chronic pain and received scheduled and as needed medications for pain. Continued interview confirmed it was their expectation that physician's orders were followed. The Medical Director stated that Resident #56 had no change in pain characteristics or behaviors as a result of not receiving Lidocaine patches as ordered. During an interview on 12/14/2022 at 8:16 AM, the Administrator stated Resident #56 had an order for Lidocaine 4% patches. Lidocaine 4% patches are over the counter medications and available as house stock in the facility. Lidocaine 5% must be dispensed by the pharmacy. The Administrator stated some of the nurses did not realize the difference in the 2 patches and did not realize the Lidocaine 4% patches that Resident #56 had ordered were available in the facility and did not have to come from the pharmacy. The Administrator confirmed Resident #56 did not receive Lidocaine patches as ordered by the physician and it was the facility's expectation that physician's orders were followed. During a telephone interview on 12/14/2022 at 10:01 AM, RN #1 stated there were occasions when Resident #56's Lidocaine patch was unavailable to administer and she would notify the pharmacy the patches were unavailable. RN #1 stated she was recently made aware that the Lidocaine Patches were facility stocked and did not have to come from the pharmacy. Resident #56 had scheduled and as needed pain medications, which were given and managed the resident's pain. Resident #56's pain remained at baseline with no changes. Interview revealed RN #1 requested the lidocaine patches from the pharmacy, who did not have the 4% patches, when the patches should have been obtained from the facility's central supply. Attempted telephone interview with Licensed Practical Nurse (LPN) #1 unsuccessfully on 12/14/2022 at 10:10 AM. During an interview on 12/14/2022 at 10:30 AM, LPN #2 stated she was unable to recall any time when Lidocaine Patches were unavailable to administer and Resident #56 always showed the same demeanor during her interactions with the resident and no distress was noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (Resident #42) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Fall Management, reviewed 9/29/2022, showed .Implement interventions .consistent with a resident's .care plan .Supervision .Refers to an intervention and means of mitigating the risk of an accident .During the admission .a care plan will be developed .interdisciplinary team will review and revise the care plan .upon a fall . Resident #42 was admitted to the facility on [DATE] with diagnoses including Fracture of Third Lumbar Vertebra, Wedge Compression Fracture of Fourth Lumbar Vertebra and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 was severely cognitively impaired. The resident was dependent of 2 staff members for bed mobility and toileting. Review of the facility's fall investigation dated 11/21/2022, showed Resident #42 had an unwitnessed fall from the bed. The resident was found lying on the floor with a skin tear to the left knee and left toe. The immediate action taken was .Gym mats . Review of the Care Plan dated 11/22/2022, showed Resident #42 had an actual fall with minor injury and was updated on 11/29/2022 with an intervention of fall mats. During an observation on 12/12/2022 at 12:02 PM, Resident #42 was lying in bed with no fall mats beside the bed. During an observation on 12/13/2022 at 1:41 PM, the resident was lying in bed with no fall mats beside the bed. During an interview on 12/13/2022 at 2:13 PM, the 100-Hall Unit Manager confirmed that there were no fall mats in Resident #42's room. After the interview, the Unit Manager brought fall mats to the resident's room for placement. During an interview on 12/14/2022 at 10:24 AM, the MDS Coordinator stated new interventions were put on the care plan by unit managers after a fall was discussed. She stated the interventions should be put into place before the intervention was added on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate medical record for 1 resident (Resident #56) of 18 residents reviewed for medical records. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, and Dorsalgia (back pain). Review of the [named facility] PHYSICAL MEDICINE & REHABILITATION prescription dated 9/28/2022, showed .Methadone 10 mg [milligrams] .3 tabs [tablets] PO [by mouth] QAM [every morning] .#9 (nine) .NO REFILLS . Review of a Controlled Substance Verbal Prescription Order from Practitioner dated 10/1/2022, showed .Methadone 10 mg .Dispense Quantity .#9 .3 tabs PO QAM (for pain) . No refills were ordered. Review of a prescription dated 10/3/2022, showed .METHADONE 10 MG TABLET .Take 3 tablet by mouth once a day .PRESCRIBED QUANTITY: 6 (SIX) TABLETS .DAYS SUPPLY: 2 .DIAGNOSIS .DORSALGIA .REFILLS .0 (ZERO) . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact and received scheduled and PRN (as needed) pain medications. Resident #56 received Opioid (narcotic medications used for severe pain control) medications on all 7 days of the look back period. Review of the Medication Administration Record (MAR) dated 10/1/2022 - 10/31/2022, showed an order dated 9/28/2022 for .Methadone .10 MG .Give 3 tablet by mouth one time a day for chronic back pain . It was noted that the resident did not receive the Methadone on 10/8/2022, 10/9/2022, 10/10/2022, 10/11/2022, 10/12/2022, or 10/13/2022. Continued review showed an order dated 9/28/2022 for .OxyCODONE-Acetaminophen [opioid] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. The resident received the medication on 10/1/2022 at 5:27 PM, 10/2/2022 at 6:33 AM, 1:27 PM, and 9:30 PM, 10/3/2022 at 5:16 AM, 1:26 PM, and 7:57 PM, 10/4/2022 at 3:29 AM and 9:00 PM, 10/5/2022 at 2:39 AM, 8:36 AM, 2:29 PM, and 9:18 PM, 10/6/2022 at 4:10 AM, 1:54 PM, and 8:11 PM, 10/7/2022 at 5:12 AM, 12:25 PM, and 7:32 PM, 10/8/2022 at 6:05 AM, 12:05 PM, and 7:58 PM, 10/9/2022 at 6:27 AM and 7:45 PM, 10/10/2022 at 1:58 AM, 9:58 AM, 4:00 PM, 10:10 PM, 10/11/2022 at 4:59 AM, 10/12/2022 at 6:28 AM and 1:47 PM, 10/13/2022 at 4:10 PM, 12:01 PM, and 6:01 PM. It was noted that all Oxycodone-Acetaminophen administrations were effective at treating Resident #56's pain. Review of the Orders - Administration Note dated 10/8/2022 at 8:26 AM, showed .Methadone . Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/9/2022 at 8:13 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/10/2022 at 9:57 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .waiting on pharmacy . Review of the Orders - Administration Note dated 10/11/2022 at 10:05 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .waiting on pharmacy . Review of the Orders - Administration Note dated 10/12/2022 at 8:53 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of the Orders - Administration Note dated 10/13/2022 at 9:01 AM, showed .Methadone .Tablet 10 MG .Give 3 tablet by mouth one time a day for chronic back pain .Waiting on pharmacy . Review of a prescription dated 10/13/2022, showed .METHADONE 10 MG TABLET .Take 3 tablet by mouth once a day .PRESCRIBED QUANTITY: 63 (SIXTY-THREE) TABLETS .DAYS SUPPLY: 21 .DIAGNOSIS .CHRONIC PAIN .REFILLS .0 (ZERO) . Observation and interview with Resident #56 on 12/13/2022 at 4:04 PM, in the resident's room, showed the resident lying in bed eating a snack and watching TV with no signs of distress observed. Resident #56 stated he had chronic neck and back pain. Pain control interventions included medications, therapy, and repositioning. Resident #56 stated the pain control interventions .help . his pain but did not .cure it . Resident #56 stated he had been taking Methadone .for a long time . and there had been .a few times . the Methadone was not administered at the facility. Resident #56 denied any changes or worsening in his pain. During a telephone interview on 12/13/2022 at 5:14 PM, Nurse Practitioner #1 stated Resident #56 was admitted to the facility after a stroke. Resident #56's daughter reported that the resident had been seen at an outpatient clinic for pain control and was taking methadone. Resident #56's daughter stated he was always in pain. Resident #56 was on a scheduled and as needed pain medication regimen at the facility. Nurse Practitioner #1 saw Resident #56 on 10/3/2022, 10/10/2022, and 10/24/2022 and no acute signs of distress were noted. Nurse Practitioner #1 ordered a .few days . supply of Methadone after her 10/3/2022 visit. Methadone required a specific prescribing diagnosis to order routinely, and it was unclear what Resident #56's diagnosis was in order to receive a continuous daily supply of Methadone, so a pain management consult was requested on her 10/10/2022 visit. During an interview on 12/14/2022 at 10:00 AM, the Regional Director of Clinical Services stated the 9/28/2022 order for Methadone was for a 3-day supply and should have been discontinued after 3 days. The order for Methadone obtained on 10/1/2022 was for a 3-day supply and should have been discontinued after 3 days. The Methadone order dated 10/3/2022 was for a 2-day supply and should have been discontinued after 2 days. Another order for Methadone was received 10/13/2022. Resident #56 did not have an active order for Methadone from 10/8/2022 - 10/13/2022. The Regional Director of Clinical Services confirmed Resident #56's Methadone order was entered into the facility's system incorrectly upon admission on [DATE] as daily without a discontinue date. Each subsequent order for Methadone should have been entered into the facility's system with the start date it was ordered and discontinued after the prescribed quantity was administered. During an interview on 12/14/2022 at 11:19 AM, the Regional Director of Clinical Services confirmed Resident #56's Methadone orders were entered into the facility's system incorrectly and the medical record was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete an accurate Discharge Minimum Data Set (MDS) Assessment for 1 resident (#48) of 3 residents reviewed for discharge. The findings include: Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Neoplasm of Right Ovary, Atrial Fibrillation, Urinary Tract Infection, Muscle Weakness, Dysphagia, Dementia, Gastro-esophageal Reflux Disease, and Major Depressive Disorder. Medical record review of a physician's order dated 8/12/19 revealed .Patient to discharge home . Medical record review of the discharge summary note dated 8/19/19 revealed .Patient discharged home with daughter left per private vehicle . Medical record review of the Discharge MDS assessment dated [DATE] revealed .Discharge Status .Acute hospital . Interview with the MDS Coordinator on 9/25/19 at 3:16 PM, in the MDS office, confirmed Resident #48 had been discharged home and the Discharge MDS Assessment reflected an inaccurate discharge status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to address the risk for pain on the baseline care plan for 1 resident (#248) of 9 residents reviewed for pain of 28 residents sampled. The findings include: Review of the facility policy Baseline Care Plan issued 8/24/17 revealed .develop a baseline care plan .that incorporates the resident's goal, preferences, and services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being .provide effective person-sentered [centered] care of the resident that meet professional standards of care .update the baseline care plan as needed to reflect current needs until the comprehensive care plan is developed . Medical record review revealed Resident #248 was admitted to the facility on [DATE] with diagnoses including Personal History of Malignant Neoplasm (cancer) of Breast, Malignant Neoplasm of Bone, Anemia, and Muscle Weakness. Medical record review of an incomplete 5 day Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the baseline care plan dated 9/17/18 revealed no documentation of the risk for pain. Medical record review of the Physician's orders dated 9/14/18 revealed .ibuprofen [pain medication] .tablet every 8 hours PRN [as needed] .pain . further review revealed .Pain assessment every shift . Medical record review of a Physician's orders dated 9/20/18 revealed .Tramadol [pain medication] prn pain . Medical record review of the medication administration record dated 9/2018 revealed the resident had received pain medication daily from 9/20/18 - 9/26/18. Interview with Resident #248 on 9/24/18 at 2:31 PM, in the resident's room, revealed the resident had pain .I do .I have degenerative spine disease . Interview with the Director of Nursing on 9/26/18 at 8:05 AM, in the conference room, confirmed the resident had complained of pain since admission and had received pain medication. Continued interview confirmed the facility failed to care plan the risk for pain on Resident #248's baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #248 was admitted to the facility on [DATE] with diagnoses including Personal History of Malignant Neoplasm (cancer) of Breast, Malignant Neoplasm of Bone, Anemia, and Muscle Weakness. Medical record review of an incomplete 5 day Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Physician's order dated 9/18/18 revealed .Tramadol 50mg [milligrams] .[1tablet] po [by mouth] q [every] 4hrs prn [as needed] pain 1-5 [based on a pain scale of 1-10 with 1 being mild pain and 10 being the worst pain imaginable] .[2 tablets] .po q 4hrs prn pain 6-10 . Medical record review of a Physician's orders dated 9/20/18 revealed .Tramadol 50mg [1 tablet] po q 4hrs prn pain . Medical record review of the Medication Administration Record (MAR) dated 9/2018 revealed the MAR had not been updated with the order dated 9/20/18. Further review revealed Tramadol 2 tablets had been administered 4 times since 9/20/18. Interview and observation with Resident #248 on 9/25/18 at 4:04 PM, in the resident's room, revealed the resident had requested pain medication due to current pain level of 6. Observation revealed Registered Nurse #1 entered the resident's room and administered 2 tramadol tablets to Resident #248. Interview with the Director of Nursing on 9/26/18 at 8:05 AM, in the conference room, confirmed the MAR had not been updated with the Physician's order dated 9/20/18 and the physicians order had not been followed. Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 2 residents (#13, #248) of 28 residents sampled. The findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Displaced Bimalleolar Fracture of the Left Lower Leg [fractured ankle], Essential Tremor, and Type 2 Diabetes. Medical record review of the September 2018 Physician Orders revealed an order dated 8/6/18 .LLE [Left Lower Extremity] Boot to be worn for transfers and when OOB [Out Of Bed]. May remove for skin checks/therapy . Observation and interview with Resident #13 on 9/25/18 at 10:15 AM, revealed she wears her boot at bedtime, staff assist with transfers by placing the wheel chair next to the bed, put the walker in front of her, and she does most of the work to stand turn and sit on the bed, the staff have to lift her legs. Observation revealed the resident was sitting in the wheel chair and had tennis shoes on with no boot present. Observation and interview on 9/26/18 at 8:50 AM in Resident #13's room, revealed Certified Nurse Assistant (CNA) #1, CNA #2 and Restorative CNA #3 assisted Resident #13 to sit on the side of the bed, using a gait belt assisted her to stand, placed the walker in front of the resident, and with 2 CNA's using the gait belt the resident walked to the wheel chair and sat down. Interview with the 3 CNA's revealed Resident #13 only wears a boot when in bed. Further interview confirmed the resident did not have a boot on when transferring from the bed to the wheel chair. Interview with the Director Of Nursing and the Licensed Practical Nurse Unit Manager #1 on 9/26/18 at 9:22 AM, at the 100 hallway nurse's station confirmed the physician's order for the boot to be worn during transfers was not followed.