**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide one resident (Resident #3), in a sample of eight residents, with appropriate care and services to promote the highest possible level of functioning and well being for a resident with dementia, by recognizing and thoroughly addressing the resident's mental and psychosocial needs. The facility did not attempt gradual dose reductions to ensure the resident was on the lowest amount of medication possible, did not document attempts at finding the root cause of behaviors, or evaluate and attempt new interventions, did not provide adequate monitoring of the resident to prevent the resident from leaving the building, from having falls inside and outside the facility (falling in a ditch), or wandering in and out of other resident's rooms to prevent altercations between residents. The resident experienced multiple falls, wandering, agitation, physical altercations with other residents and psychological distress. The facility census was 33. Review of the facility policy Dementia, Clinical Protocol, revised November 2018, showed the following: -As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition; -The interdisciplinary team (IDT) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes; -Dementia will be differentiated from delirium to the extent possible in residents presenting with impaired cognition. Delirium may be especially problematic in individuals with underlying dementia; -Prominent symptoms of delirium may include reduction in alertness, appetite, attention span, function, and responsiveness; confusion, alternating agitation and lethargy, fluctuation in level of consciousness, hallucinations, and delusions. -The physician will identify individuals taking cholinesterase inhibitors or other medications used to try to stabilize cognitive function, or medications such as antipsychotic medications and mood stabilizers that are commonly ordered to try to manage problematic behavior and disturbed mood; -The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes (see policy on Delirium/Altered Mental States); -The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments; -The staff and physician will collaborate to define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and in considering healthcare treatment options including life-sustaining treatments; -The staff and physician will collaborate to stage dementia and identify prognosis; -Behavior, Mood and Cognition: a. Individuals with dementia can also have a personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions (ADRs) or other conditions causing or contributing to impaired cognition and problematic behavior; b. As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications; -As needed, the physician will document the basis for conclusions about the category and causes of a resident's dementia or impaired cognition; for example, multi-infarct disease, Alzheimer's disease, Lewy Body Disease (a form of dementia), etc.; -The physician will order any diagnostic tests indicated to clarify the nature or causes of dementia and identify other co-existing or alternative causes of cognitive impairment and problematic behavior; for example: -The staff and physician will determine any relationship between the resident's level of pain and cognitive loss; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; -The facility will strive to optimize familiarity through consistent staff-resident assignments; -Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools); -Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT; -The physician will help define potential benefits and risks of medical interventions (including cholinesterase inhibitors and other medications used to enhance or stabilize cognition) based on individual risk factors, current conditions, history and details of current symptoms; -The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements; -Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time, unless a clinical rationale for higher doses or longer-term use is documented; -If a psychiatric consultant is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress; -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician; -The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors; -The physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. Review of the Dementia training provided to the facility staff, dated November 2023, showed the following: -Dementia is the loss of cognitive functioning, thinking, remembering and reasoning, as well as behavioral issues to such an extent that it interferes with relationships, daily life and activities; -Behaviors can cause patient suffering and are responsible for caregiver stress, institutionalization and hospitalization; -Identification of predisposing and precipitating factors is very important; -Addressing the causes of behavioral disturbances, including comorbid conditions, polypharmacy, pain, personal need, environmental factors, etc., is critical to successful outcomes; -The management approach to behaviors in dementia patients should be structured and thorough; -Ensuring the safety of the patient and others should be paramount; -Assessing the underlying need is critical. Carefully listening to a patient, even when the information is not clear, frequently yields positive results; -Identify the causes of dementia behavior problems; -Examine the behavior objectively. Are the behavior/actions truly a problem? Problem behaviors are typically those that can result in an adverse outcome for the patient or others. For example: can they result in harm?; -Look for patterns that help predict and prevent problem behaviors; -Ask what happened just before the problem behavior started. Did something specific trigger that behavior?; -Is there a certain time of day that seems to be more difficult? Sundown for example? Or bath/shower time?; -Are certain times of the year more difficult? Winter, when days are darker and nights longer, for instance?; -Remember to focus on the why when approaching assessment. Why might they be behaving this way, rather than what they are actually doing; -Understand behavior can often be a reaction to stress or a frustrated attempt to communicate. If you can establish why they're stressed or what is triggering the discomfort, you should be able to resolve the problem behavior more easily; -Are all of their basic human needs being met? Meeting an unmet need can quickly resolve the reason for the behavior in the first place; -A four-step clinical approach to managing behavioral disturbances in dementia patients can be followed: 1. Ensure patient is not in imminent danger to self or others. Chemical and/or physical restraints may be needed in severe cases; 2. Assess for delirium, comorbid medical illness(es), environmental factors or medication causing behavioral disturbances; 3. Look for and treat specific psychiatric syndromes such as depression, delusions and hallucinations, which respond better to pharmacological interventions compared with other behavioral disturbances; 4. Formulate and implement a behavioral plan to identify the antecedents and modify the consequences to improve the behavioral disturbances; -Loneliness is best treated with involvement of the person with the most positive relationship with the patient. That person should interact with the patient in a warm and loving manner. Other interventions found useful are one-to-one interaction with a new caregiver, videos of family, contact with animals and massage therapy; -Boredom is managed by providing stimulation with structured and unstructured activities and accommodating agitated behaviors. Sensory stimulation includes music tailored for the patient, aromatherapy and touch therapy; Reading material can be provided. Provide clothing with buttons, snaps and other articles sewn on for the patients to fiddle with rather than their own clothing. It is important to provide a useful activity, such as folding towels or kneading dough; -Depression, major or minor depression is seen in up to one half of patients with dementia and can be differentiated from apathy by the presence of psychic distress and a low mood state. Unlike most behavioral symptoms, the frequency of depression does not necessarily increase with overall disease severity. Depression frequently goes unrecognized in patients with dementia because of behavioral disturbances and aggression. Depression Interventions: Both pharmacological and nonpharmacologic treatment approaches have been found to be helpful in reducing depression in cognitive impairment and dementia. Pharmacological treatment of depression in patients with dementia, although common, presents some unusual difficulties. Since dementia patients may be less able to communicate, clinicians and caretakers must carefully observe patients for evidence of adverse events when new medications are introduced; -Emotion-Oriented Therapies: The primary aim of emotion-oriented therapies is to fit the therapy to emotional needs of people with dementia, and by doing so, improve quality of life, social functioning and ability to cope with the cognitive, emotional and social consequences of the disease as they subjectively experience them. Examples of emotion-oriented approaches include reminiscence, reality, validation and simulated presence therapy; -Anxiety: Anxiety is more prominent in the earlier phases of the illness and often results from anticipation of potentially stressful circumstances or an adjustment reaction to the increasing dependency associated with progressive functional decline. Interventions are similar to those of depression, but also continue into familiar with anxiety; -Behaviors and interventions: -Sensory, goal: preventing incident-music therapy, aromatherapy, bright light therapy, multisensory stimulation; -Structured Activities, goal: preventing incidents: dancing, exercise, social interaction, music therapy, art therapy, and outdoor walks; -Complementary and Alternative Medicine: Preventing and treating incidents-aroma therapy, reflexology, acupuncture, acupressure, message therapy, and Reiki therapy (touch therapy to reduce stress); -Psychological: preventing incidents-validation therapy, reality orientation, reminiscence therapy, support groups; -Sundowning: A set of neuropsychiatric symptoms occurring in elderly persons with or without dementia at the time of sunset, evening or at night. These behaviors represent a wide variety of symptoms such as confusion, disorientation, anxiety, agitation, aggression, pacing, wandering, resistance to redirection, screaming, yelling, etc. Some of these behaviors may not be specific to Sundowning and can be the manifestation of dementia, delirium, Parkinson's disease and sleep disturbances. Sundowning is distinguished by disruptive behaviors specifically in the late afternoon, evening or at night. Environmental cues can impact a person's Sundowning, adding to their agitation, confusion or aggressiveness. To set up the immediate environment to lessen the symptoms of Sundowning, try the following: Keep window coverings open for maximum exposure to bright light during the day. At dusk, close window coverings and turn lights on to eliminate shadows which can cause confusion. Create a quiet early evening routine include a walk or calming background music. Minimize loud background noises such as banging pots or sudden loud noises. If needed, create some white noise to lessen the impact of sudden noises. Minimize clutter and/or distractions such as the number of people in the room; Monitor TV watching and the images on the screen, which may be upsetting. Structure the day and maintain a stable routine as much as possible to help the patient know what to expect. Give simple single step instructions for meals, bathing, etc. Eliminate caffeine and alcohol especially in the late day. Include outside physical activity and exercise everyday. Keep daytime naps short, and earlier rather than later in the day; -Apathy: Apathy occurs as frequently as aggression or psychosis in dementia patients and is as important a source of caregiver distress . Best characterized as a disturbance of motivation, including loss of interest, fatigue, motor retardation and affective blunting. Responds poorly to current psychotropic medications. Nonpharmacological interventions include; music, intervention group, exercise, multisensory stimulation, pet therapy and massage; -Wandering/pacing is more often a nuisance to other residents and caregivers than to the patient. Using identification bracelets and position alarms, putting alarms and complex locks on doors and avoiding restraints; Outdoor walks and outdoor wandering areas. Finger foods or fanny packs with snacks; -Distracting places for the pacer to sit, relax and rest; -Physical aggression: Physical aggression is found to be associated with depression, psychoses, younger age, use of psychotropic drugs, as well as with dementia itself. In mild-to moderate cases, behavioral interventions are the first line of treatment. In severe persistent cases, atypical antipsychotics or mood stabilizers may be considered for a limited period; -Resistiveness: Resisting care is defined as any patient behavior which prevents or interferes with the care provider performing or assisting with activities of daily living for the patient including bathing, eating, toileting, dressing and grooming. Resistiveness is extremely tiring and burdensome, frequently leading to caregiver burnout, increased staff turnover in long-term care facilities, and even caregiver injuries. Resistiveness is best managed by caregiver education and training in nonpharmacologic interventions including: clear respectful age appropriate tone, intentional listening, follow through with appropriate patient requests; -Delirium: Confusion, seeing things that don't exist (hallucinations, restlessness, agitation or combative behavior, calling out, moaning or making other sounds, being quiet and withdrawn - especially in older adults, slowed movement or lethargy. Patients with dementia have a lower threshold for developing delirium and do so with greater frequency. Delirium should be promptly identified and treated; -Delirium interventions: Social activities, adequate sleep, adherence to a strict schedule, maintenance of proper stimulation level, adequate hydration, reformatting tasks with occupational therapy; -Disruptive vocalization tends to occur along with various other agitated behaviors and is associated with depression, physical discomfort and response to some environmental factors. Occurs during patient care activities, particularly toileting and bathing; -Disruptive vocalization interventions include: music, differential reinforcement, rewarding silence or appropriate requests (when screaming is being reinforced by contingent staff attention and massage therapy. 1. Review of Resident #3's face sheet showed the following: -admitted to the facility 2/17/21; -Diagnoses including dementia, insomnia (inability or disruption to sleep) and depressive episodes. Review of the resident's care plan, updated 10/6/22, showed the following: -Diagnoses including psychotic disturbance (perceiving or interpreting interpret reality in a very different way from people around you), mood disturbance, anxiety, cognitive communication deficit, abnormalities of gait and mobility, reduced mobility, need for assistance with personal care and unsteadiness on feet; -The resident was at risk for falling due to occasional unsteady gait; -Analyze the resident's falls to determine pattern/trend; -Assure the resident was wearing eyeglasses that were clean and in good repair; -Assure the floor is free of glare, liquids and foreign objects; -Encourage the resident to assume a standing position slowly; -Give the resident verbal reminders not to transfer when feeling weak or unsteady without assistance; -Keep the resident's bed in the lowest position with the brakes locked; -Place the resident's call light in reach at all times; -Keep personal items and frequently used items within reach; -Nightlight on in the room at night; -Physical therapy consult for strength training, toning, positioning, transfer training, gait training, mobility devices; -Keep environment free of clutter; -Ensure the resident had proper, well-maintained footwear; -No interventions related to the resident being an elopement risk. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, completed by staff, dated 4/4/23, showed the following: -The resident had moderately impaired cognition; -He/She experienced delusions; -Continuous inattention and disorganized thinking does not fluctuate; -He/She had wandering behavior that occurred one to three days, out of seven days; -He/She had experienced a fall in the last two to six months prior to admission; -Receives antipsychotic and antidepressant medications; -Antipsychotic received routinely, no gradual dose reduction (GDR) (a dose reduction or discontinuation of certain medications) attempt and no physician documentation of a contraindication. Review of the resident's nursing note, dated 5/12/23 at 3:41 P.M., showed the following: -The resident was insistent about leaving. He/She suddenly stood and leaned over Registered Nurse (RN) I, started to claw at RN I's neck, and yelled; -RN I alerted the administrator the resident was looking to leave; -The administrator met the resident at the door and tried to redirect the resident; -The resident started banging on the door and yelled. The Certified Medication Technician (CMT) helped the administrator get the resident away from the door; -The resident tried to kick and hit staff and clawed the CMT; -The nurse called the on-call physician, who ordered Haldol (antipsychotic) 5 milligrams (mg)/milliliter (ml), give half a ml=2.5 mg intramuscularly (IM) now and may repeat dose in 30 minutes if needed; -Two staff members held the resident while the medication was administered; -The resident called staff names and tried to hit, kick and bite; -The staff brought the resident to the nurses' station, the administrator observed the resident and kept other residents out of his/her reach. Review of the resident's care plan showed no documentation, revisions, or review related to the resident's behavior on 5/12/23. Review of the resident's nursing note, dated 5/28/23 at 7:40 P.M., showed the resident sat on the bench in the hallway, fell asleep, rolled off the bench and landed on the floor. Review of the resident's care plan showed no documentation, revisions, or review related to the resident's fall on 5/28/23. Review of the resident's nursing note, dated 8/3/23 at 12:30 P.M., showed the following: -The resident went through the front door and the staff walked with the resident; -The nurse attempted to redirect the resident back to the door to come inside, but the resident reached up and hit the nurse in the face and yelled to leave him/her alone and do not touch him/her; -The nurse backed off and walked with the resident a bit more and was able to get the resident to sit down in a chair outside; -A different staff member was able to direct the resident back inside. Review of the resident's care plan showed no documentation regarding the resident's elopement attempt on 8/3/23. Review of the resident's nursing note, dated 8/5/23 at 12:01 P.M., showed during lunch, the resident sat in his/her recliner. He/She attempted to stand up but slid onto the floor. Review of the resident's care plan showed no documentation related to the resident's fall on 8/5/23. Review of the resident's nursing note, dated 8/18/23 at 9:31 P.M., showed the following: -The resident asked staff questions about what to do and was unhappy with any answer; -The resident did not stay with any activity provided such as a book, word search, or television; -The Activity Director gave the resident clothes to fold and the resident sat and angrily folded the clothes; -The resident grabbed RN I's hand as he/she walked towards the resident's room and yelled at RN I for holding his/her hand and dragging him/her down the hallway; -The resident tried to grab an empty supper tray from a kitchen helper's hand and yelled, Let me eat it, I'm hungry!; -Registered Nurse (RN) I tried to distract the resident by asking the resident to follow RN I for a snack, but the resident was not distracted and followed the kitchen helper into the break room and tried to grab the tray; -RN I told the resident the kitchen helper was going to wash the tray and the resident yelled, I know how to wash dishes give it here!; -RN I helped the kitchen aide escape the break room and the kitchen aide grabbed dirty napkins to put in the laundry room and the resident tried to rip the laundry basket out of his/her hands while continuing to yell; -The resident tried to hit RN I while RN I tried to distract the resident from the kitchen helper, and then the resident grabbed the kitchen helper by the shirt sleeve and the kitchen aide walked back to the nurses' station with RN I and the resident to convince the resident to let go; -RN I took sandwiches and snacks out of the refrigerator and the resident yelled that he/she did not want any of it and was not hungry; -The resident called RN I names from across the nurses' station, then grabbed Certified Nurse Assistant (CNA) papers off the nurses' station, tried to read the papers, saw his/her name on the papers, and became angry; -The CNA tried to get the resident to give up the papers. The resident grabbed the CNA's thumb and tried to bend their thumb backwards; -The CMT was able to get the resident to release the CNA's thumb, but the resident tried to bite both staff members; -A different CNA was able to convince the resident to get dressed for bed in his/her room; -The resident threatened the CNA verbally, but cooperated with dressing and went to bed. Review of the resident's care plan showed no documentation regarding the resident's behavior or interventions from 8/18/23. Review of the resident's physician orders, dated October 2024, showed the following: -Duloxetine (antidepressant) delayed release 20 milligrams (mg), give one tablet once a day for depressive episodes (original order dated on 7/14/22); -Trazodone (antidepressant) 50 mg, give one tablet at bedtime for insomnia (original order dated 7/14/22); -Risperidone (antipsychotic) 0.5 mg three times daily and 0.25 mg one time daily for dementia (on Risperidone on admission 2/17/21, last increase 6/30/23). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Inattention and disorganized thinking present fluctuates; -Physical and verbal symptoms directed toward others; -Rejection of care one to three days out of the last seven days; -Wandering 4-6 days out of seven days; -Receives antipsychotics and antidepressants; -Anitpsychotics received routinely, no GDR attempt and no physician documentation of a contraindication. Review of the resident's pharmacy consultation report, dated 10/29/23, showed no GDR was recommended by the pharmacy consultant; no documentation a GDR was declined or documentation provided to continue duloxetine, Trazodone, or risperidone dosages by the physician. Review of the resident's care plan for falls, last reviewed/revised 11/6/23, showed no new interventions or evaluation of current interventions related to falls, behaviors, or elopement attempts. Review of the resident's care plan, updated 11/7/23, showed the following: -The resident had disturbed sleep pattern related to insomnia; -He/She received an order for Trazodone at bedtime, which proved helpful with sleep; -He/She received an antidepressant medication, duloxetine 20 mg daily; -Resident receives antipsychotic medication, risperidone; -Resident will not exhibit signs of drug related adverse reactions: hypotension; sedation; anticholinergic symptoms( dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating); extrapyramidal symptoms (dysfunction such as dystonia (continuous spasms and muscle contractions), akathisia (may manifest as motor restlessness), Parkinsonism characteristic symptoms such as rigidity, bradykinesia (slowness of movement), tremor, and tardive dyskinesia (TD) (irregular, jerky movements); -Monitor behavior and response to medication and Abnormal Involuntary Movement Scale (AIMS) (a rating scale to measure involuntary movements known as tardive dyskinesia (TD) (a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications)) and functional status on a regular basis, -Quantitatively and objectively document behaviors; -Under physician's order, attempt gradual dose reductions; -The pharmacy consultant reviewed as a regularly scheduled task. Review of the resident's nursing note, dated 11/9/23 at 5:30 P.M., showed the staff found the resident in a room across the hall from the resident's room, sitting on the floor. Review of the resident's care plan did not show revision, updates or reviews after the resident's fall on 11/9/23. Review of the resident's nursing note, dated 12/21/23 at 6:20 A.M., showed the resident yelled out and staff found him/her sitting on the floor in his/her room with his/her pants around his/her thighs. Review of the resident's care plan did not show revision, updates or reviews after the residents fall on 12/21/23. Review of the resident's nursing notes, dated 12/27/23 at 10:24 P.M., showed the following: -The resident walked to the front door and demanded to leave the building; -He/She hit and kicked staff, yelled loudly, and took over 25 minutes to convince the resident to go elsewhere. Review of the resident's care plan showed no documentation regarding the resident's behavior or interventions from 12/27/23. Review of the resident's physician orders, dated January 2024, showed the following: -Duloxetine delayed release 20 mg, give one tablet by mouth once a day for depressive episodes; -Trazodone 50 mg, give one tablet by mouth at bedtime for insomnia; -Risperidone 0.5 mg three times daily and 0.25 mg one time daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -He/She did not have symptoms of depression; -He/She received antipsychotics and antidepressants; -Antipsychotics were received routinely; -A GDR had not been attempted and the physician did not document a clinical contraindication to attempting a GDR. Review of the resident's nursing note, dated 1/30/24 at 1:46 A.M., showed staff often provided one-on-one oversight when the resident was confused because he/she tried to leave or entered other resident rooms. Review of the resident's care plan showed no documentation regarding the resident's behaviors with interventions for 1/30/24. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She experienced delusion, physical behaviors and verbal behaviors; -He/She rejected care that occurred one to three days during seven-day review; -He/She had wandering behavior that occurred four to six days, but less then daily; -He/She had two falls without injury since last assessment; -He/She had a wanderguard alarm; -Receives antipsychotics and antidepressants; -Anitpsychotics received routinely, no GDR attempt and no physician documentation of a contraindication. Review of the resident's elopement risk assessment, dated 2/13/24, showed the resident was at risk for elopement and staff placed a wanderguard censor (censor that sounds an alarm and doors to lock worn by residents). Review of the resident's nurse note, dated 2/13/24 at 2:06 P.M., showed the following: -Resident has been up and very active this shift; -Multiple attempts to go out front door, convinced the resident he/she drove here and he/she can leave when he/she wants to; -Difficult to redirect, needing extra supervision. Review of the resident's nursing note, dated 2/13/24 at 10:55 P.M., showed the following: -Resident has continued to be restless all shift; -Several more attempts to leave the facility and open doors. The resident's care plan did not include updates, or new information with the residents exit seeking and behaviors on 2/13/24. Review of the resident's nursing note, dated 2/14/24 at 10:25 P.M., showed the following: -Resident is very confused & uncooperative at times with care; -Roams in hallway frequently; -Has wanderguard (bracelet that triggers the doors to lock and alarm) and exit seeks at times. The resident's care plan did not include updates, or new information with the residents exit seeking and behaviors on 2/14/24. Review of the resident's nursing note, dated 2/16/24 at 3:57 P.M., showed yesterday the resident was restless and did attempt to exit the front door several times. The resident was difficult to redirect except he/she wants to hold hands with staff and go anywhere they are. This morning the resident was in the dining room and repeatedly yelling, very loudly, I am hungry feed me now!. He/She has continued to do the same thing throughout the day in different scenarios. After breakfast he/she was repeatedly screaming, I am cold, get me a blanket! and kept increasing his/her volume even after staff told him/her they would get blanket, he/she continued to scream until the blanket arrived. The resident's care plan did not include updates, or new information with the residents exit seeking or behaviors on 2/16/24. Review of the resident's nursing note, dated 2/18/24 at 6:40 P.M., showed staff notified the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #14's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Physical behavioral symptoms occurred one to three days; -Other behavioral symptoms occurred four to six days but less than daily; -Behaviors were worse than previous assessment; -Required extensive assistance from one staff for bed mobility (changing position), dressing, toilet use, and transfers; -Did not have pain; -On scheduled pain medications; -Received PRN pain medications. Review of the resident's care plan, revised 2/13/19, showed the following: -Diagnoses included flaccid hemiplegia (paralysis on one side of the body) affecting left non-dominant side with pain in left shoulder, right elbow, right wrist, joints of right hand; chronic pain; diabetes mellitus Type II; and Parkinson's disease; -The resident recently started yelling out with no words, just yelling; -Staff observed the resident smacking himself/herself in the face, stomach, and legs; -His/her yelling seems to lessen while in bed and staff should offer to put the resident in bed after meals and activities; -Limited in ability to transfer himself/herself related to left sided weakness; -Recently had a stroke that caused left sided flaccidity and staff to transfer with mechanical lift; -Stroke caused left sided weakness as well as bowel and bladder incontinence. (The resident's care plan did not address assessing pain and interventions for pain.) Review of the resident's medical record showed no evidence staff completed a comprehensive pain assessment for the resident. Review of the resident's physician's orders for March 2019 showed the following: -Butrans Schedule III narcotic patch (used to treat moderate to severe chronic pain that is not controlled by other medications) weekly, 5 microgram per hour, one transdermal (medication absorbed slowly through the skin) for chronic pain; -Tylenol extended release 650 mg four times a day PRN (originally ordered on 5/1/18). Review of the resident's Medications Flow sheet, dated March 2019, showed to apply one Butrans transdermal patch every week on Wednesday. Review of the resident's PRN Medications Notes, dated 3/8/19 at 8:00 A.M., showed staff administered Tylenol 650 mg upon the resident's request. Staff did not document they assessed the location of the resident's pain, the severity, or the effectiveness of the medication. Review of the resident's PRN Medication Notes, dated 3/12/19 at 7:00 A.M. and 12:00 noon, showed staff administered Tylenol 650 mg upon the resident's request and documented the Tylenol helped. Staff did not document they assessed the location of the pain or the severity of the resident's pain. Review of the resident's PRN Medication Notes, dated 3/14/19 at 8:00 A.M. and 12:00 noon, showed staff administered Tylenol 650 mg and documented the resident complained of pain and the result was the Tylenol medication helped. Staff did not document they assessed the location and severity of the resident's pain. At 7:00 P.M., staff administered Tylenol 650 mg for complaints of ankle pain and documented the result as the resident was resting. Review of the resident's PRN Medication Notes dated 3/15/19 at 12:00 noon, showed the staff administered Tylenol 650 mg when the resident requested the medication. Staff did not document they assessed the location of the resident's pain, the severity of pain, or the effectiveness of the medication. Review of the resident's PRN Medication Notes, dated 3/16/19 at 8:00 A.M., showed staff administered Tylenol 650 mg for resident's complaint of pain. The result was the resident was resting. Staff did not document they assessed the location of the residents pain or the severity. Review of the resident's PRN Medication Notes, dated 3/17/19 at 8:00 A.M., showed staff administered Tylenol 650 mg for the resident's complaint of pain. The result was the resident was resting. Staff did not document the location of the resident's pain or the severity. Review of the resident's PRN Medication Notes, dated 3/18/19 at 8:00 A.M., showed staff administered Tylenol 650 mg for the resident's complaint of pain. The result was the medication helped the resident. At 12:00 noon, staff administered Tylenol 650 mg for the resident's complaint of pain. The result was the resident was resting. Staff did not document the location of the resident's pain or the severity. Review of the resident's PRN Medication Notes, dated 3/20/19 at 8:00 A.M. and 12:00 noon, showed staff administered Tylenol 650 mg for the resident's complaint of pain. The result was the Tylenol medication helped the resident. Staff did not document the location of the resident's pain or the severity of his/her pain. Review of the resident's PRN Medications Flow sheet, dated 3/21/19, showed staff administered Tylenol 650 mg. (There was no place on the flow sheet to write the time the medication was given, and no place for staff to document their assessment of the resident's pain.) Review of the resident's PRN Medication Notes showed no documentation staff administered Tylenol 650 mg to the resident on 3/21/19. Staff did not document they assessed the location of the resident's pain, the severity, or the effectiveness of the medication. Review of the resident's PRN Medication Notes, dated 3/22/19 at 12:00 noon, showed staff administered Tylenol 650 mg for the resident's complaint of pain. The result was the resident was resting. Staff did not document the location of the resident's pain or the severity. Review of the resident's PRN Medications Flow sheet, dated 3/25/19, showed staff administered Tylenol 650 mg two times to the resident (no times documented). Review of the resident's PRN Medication Notes showed there was no documentation staff administered Tylenol 650 mg to the resident on 3/25/19. Staff did not document they assessed the location of the resident's pain, the severity, or the result of the Tylenol medication. Review of the resident's PRN Medications Flow sheet, dated 3/26/19, showed staff administered Tylenol 650 mg to the resident. Review of the resident's PRN Medication Notes, dated 3/26/19 at 8:00 A.M., showed staff administered Tylenol 650 mg when resident requested the medication. Staff did not document they assessed the location of the resident's pain, the severity, or the result of the Tylenol medication. Review of the resident's PRN Medication Notes, dated 3/27/19 at 8:00 A.M. and 12:00 noon, showed staff documented the resident requested the Tylenol 650 mg and the result was the Tylenol medication helped for the 8:00 A.M. dose and the resident rested for the 12:00 noon dose. Staff did not document they assessed the location and severity of the resident's pain. Review of the resident's PRN Medication Notes, dated 3/28/19 at 8:00 A.M., showed staff documented the resident requested the Tylenol 650 mg and the result was the Tylenol medication helped. Staff did not document they assessed the location and severity of the resident's pain. Review of the resident's PRN Medications Flow sheet, dated 3/29/19, showed staff administered Tylenol 650 mg to the resident. Review of the resident's PRN Medication Notes, dated 3/29/19 at 12:00 noon, showed staff documented the resident was yelling. Staff did not document they assessed the resident for pain, the location and severity of pain, and the result of administering the Tylenol 650 mg. Review of the resident's PRN Medications Flow sheet, dated 3/30/19, showed staff administered Tylenol 650 mg to the resident. Review of the resident's PRN Medication Notes, dated 3/30/19 at 8:00 A.M., showed staff documented the resident requested the Tylenol 650 mg and the result was the Tylenol medication helped. Staff did not document they assessed the location and severity of the resident's pain. At 12:00 noon, the resident requested Tylenol 650 mg for complaint of pain. The result was sleeping. Staff did not document they assessed the location and severity of the pain. Observation on 4/3/19 at 6:06 A.M. showed CNA C entered the resident's room and told the resident it was time to get up for breakfast. The resident moaned, shook his/her head no. The resident said he/she didn't want to get up, and didn't want breakfast. The resident said he/she didn't feel well and didn't sleep well. CNA C told the resident everything would be okay. The resident continued to moan and grimace as staff attached the lift sling to the mechanical lift. The resident yelled out, Oh, oh! He/she grimaced, his/her eyebrows were furrowed, his/her mouth was clenched and his/her eyes were closed as CNA E and CNA C transferred the resident from the bed to the wheelchair. The resident's extremities were stiff. The resident said, I hurt all over. When staff moved the resident's left limp foot on to the foot pedal on his/her wheelchair, the resident closed his/her eyes, furrowed his/her brow, and yelled, Oh, oh! Staff washed the resident's face, brushed his/her hair, and pushed the resident to the nurse's station to wait for breakfast. During interview on 4/4/19 at 12:45 P.M., CNA E said he/she assumes the resident Hollers to be hollering. The resident sometimes says he/she is hurting when he/she is hollering. The resident gets scheduled pain medication in the morning so he/she did not tell the charge nurse the resident was in pain yesterday morning (4/3/19) when they got the resident out of bed. CNA E did not know if the resident got any pain medication. During interview on 4/9/19 at 11:50 A.M., CNA C said the resident was with it and could carry a conversation with others. The resident had pain all the time especially when staff provided care. The resident had a lot of pain when getting out of bed. The resident usually had pain in his/her arm and foot. The resident hollers all the time. Staff do not turn the resident routinely every night, so his/her back and legs hurt. The resident has told him/her the night shift staff put him/her to bed and leave him/her that way all night. They probably should have left the resident in bed when the resident said he/she did not want to get up or eat breakfast. Staff tell the charge nurse when the resident is having pain. CNA C was unaware if the resident had any pain medication or was given any pain medication after they got the resident out of bed. During interview on 4/3/19 at 7:10 A.M., the resident, who sat in the wheelchair at the dining room table, said the pain was better now, but he/she still hurt all over. It was like someone sticking needles in me. He/she rated his/her pain as a 6 or 7 (on a pain scale of 1 to 10, with 10 being the most pain). Review of the resident's PRN Medications Flow sheet, showed on 4/3/19 at 8:00 A.M., showed staff administered Tylenol 650 mg for complaints of pain and documented the resident's pain was rated an 8 which was severe pain. Staff documented the medication helped. Observation on 4/3/19 at 8:10 A.M., showed CNA K took the resident to his/her room. The resident moaned and said, My back hurts. He/she put his/her hand behind his/her back to rub it. CNA K went to check with the nurse for something for the resident's pain. The resident said an occasional oh, oh as he/she sat in the wheelchair. During interview on 4/3/19 at 8:11 A.M., CNA K said he/she asked the CMT D who said he/she just gave Tylenol to the resident (within the past half hour.) Observation on 4/3/19 at 8:20 A.M. showed the resident occasionally said, Oh, oh which could be heard in the hallway. During interview on 4/3/19 at 8:20 A.M., the resident, who sat in the wheelchair in the room, said his/her pain was a6 in his/her back. He/she said sometimes Tylenol worked to relieve pain. During interview on 4/3/19 at 1:20 P.M., the resident, who was in bed, said the pain in his/her back was a little better. The resident said his/her pain was a 6. Observation on 4/4/19 at 7:14 A.M., showed the resident sat at the dining room table waiting for breakfast. The resident rubbed his/her right leg several times as he/she moaned, Oh, oh. During interview on 4/4/19 at 7:40 A.M., CNA F said the resident sometimes says he/she hurts all over. The resident hollered when he/she rolled him/her over in bed this morning to dress him/her. CNA F said he/she told the night charge nurse early this morning but did not know if he/she gave any medication to the resident. CNA F will tell the charge nurse and ask if they can give the resident pain medication. Review of the resident's PRN Medications Flow sheet, showed on 4/4/19 at 8:00 A.M., staff administered Tylenol 650 mg for complaint of pain and documented the resident's pain was a 7 which was severe pain. Staff documented the medication helped. During interview on 4/4/19 at 7:05 P.M., CMT G, night shift staff, said the resident usually said he/she did not have pain but he/she does have pain. The resident has pain in his/her left foot. During interview on 4/4/19 at 7:15 A.M., LPN H said when the resident said Oh, oh, it meant he/she wants peaches to eat, or to lie down, or he/she didn't know why. He/she didn't know if the resident was having pain. If the medication technicians give pain medication, staff was to assess the resident's pain on a scale of 1-10. A long time ago, they had a place in the MAR to chart the pain, but not sure about this now. During interview on 4/3/19 at 12:03 P.M, CMT D said he/she asks a resident on the pain scale of 1 to 10 but did not write it down anywhere since there was no place to write it on Resident #14's MAR. During interview on 4/4/19 at 2:45 P.M., the director of nursing (DON) said the resident knows when he/she is in pain and staff should offer a PRN pain medication to the resident before getting the resident up in the morning. During interview on 4/9/19 at 4:10 P.M., the resident's physician said the resident had PRN Tylenol available for pain. He/she ordered the medication for staff to use as needed. During interview on 4/4/19 at 1:35 P.M., the CMT/MDS Coordinator said when completing the pain assessment on the MDS, he/she marks the resident does not have pain if a resident has not taken PRN pain medications. If the resident received a scheduled pain medication, he/she asks the resident if they have had any pain in the last seven days. If a resident was unable to tell him/her, there were triggers to watch for in the resident and he/she knows to watch and monitor the resident. The medication technicians were to chart on a pain scale when the resident had pain. During interview on 4/17/19 at 10:24 A.M., the CMT/MDS Coordinator said they do not complete comprehensive pain assessments on any residents. During interview on 4/4/19 at 2:33 P.M., the DON said the CNAs were good to report to the charge nurse if a resident had pain. The CMTs were to ask residents if they had pain and offer PRN pain medication to the residents. The charge nurse was to call the physician, even in the night, if the resident had pain and nothing was scheduled for PRN pain medications. It was unacceptable for a resident to be in pain and staff to tell the resident pain medication wasn't due yet. If a scheduled pain medication was not due and the resident was in pain and needed something for pain, the nurse was to call the physician for guidance and pain medication for relief of pain. Based on observation, interview, and record review, the facility failed to maintain an effective pain management program for two residents (Residents #10 and #14), in a review of 12 sampled residents. The facility failed to adequately assess and monitor Resident #10's pain. The resident exhibited pain in the morning hours prior to his/her scheduled pain medication. Staff continued to provide care after the resident continued to express he/she was having intense pain. The facility did not notify the physician of the resident's complaints of pain and did not provide any non-pharmacological interventions to address the resident's pain. The facility failed to adequately assess Resident #14's pain, failed to consistently document the location and severity of the resident's pain when giving PRN pain medication, failed to develop a care plan with interventions to address the resident's pain, failed to ensure the resident's pain medication was effective in treating his/her pain, and failed to provide PRN medications when the resident expressed pain during care. The facility census was 31. 1. Review of the facility policy, Pain Assessment and Management, obtained from the Nursing Services Policy and Procedure Manual for Long-Term Care, revised March 2015, showed the following: -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his/her clinical condition and established treatment goals; -A multidisciplinary care process that includes assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary; -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -Recognizing Pain: observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain; -Possible behavioral signs of pain: verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw, etc; changes in gait, skin color and vital signs; behavior such as resisting care, irritability, depression, decreased participation in usual activities; -Limitations in level of activity due to presence of pain; guarding, rubbing or favoring a particular part of the body; difficulty eating or loss of appetite; insomnia, and evidence of depression, anxiety, fear or hopelessness; -Ask the resident if he/she is experiencing pain. Be aware the resident may avoid the term pain and use words such as throbbing, aching, hurting, cramping, numbness or tingling; -Assessing Pain: during the comprehensive pain assessment, gather information from the resident (or legal representative); -Characteristics of pain: intensity of pain (as measured on a standardized pain scale); descriptors of pain; patter of pain such as constant or intermittent; location and radiation of pain; frequency, timing and duration of pain; factors that precipitate or exacerbate pain; factors and strategies that reduce pain, symptoms that accompany pain such as nausea, anxiety; -Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level; -Discuss with the resident (or legal representative) the goals for pain management and satisfaction with the current level of pain control; -Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated such as bathing, dressing, or other activities of daily living; treatments such as wound care or dressing changes; ambulation or physical therapy; turning or repositioning; -Defining Goals and Appropriate Interventions: Interventions shall be consistent with the resident's goals for treatment and goals will be specifically defined and documented; shall reflect the sources, type and severity of pain, and shall address the underlying causes of the resident's pain; -Implementing Pain Management Strategies: The physician and staff will establish a treatment regimen based on the resident's medical condition, current medication regimen, nature, severity and cause of the pain, course of the illness, and treatment goals. Implement the medication regimen as ordered, carefully documenting the results of the interventions; -Monitoring and Modifying Approaches: re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Monitor the following factors to determine if the resident's pain is being adequately controlled: the resident's response to interventions and level of comfort over time, the status of the underlying cause(s) of pain, if identified previously, and the presence of adverse consequences to treatment. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tool (e.g. approved pain scales, etc.) and relevant criteria for measuring pain management such as signs and symptoms; -If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated; -Documentation: Document the resident's reported level of pain with adequate detail such as enough information to gauge the status of pain and the effectiveness of interventions for pain as necessary. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record; -Report the following information to the physician or practitioner: significant changes in the level of the resident's pain; any adverse effects from pain medications; and prolonged, unrelieved pain despite care plan interventions. 2. Review of Resident #10's care plan, last revised on 8/8/18, showed the following: -The resident had complaints of chronic pain related to old vertebra fracture, osteoporosis (a bone disease that causes the bones to become weak and brittle) and bunions. Pain site was at the back of the resident's legs and feet; -The resident's legs are the most painful. The resident's pain was well controlled when handled gently during care and positioned with pillows for support; -The resident liked his/her legs elevated on pillows when in bed. Staff was to report any complaints or signs or symptoms of pain to the charge nurse; -He/she had pain medication he/she could have as needed. He/she did not like to take oral pain medication because of fear of side effects, although staff should still monitor for pain during care and offer medications per orders; -Use non-medicated pain relief measures per treatment administration record (TAR); -Offer and administer pain medication per medication administration record (MAR) -Reinforce that he/she will be monitored for adverse effects, monitor and record effectiveness. Report adverse side affects; -Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/5/19, showed the following: -Severe cognitive impairment; -Clear speech; -Makes self-understood and understands others; -Did not reject care; -Required extensive assistance of one staff member with bed mobility, transfers, dressing, toileting, personal hygiene and bathing; -No scheduled pain medication; -The resident received as needed (PRN) medication; -No non-medication interventions; -No presence of pain. Review of the resident's medical record showed no evidence staff completed a comprehensive pain assessment for the resident. Review of the resident's Physician Order Sheet (POS), dated February 2019, showed the following: -Diagnoses included chronic pain, unspecified fracture of unspecified lumbar vertebra, and abnormal posture; -Acetaminophen (Tylenol; pain reliever) 500 milligrams (mg), one tablet as needed for pain every six hours. Review of the resident's nurse's notes, dated 2/25/19 at 1:45 A.M., showed the resident yelling out for pain, Mama, I'm hurting. Staff asked the resident if he/she would like PRN Tylenol. The resident said, Yes, please. Staff gave PRN Tylenol as ordered. Staff repositioned the resident and applied moon boots to protect his/her heels. Review of the resident's nurse's notes, dated 2/26/19 at 5:27 A.M., showed the resident asked for and received Tylenol for pain all over. The resident was resting at 5:30 AM. Review of the resident's POS, dated March 2019, showed the resident had an order for Tylenol 500 mg every six hours as needed for pain. Review of the resident's nurse's notes, dated 3/1/19 at 3:00 A.M., showed the resident asked for and received Tylenol for pain. Pain medication was effective. Review of the resident's nurse's notes, dated 3/4/19 at 4:00 A.M., showed the resident asked for and received Tylenol for pain all over.' Pain medication was effective. Review of the resident's nurse's notes, dated 3/5/19 at 4:15 A.M., showed the resident complained of heel pain. He/she asked for and received Tylenol. Staff also repositioned the resident to take any pressure off his/her feet. Staff documented effective. Will continue to monitor. Review of the resident's nurse's notes, dated 3/8/19 at 2:00 A.M., showed the resident asked for and received a PRN Tylenol for heel pain. He/she was resting with eyes closed at 3:00 A.M. Will continue to monitor. Review of the resident's POS, dated March 2019, showed the following: -On 3/8/19, a new order for Tylenol 325 mg, two tablets (650 mg) three times a day at 8:00 A.M., 1:00 P.M., and 6:00 P.M. -On 3/8/19, an order to discontinue Tylenol 500 mg every six hours as needed for pain. Review of the resident's nurse's notes showed no documentation to show the reason the resident's Tylenol 500 mg PRN was discontinued and a new order was obtained for scheduled Tylenol 325 mg, two tablets three times a day. Review of the resident's nurse's notes, dated 3/9/19 at 4:00 A.M., showed the resident asked for and received PRN Tylenol for pain. Staff documented it was effective. (Review of the resident's medical record showed the resident's PRN Tylenol was discontinued on 3/8/19.) Review of the resident's physician order sheets (POS), dated April 2019, showed the following: -On 3/11/19, an order to discontinue Tylenol 325 mg, two tablets (650 mg) three times a day at 8:00 A.M., 1:00 P.M., and 6:00 P.M. -On 3/11/19, a new order for Tylenol 325 mg four times daily at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. for chronic pain. (The resident did not have an order for PRN pain medication.) Review of the resident's nurse's notes showed no documentation to show the reason the resident's pain medications were changed on 3/11/19. Observation on 4/3/19 at approximately 6:30 A.M., showed the following: -The resident lay in bed in a dark room and yelled out, Oh my feet are killing me! Help me, I hurt so bad! -The resident had facial grimacing; -Certified Nurse Assistant (CNA) J entered the resident's room, lifted the resident's feet and asked the resident what was wrong. The resident immediately cried out, That hurts! My feet are killing me! Help me! -CNA J walked out of the resident's room into the hall and reported the pain to Licensed Practical Nurse (LPN) I. LPN I said the resident could not have anything for pain until 8:00 A.M. CNA J went back into the resident's room and explained to the resident he/she could not have anything for pain now; -CNA C and CNA E walked into the resident's room to assist the resident out of bed. The resident continued to scream, I need something for pain! My feet are killing me! Oh momma, help me please! CNA C said the resident was really hurting today; -CNA C and CNA E transferred the resident with the mechanical lift to his/her wheelchair. The resident continued to cry out in pain; -The resident exhibited facial grimacing; -Staff pushed the resident in his/her wheelchair to the dayroom and placed him/her in front of the television. Observation on 4/3/19 at 6:44 A.M., showed CNA C reported to LPN J the resident was screaming out in pain today and needed something. LPN J responded the resident was on scheduled medication and could not have anything until 8:00 A.M. LPN J said he/she had directed Certified Medication Technician (CMT) D to give the resident something for pain as soon as the resident was scheduled to have it. Observation on 4/3/19 at 7:00 A.M., showed the resident sat in the dayroom. The resident exhibited facial grimacing. Observation on 4/3/19 at 7:31 A.M., showed the resident sat in his/her wheelchair in the day room and said, I hurt! My feet are killing me! The resident exhibited facial grimacing and furrowed brow. Observation on 4/3/19 at 7:46 A.M., showed the resident sat at the table. The resident exhibited a furrowed brow and groaned, Oh, oh. During interview on 4/3/19 at 7:50 A.M., CMT D said the resident was in pain a lot before his/her scheduled Tylenol was due. The resident cried out in pain but did not have a PRN pain medication available anymore, and there was nothing he/she could do for the resident. He/she had passed his/her concern regarding the resident's uncontrolled pain to the charge nurse and nothing was done. He/she felt the resident waited so long for staff to give him/her something for pain that the resident became upset and often refused when staff finally got around to giving the resident something for pain. He/she attempted to administer the Tylenol around 7:30 A.M. this morning and the resident refused. During interview on 4/3/19 at 10:50 A.M., the resident said the following: -The staff at the facility talked down to him/her and didn't listen when he/she complained of being in pain; -He/she was in so much pain this morning when staff got him/her up. The level of pain he/she was in was the highest number possible on a pain scale; -The staff at the facility did not think his/her complaint (of pain) was justified. It was his/her body and he/she knew when he/she was in pain; -He/she was in an accident years ago and he/she had pain in his/her legs and feet all the time; -He/she would like to have called the physician himself/herself when he/she was in so much pain and staff did nothing; -The staff just said he/she couldn't have anything for pain yet; -He/she was in so much pain he/she did not have good sense. Staff did not take him/her seriously. He/she felt he/she couldn't control himself/herself as he/she hurt so bad, and he/she was out of sorts; -The pain affected his/her sleep and appetite; -He/she was educated and the staff acted like he/she didn't know anything; -When staff finally got around to giving him/her something, I thought heck with you, you made me wait so long, I won't take it now. I was so mad they wouldn't give it to me when I needed it. When I needed it, they didn't take me serious. During interview on 4/3/19 at 9:24 A.M., CNA E said the following: -The resident cried and hollered out in pain frequently; -Today was a bad day for the resident, as he/she had a lot of pain this morning; -When the CNAs reported the resident's pain, the charge nurse said the resident's [TRUNCATED]