Based on interview and record review, the facility failed to honor Resident 1's rights when a Licensed Nurse cut Resident 1's hair without permission. This failure decreased the facility's potential to ensure residents' rights and respect residents' different cultures. Findings: A review of Resident 1's admission record indicated admission to the facility on 5/7/20 with diagnosis which included left-sided weakness as a result of a stoke, lupus (an autoimmune disease which can affect tissue and organs), and depression. A review of a Minimum Data Set (MDS, an assessment tool), dated 2/15/23, indicated Resident 1 had mild memory problems. A review of a progress note dated 3/2/23 at 8 p.m., indicated, .Resident [1] is disappointed that his hair was cut without his consent . In an interview on 3/17/23 at 9:45 a.m., Resident 1 confirmed a nurse cut his hair without asking his permission. Resident 1 stated he felt the LN was disrespectful because he was Native American and hair was an important, sacred, and significant representation of his culture. Resident 1 stated he kept his braid and still had it in his personal possessions. In an interview on 3/17/23 at 10:15 a.m., the Administrator verified the LN should not have cut Resident 1's hair without his consent as it was against the facility policy and procedure for resident rights. In an interview on 3/17/23 at 10:30 a.m., the Director of Nurses (DON) stated Resident 1's rights were not respected. In an interview on 3/21/23 at 3:49 p.m., Certified Nurse Assistant C (CNA C) stated she witnessed Resident 1 tell the LN, No when she stated she was going to cut his hair. The CNA C also stated, [Resident 1] reached up to feel his hair and [the LN] said [it was] too late .[Resident 1] was upset .He was about to cry .[The LN] showed no regret .She asked me to lie and tell him to say it was OK. He was embarrassed and ashamed. After it happened, he pulled his hoodie up so no one could see his hair. A review of the facility's policy and procedure titled Resident Rights, revised 1/1/12, indicated, .Resident's [sic] have freedom of choice .about how they wish to live their everyday lives and receive care .Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review indicated Resident 146 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Head and Neck of Left Femur (Thigh bone) and Benign Prostatic Hyperplasia (Prostate gland enlargement), according to the facility Face Sheet (Facility Demographic). During a concurrent observation and interview on 5/03/22 at 10:48 a.m., Resident 146 was observed in bed, in a hospital gown. He stated he had been in a lot of pain for several days. Resident 146 stated the night of 5/02/22, he pressed the call light because he needed pain medicine. Resident 146 stated his pain level was 8 out of 10. Resident 146 stated Unlicensed Staff A responded to the call light, and he requested pain medication. Resident 146 stated Unlicensed Staff A came back and told him the Licensed Nurse (Licensed Nurse B) assigned to him stated he was not due for his pain medication (indicating it was not time for him to receive pain medication). Resident 146 stated no interventions were attempted to relieve his pain, and eventually he fell asleep in excruciating pain. During an interview on 5/03/22 at 3:29 p.m., Unlicensed Staff A confirmed being assigned to Resident 146 the night of 5/02/22. Unlicensed Staff A also confirmed Resident 146 requested pain medication, and she notified Licensed Nurse B, who was Resident 146's assigned Licensed Nurse, about his request. Unlicensed Staff A stated Licensed Nurse B told her Resident 146 was not due for his pain medication, so she went back to Resident 146's room and provided him with that information. Record review of Resident 146's MAR and Nursing Notes did not mention Resident 146's episode of pain the night of 5/02/22 mentioned by Resident 146 and Unlicensed Staff A, or described any type of pain assessment. During a phone interview on 5/06/22 at 10:26 a.m., Licensed Nurse B confirmed being the assigned Licensed Nurse for Resident 146 the night of 5/02/22. When asked about Resident 146's request for pain medication during her shift, Licensed Nurse B stated she could not remember. Licensed Nurse B stated she checked on Resident 146 during that shift, but could not remember if she documented anything related to pain. Record review of Resident 146's care plan for acute and chronic pain did not include any specific interventions to manage his pain, and no non-pharmacological interventions other than hot or cold packs for comfort. Some of the interventions in the care plan indicated, Administer prescribed medication before activity and therapy .Determine Resident's satisfactory pain level .Establish a pain management treatment plan. During an interview on 5/05/22 at 2:47 p.m., the DON confirmed creating Resident 146's care plan for pain. The DON stated she did not ask Resident 146 if hot and cold packs were effective in relieving his pain, and confirmed these were the (only) non-pharmacological interventions written in the care plan. The DON confirmed the care plan was generalized. When asked to provide Resident 146's pain management treatment plan (documented in the care plan), she stated this plan had not been documented. Record review of Resident 146's MAR indicated he had received 6 doses of Hydrocodone Acetaminophen (A combination medicine used to treat moderate to severe pain) 10-325 mg (Milligrams) tablets as needed, from 5/01/22 through 5/04/22 for pain levels of 7 out of 10. The pain reassessments after the administration of this medication were documented as 0 out of 10 after every administration. Yet, during an interview on 5/06/22 at 11:17 a.m., Resident 146 stated his pain level was never 0, even with medication, and stated the lowest level it reached, even after taking pain medication was 6 out of 10. Resident 146 stated he could tolerate pain levels of 4 out of 10 but it never reached that level. Resident 146 stated on 5/06/22, he pushed the call button three to four times to request pain medication, but nobody had provided him with it. Resident 146 stated his pain management system was not working out, and confirmed he was suffering. Resident 146 stated facility staff were not doing enough for him, and stated non-pharmacological interventions had never been attempted for him at this facility. Resident 146 stated the pain was on his left hip area, and it was dull in quality when immobile, but sharp when he moved. Record review of a physician order dated 4/22/22 at 3:00 p.m. indicated, Assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. Resident 146's MAR indicated his pain level from 5/01/22 through 5/05/22 reached a level of 8 out of 10 on five occasions, and 7 out of 10 on one occasion. The DON was asked on 5/06/22 at 10:01 a.m., to provide pain reassessment documentation of these pain levels documented on Resident 146's MAR from 5/01/22 through 5/05/22. During an interview with the DON on 5/06/22 at 11:01 a.m., she stated there was no documentation these pain levels were reassessed. During an interview with the DON on 5/06/22 at 12:44 p.m., the DON stated if a Resident's pain management plan was not effective, the doctor had to be notified for a revision, and this notification was required to be documented. The DON stated non-pharmacological interventions should be attempted, and pain reassessed after documenting high levels of pain. The DON was asked what was the expectation of a Licensed Nurse after unlicensed personnel notified her a Resident was requesting pain medication for high levels of pain. The DON stated the Licensed Nurse was supposed to assess the pain, medicate appropriately and try non-pharmacological interventions if pain was not relieved. The DON also stated the physician had to be notified if the pain was not relieved to a comfortable level. 3) Record review indicated Resident 24 was admitted to the facility on [DATE] with medical diagnoses including Hemiplegia (Paralysis on one side of the body), Hemiparesis (Weakness on one side of the body) and Chronic Pain, according to the facility Face Sheet. During an interview on 5/03/22 at 10:36 a.m., Resident 24 stated she was frequently in pain, mostly in her feet, and her pain level at the moment was about a 9 from a scale from 1 to 10. Record review of a physician order dated 1/20/22 at 7:00 a.m. indicated, Assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. Resident 24's MAR indicated her pain level from 5/01/22 through 5/04/22 reached a level of 5 out of 10 on one occasion. The DON was asked on 5/06/22 at 10:01 a.m., to provide pain reassessment documentation of this pain level documented on 5/03/22 for morning shift. During an interview with the DON on 5/06/22 at 11:01 a.m., she confirmed there was no documentation this pain level was reassessed. Record review of Resident 24's care plan for chronic pain did not include any specific interventions to manage her pain, and no non-pharmacological interventions at all. Some of the interventions in the care plan indicated, Administer pain medications per order .determine Resident's satisfactory pain level .Evaluate pain During an interview on 5/05/22 at 2:47 p.m., the DON confirmed creating Resident 24's care plan for pain. The DON confirmed the care plan was generalized and did not include any non-pharmacological interventions. Record review indicated Resident 24 was administered Morphine Sulfate (A medication used to treat moderate to severe pain), in different doses, on 4 occasions from 5/01/22 through 5/05/22 for pain levels of 7 out of 10. Reassessments of these pain levels after the administration of Morphine Sulfate were documented as 0 out of 10, which indicated the medication was effective in relieving pain. Yet, during an interview on 5/06/22 at 11:33 a.m., Resident 24 stated that with pain medication, her pain level went down to 5 or 6 out of 10, but it was not always effective. Resident 24 stated her pain level was never a 0 out of 10. During the interview on 5/06/22 at 11:33 a.m., Resident 24 was asked if there were times when she requested pain medication and was denied the medication for not being due for it. Resident 24 responded, Yes, often. When asked how she felt about it, she stated, Like I am helpless, there's nothing I can do. Resident 24 confirmed she was suffering. When asked if the facility had attempted non-pharmacological interventions to relieve her pain, Resident 24 stated they had not. When asked if her medication regimen for pain control was effective, Resident 24 stated it was not. Resident 24 was observed showing facial expressions of pain. When asked if she was involved in any activities, Resident 1 stated, I hurt too much to do any other activities than TV. During an interview on 5/06/22 at 11:49 a.m., Licensed Nurse C confirmed being the assigned nurse for Resident 24 and Resident 146 the morning of 5/06/22. Licensed Nurse C confirmed being aware both residents had very high levels of pain frequently. When asked if the physician had been called in regards to these residents high pain levels, Licensed Nurse C stated, Not that I'm aware of. Record review of the facility policy titled, Pain Management, last revised in November of 2016, indicated, Facility Staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible .A Licensed Nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is significant change in status .The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions .The Licensed Nurse will administer pain medication as ordered and document medication administered on the medication Administration Record (MAR) .After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour .If there is an onset of pain , if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician. Based on observation, interview and record review, the facility failed to ensure 3 of 3 residents sampled for pain (Resident 94, Resident 146, and Resident 24) received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preference, and facility policy. Licensed nurses did not notify Resident 94's physician (Physician P) for approximately seven days when her pain was routinely high (#7-9 out of 10 on the pain scale; Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable), despite pain medication administration; Nursing staff did not notify Resident 146 or Resident 24's physicians of ineffective pain control; Nursing staff did not assess, reassess, or document Resident 94, Resident 146 and Resident 24's pain consistently and accurately; and Nursing staff did not develop, and revise when needed, person-centered care plans addressing pain for these three residents. These failures: 1) Contributed to Resident 94 experiencing moderate to severe pain, described as excruciating and screeching, for a timeframe of approximately seven days and to Resident 94 crying and moaning in pain when being repositioned; 2) Potentially prevented Resident 94, Resident 146 and Resident 24's physicians from knowing interventions ordered for them were ineffective and affording them the opportunity to make changes to the resident's plan of care; 3) Contributed to Resident 146 experiencing several days of severe pain described as, excruciating; and 4) Contributed to Resident 24 experiencing moderate pain that made her feel helpless, made her feel as if she were suffering, and prevented her from participating in activities other that watching television. Findings: 1) Review of Resident 94's medical record from her hospital stay (4/20/22 - 4/26/2022) indicated Resident 94 was a, pleasant 84 years (sic) old female with a . past medical history of mild dementia . who had fallen at home on approximately 4/19/2022 and was taken to a local hospital. Resident 94 was admitted to the hospital where she was diagnosed with a fracture of her right humerus (upper arm), left humerus (located near the elbow), and a questionable fracture of the left calcaneus (heel). Resident 94 had a surgical repair of her left elbow on 4/20/22 and was transferred to the facility on 4/26/22 (approximately six days after surgery). Review of Resident 94's facility medical record revealed physician orders, dated 4/26/2022, that indicated, Patient is capable of making informed choice and decisions .Patient is capable of participating in their plan of treatment. During an observation and concurrent interview on 5/03/2022 at 10:08 a.m., Resident 94 was lying on her back in bed. Resident 94's left arm was in an immobilization device (splint), her right arm was in a sling, and her the left side of her face had a yellow bruise. Resident 94 stated she did not remember how she injured her arms and stated she had, screeching pain in her elbow. Review of Resident 94's facility medical record revealed physician orders, dated 4/26/2022 (her admission date to the facility), that included: Assess for pain every shift and chart intensity of pain using 1-10 pain scale. 0= no pain, 1-4= mild pain, 5-7= moderate pain, 8-9= severe pain, 10= excruciating pain. every (sic) shift Non-Pharmacological interventions: A-Heat, B-Re-positioning . G-Immobilization of Joints, H-Other (document in Nurses note) . Pain medication ordered on 4/26/2022 included Norco (a narcotic pain killer) 5-325 mg (milligram), one tablet every four hours as needed for moderate pain or two tablets every four hours as needed for severe pain and Oxycodone (a narcotic pain killer), one tablet every four hours as needed for severe pain. Review of Resident 94's MAR (medication administration record; document where nurses chart various interventions and medications given) indicated from 4/26/2022 through 4/29/2022 (Physician P's initial visit with her), Resident 94's nurses assessed her pain every shift to be between #7-9 on the pain scale (moderate to severe pain). During the same three day period, Resident 94's nurses documented giving her Norco two tablets (for severe pain) approximately seven times: the pain was documented as a #7 on one occasion, #8 on three occasions, and #9 on three occasions. During the same timeframe, Resident 94's nurses also documented giving her Oxycodone approximately nine times: nurses documented the pain as a #7 on two occasions, #8 on three occasions and #9 on four occasions. Nurses documented the medications to be E (effective) and intermittently documented the decrease in the pain (reflected in a lower pain-scale number) after the medication was given (from zero to #3). Resident 94's medical record did not contain documentation that nursing staff contacted Physician P to inform him Resident 94's pain was ranging from #7-9 despite narcotic pain medication. Review of Resident 94's facility medical record revealed a physician admission note written by Physician P on 4/29/2022, three days after admission. Physician P documented, Patient is being seen today via telemed (Telemedicine allows health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology - computers, video, phone, messaging). Physician P documented Resident 94's history of present illness (fall with fractures and mild dementia), vital signs (temperature, heart rate, blood pressure, oxygen level, etc.), his physical exam, and assessment diagnosis. Documentation of Resident 94's pain was not located in the Physician P's note. Review of Resident 94's facility medical record revealed a changed physician order for Norco dated 4/29/2022, the day of the televisit. The Norco 5-325 mg, 1-2 tablets every four hours was changed to Norco 10-325 mg tablet every six hours as needed for severe pain. No changes were made to the Oxycodone order. Review of Resident 94's MAR (from 4/30/2022 through 5/4/2022) revealed conflicting pain assessments by nursing staff. On 4/30/2022, the night nurse documented Resident 94's pain as a zero, but also documented her pain was a #8 at 3:32 a.m. (when Oxycodone was given) and a #9 at 6:13 a.m. (when Norco was given). On 5/2/2022, the day and evening nurses documented her pain as a zero, but also documented her pain was a #8 (when Norco was administered). On 5/3/2022, the day shift nurse documented her pain was #3, but also documented her pain was #7 (when Oxycodone was given) . On 5/4/2022, an evening shift nurse documented her pain as a zero, but also documented her pain was #8 (when Oxycodone was given). The remainder of the nurse's MAR's pain scale documentation (from 4/26/2022 through 5/4/2022) indicated Resident 94's pain was between #7-9. Review of Nursing Progress Notes located in Resident 94's medical record revealed nursing staff did not document they notified Physician P when Resident 94's pain medication was ineffective in pain control. On 4/30/3033 at 5:44 a.m., LN Q documented Oxycodone was given at 3:32 a.m. for severe pain (#8 on the pain scale). LN Q documented the Oxycodone was ineffective by charting, Follow-up Pain Scale was: 4 (on the pain scale) . PRN (as needed) Administration was: Ineffective. At 7:48 a.m., LN Q documented Norco was given at 6:13 a.m. for severe pain (#9). She documented the Norco was ineffective by charting Follow-up Pain Scale was: 7 .PRN Administration was: Ineffective. Documentation that LN Q notified Physician P that both Oxycodone and Norco were ineffective in controlling Resident 94's pain was not located in the medical record. Review of facility policy titled, Pain Management, subtitled, Procedure, further subtitled, II. Pain Management (Revised 11/2016) indicated, E. If .the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician. During an observation and interview on 5/05/22 at 9:14 a.m., Unlicensed Staff I went into Resident 94's room. When she exited the room, Staff I stated Resident 94 was in pain. Staff I stated Resident 94 had told her she (Resident 94) would rather be dead than have that much pain. Staff I stated the nurse had already given Resident 94 pain medication and said she would tell her again that Resident 94 was in pain. During an observation 5/05/22 at 9:16 a.m., a nurse gave Staff I ice to put on Resident 94's arm. Staff I entered Resident 94's room with the ice. During an observation and concurrent interview on 5/05/22 at 9:28 a.m., Resident 94 was lying on her back in bed. Resident 94 was covered by a sheet (a blanket was on a nearby chair), the patio door was open (letting in a breeze), and her room was chilly. Ice packs were on the bed next to her. Resident 94's left arm (in a splint) was on one pillow, but her arm was below the level of her heart. Her left hand had 3-4 plus edema (moderate swelling). Resident 94's right arm was in a sling. When asked if she was in pain, Resident 94 stated her pain was, excruciating and stated she had tingling pain in her hand (left), going up to her elbow. When asked what number her pain was, Resident 94 stated, nine or ten.When asked why the ice was on the bed and not on her arm, Resident 94 stated she was in too much pain to also be cold. During an interview on 5/05/22 at 09:47 a.m., the DSD (director of staff development) stated she was familiar with Resident 94 and had helped admit her (on 4/26/2022). The DSD stated Resident 94 had fractured her left elbow and right humerus at home. The DSD stated Resident 94 was taking Norco and Oxycodone alternately for the pain but it had not been working, so the Norco was increased to 10 mg (in the past). The DSD stated Resident 94's pain was now up to a #7 or #8 and stated the medication takes the pain down to a zero, but it didn't last long. The DSD stated Resident 94's pain stayed at a zero for about an hour (after the pain medication was given). The DSD stated staff called the doctor to increase the pain medication, days ago. When asked if nursing staff had called the physician recently about Resident 94's pain control, the DSD stated, no and stated the doctors are sometimes reluctant to order narcotics. When informed Resident 94 had described her pain as a #9 or #10 and verbalized it was excruciating and tingling, the DSD stated it might be nerve pain and she may need Neurontin (a medication that treats nerve pain). During the same interview on 5/05/22 at 09:47 a.m., the DSD was informed that Resident 94's left hand had edema. The DSD stated her arm was, on a pillow. The DSD was informed Resident 94's arm was on a pillow but her arm was still below the level of her heart. The DSD was asked where Resident 94's left arm should be in order to help decrease the edema in her hand, and the DSD stated, above her heart. The DSD stated she would elevate Resident 94's left arm and agreed elevating the arm to decrease edema would likely help the pain. When asked why she was not using ice (on her left arm), the DSD stated Resident 94 did not like the ice. When asked why Resident 94 did not like the ice, the DSD stated she thought it was because the ice fell off. The DSD was informed Resident 94 had verbalized the ice made her cold and she didn't want to be cold on top of being in pain. The DSD was informed Resident 94 was covered only by a sheet, her patio door was open, and the room was chilly. The DSD stated she was not aware Resident 94 was complaining of being cold. Review of facility policy titled, Pain Management, subtitled, Procedure, further subtitled, II. Pain Management (Revised 11/2016) indicated, J. Nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Interventions include . Resident is cold . Apply warm blankets, adjust room temperature . Resident has swelling .Provide apply ice packs or cold compress . During an observation and concurrent interview on 5/05/22 at 10:18 a.m., Resident 94's daughter was at her bedside. Resident 94's left arm was elevated above her heart and she was covered by a blanket. Resident 94 stated she was warm. Resident 94's daughter stated she thought her mother was receiving enough pain medication and stated she was not too groggy (from the medication). During an interview on 5/05/22 at 10:20 a.m., Unlicensed Staff I was asked what she had done earlier to address Resident 94's pain. Staff I stated, I tried everything (but) she didn't want it. Staff I stated she tried to elevate Resident 94's arm above her heart but it hurt her shoulder. Staff I stated Resident 94 did not want ice on her arm because the ice was cold. When informed that Resident 94's patio door was open and the she was covered only by a sheet, Staff I stated, I guess I should have put a blanket on her. When asked if she was able to turn (reposition) Resident 94, Staff I stated, no because it was too painful to turn her side to side. Staff I stated it took two CNA's (certified nursing aides) to turn Resident 94. Staff I stated when they turned her to change her diaper, Resident 94 cried from the pain. During an observation and concurrent interview on 5/05/22 at 3:18 p.m., Resident 94 was lying on her back in bed. Her left arm was elevated above her heart. When asked how her pain was, Resident 94 stated it was a #6 or 7. When reminded her pain had been #8-9 that morning, Resident 94 stated she thought it was a little improved. When reminded it had been excruciating, Resident 94 stated her pain was no longer excruciating, but it would be if she moved her elbow. When asked if her pain was a little lower, Resident 94 stated she thought it was. During an interview on 5/05/22 at 3:24 p.m., Unlicensed Staff R stated she had first worked with Resident 94 on Monday, three days earlier, and had taken care of her on Tuesday as well. When asked about Resident 94's pain (on Monday and Tuesday), Staff R stated Resident 94 could not move her arms and could not turn side to side due to pain. When asked what her pain level was on Tuesday, the last day she took care of Resident 94, Staff R stated, 10 (excruciating, per the MAR). When asked if the nurses had given Resident 94 pain medication at the time, Staff R stated, yes. When asked how she changed Resident 94's diaper, Staff R stated, two of us lifted her bottom using a bridge technique (feet flat on the bed with knees bent, legs used to lift hips off the bed). When asked how Resident 94 tolerated the bridge technique to change her diaper, Staff R state she tolerated it okay and did not cry. When asked if staff were able to reposition Resident 94 every two hours (to prevent pressure ulcers - skin breakdown), Staff R stated they were not able to turn her due to her pain. Staff R stated they elevated her arm on pillows and intermittently applied ice. During an interview on 5/05/22 at 3:38 p.m., Licensed Nurse Q stated she was Resident 94's nurse that evening. Nurse Q stated she had been Resident 94's nurse the prior evening as well and stated she had pain issues at that time, but the pain medication had taken her pain down to a tolerable level. Nurse Q stated the Norco and Oxycodone worked okay yesterday and Resident 94's pain, at #8, was brought down to zero. Nurse Q stated some days Resident 94 was still hurting after her pain medication and, there's nothing else I can give. When asked if she had called Resident 94's doctor on those occasions to inform him the pain medication was not providing adequate pain control, Nurse Q stated she had, sent a message but stated she had not sent any messages recently. Nurse Q stated she applied hot packs and stated ice packs did not work. When asked about repositioning Resident 94, Nurse Q stated it required two staff to turn Resident 94 but she was not comfortable during the process. When asked how she knew Resident 94 was not comfortable during repositioning, Nurse Q stated, she moans a little. During an interview 05/05/22 at 4 p.m., the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were asked about Resident 94's pain that day. The ADON stated she had called Physician P earlier in the day and her Oxycodone was changed to a scheduled dose (rather than as needed) and the Norco was unchanged. The ADON stated they would wait, a few days to assess the benefits of the interventions. The ADON stated if Resident 94 was still in pain (after a few days), they would make a second call to Physician P to get the pain under control. The DON stated Resident 94's pain should have been managed, a long time ago by notifying the physician about her pain. Review of Resident 94's medical record revealed no documentation in the nurse progress notes that nursing staff had called to notify Physician P of Resident 94's high pain levels. Review of Resident 94's medical record revealed a Social Service progress note written by Staff S on 5/5/2022 at 5:23 p.m. Staff S documented, Resident stated 'Id (sic) rather die than be in this pain' Resident is on q-15 checks (every 15 minute checks by staff). Notified daughter . Will continue to monitor. Staff S documented a note on 5/6/2022 at 9:16 a.m. that indicated, Room visit with resident. She in in (sic) bed comfortable. Writer asked resident about statement she made yesterday Resident stated 'They just changed me and I was in a lot of pain and at that brief second I felt like that but it passed. I have no intentions ofhurting (sic) myself I just don't want to be in pain anymore'. During a telephone interview 05/06/22 at 9 a.m., Physician P was asked about Resident 94's admission and pain control while at the facility. Physician P stated he provided telemedicine services and Resident 94 had been seen via televisit (on 4/29/22) only. Reviewed observations, interviews, and record review regarding Resident 94's pain with Physician P including: Resident 94's description of screeching and excruciation pain, pain levels frequently between #7-9 despite pain medication, ice inconsistently applied by staff, limited repositioning secondary to pain, and left arm not elevated above the heart. Physician P stated Resident 94's Norco was increased from 5 to 10 on the day of the televisit (4/29/2022, approximately seven days earlier). Physician P stated nursing staff called him yesterday (5/5/2022) and he made changes to the Oxycodone (changed it to routine, versus as needed) and added Neurontin (medication for nerve pain). Physician P stated they had been trying to meet Resident 94's needs but they did not want to overmedicate her. Physician P was asked if nursing staff had notified him of Resident 94's uncontrolled pain from the time the Norco was increased (4/29/2022) until yesterday (a timeframe of approximately seven days), Physician P stated nursing did not notify him. Physician P was asked if any changes to Resident 94's pain medication had occurred between 4/29/2022 and yesterday (seven days), Physician P stated he was not aware of any changes. When asked if he would have wanted to know about Resident 94's poor pain control, Physician P stated, of course. He stated they were there to help patients. He stated if a medication regime was not working, they would make changes. Physician P stated if Resident 94 had severe pain despite being routinely medicated, she may need additional imaging studies. Physician P stated Resident 94 was at risk for a DVT (deep vein thrombosis, blood clot) and she may need to return to the hospital for an ultrasound to rule out a blood clot. During a telephone interview on 5/09/22 at 12:17 p.m., the DON was asked about Resident 94's status. The DON stated Resident 94 had been sent to the emergency room at the hospital where it was determined she was negative for a DVT (she did not have a clot). The DON stated Resident 94 was sent back to the facility (after her hospital visit) and was doing good. The DON stated Resident 94's pain was improved, she was started on Neurontin, and her pain had decreased to #5 out of 10. Review of Resident 94's care plan for Acute Pain (dated 4/26/2022) indicated the goal of care was, Resident will be free of pain/discomfort. The care plan indicated interventions included, Administer ice packs as ordered Administer pain medication per order, if non-medication interventions are ineffective . Evaluate the effectiveness of pain-relieving interventions (non-medication and medication) .Evaluate non-verbal indicators of pain .Evaluate pain . The Acute Pain care plan did not identify non-medication interventions and did not indicate the physician should be notified if interventions were unsuccessful at controlling pain. Review of facility policy titled, Pain Management, subtitled, Policy (Revised 11/2016) indicated, Facility staff will help the resident attain or maintain their highest level of well-being whole working to prevent or manage the resident's pain to the extent possible. Under subtitle, Procedure, further subtitled, I. Pain Assessment the policy indicated, D. The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions . i. Goals for pain management and the acceptable level of pain relief will be determined in conjunction with the resident when possible. Review of the RN (registered nurse) Staff Nurse Job De[TRUNCATED]