3. A facility policy titled, Wandering and Elopements, dated 2001, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The section titled Policy Interpretation and Implementation included 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An admission Record revealed the facility admitted Resident #190 on 08/04/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease; insomnia; dementia in other diseases classified elsewhere, unspecified severity, with agitation; and bipolar disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2023, revealed Resident #190 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident wandered daily during the assessment period. The MDS revealed the resident's wandering put the resident at significant risk of getting to a potentially dangerous place. The MDS revealed the resident required supervision with locomotion on and off the unit. Resident #190's undated Baseline Care Plan revealed that the resident was at risk for elopement. Resident #190's Care Plan included a diagnosis area, initiated on 08/22/2023, that indicated the resident was an elopement risk and wandered related to a history of attempts to leave the facility unattended and wandering aimlessly. The admission Record and MDS revealed an admission date of 08/04/2023; in contrast, an admission summary Progress Notes identified an admission date of 08/05/2023. Resident #190's admission summary Progress Notes, dated 08/05/2023 at 1:43 PM, revealed Registered Nurse (RN) #5 documented that the resident arrived with family and had diagnoses of Alzheimer's disease, dementia, and insomnia. The notes revealed the family seemed in a hurry and did not stay long, although the nurse did go over the paperwork with them. The notes revealed the resident was extremely forgetful and confused as to why they were in the facility. The note revealed, per the family, the resident had dementia for a while and had been living with another family member until they could no longer take care of the resident. The notes revealed the family reported that there had been multiple incidents when the resident left the house and no one could find them, and the police would get involved. The notes revealed the family reported they took the resident to the hospital, where they assessed and referred the resident for long-term care. A DLBC [Division of Licensing and Background Checks] - Form 358: Facility Reported Incidents, sent to the State Agency on 08/05/2023 at 9:25 PM, revealed that, on 08/05/2023 at 7:15 PM, Resident #190 eloped from the facility. The form revealed the facility provided a detailed account of the incident, which included the Resident is new to the facility and has dementia. Family needed more help with [the resident] because [the resident] wanders and was becoming more than family could handle. Resident came into a new environment and was wanting to leave because it was unfamiliar to [the resident]. [The resident] was wondering the building trying to get out and staff was trying to help [the resident] fill [sic] welcome and safe. Multiple calls were placed to residents [family] to help calm [the resident]. Resident then went out back door where the alarmed [sic] sounded. By the time staff got there resident had already made it out of the building and resident was not in sight when staff when [sic] out doors [sic]. Staff looked around the inside and outside of the building and resident could not be found. Sheriff's office was called and [Administrator] was called. Deputy found resident down the road at a house close by the facility. Resident was taken back to the facility where they were able to help [the resident] back into the building gaining [the resident's] trust. Resident is happy and relaxed currently in the building after talking with [Administrator] and resident's [family]. The DLBC - Form 358: Facility Reported Incidents revealed Resident #190 eloped from the facility on 08/05/2023 at 7:15 PM through a back door where the alarm sounded; in contrast, behavior Progress Notes revealed the resident eloped on 08/06/2024 at 4:00 PM through an emergency exit in the kitchen. Resident #190's behavior Progress Notes, dated 08/06/2023 at 4:00 PM, revealed RN #6 documented that, at approximately 4:00 PM, Resident #190 left the security of the facility through an emergency exit in the kitchen. The notes revealed the sheriff's office was called within five minutes of the resident's absence, and the resident was soon located and brought back to the facility by a sheriff's deputy. The notes revealed the resident was agitated at that time but was able to be calmed. The notes revealed a facility aide was able to sit with the resident, one-on-one, and for a period of time, noting this intervention offered improvement to the resident's mood and disposition. The notes revealed that, at approximately 8:00 PM, the resident was highly agitated and attempted to leave the facility for a second time. The notes revealed multiple aides were involved with reorienting the resident and encouraging them to remain calm. The notes revealed the resident became belligerent and yelled profanities at staff. The notes revealed the resident was also aggressive toward the aides, pushing them out of the way of the direction the resident was traveling. The notes revealed that, at approximately 9:00 PM, with direction from facility management, facility staff was able to reason with the resident and the resident agreed to take bedtime medications and after a period of an hour retired for the evening. The admission summary Progress Notes, dated 08/05/2023 at 1:43 PM, revealed the family reported that there had been multiple incidents when the resident left the house and no one could find them, and the police would get involved; in contrast, the DLBC - HS FORM 359: Follow-Up Investigation Report revealed the facility indicated that, at the time the resident was admitted , the only information provided was a diagnosis of dementia and that the resident wandered, with no indication that there was a risk of elopement at that time. A DLBC - HS FORM 359: Follow-Up Investigation Report, sent to the state agency on 08/10/2023 at 3:11 PM, revealed the facility indicated that there was not very much information given due to the elopement occurring on the same day the resident was admitted to the facility. The facility indicated that, at the time the resident was admitted , the only information provided was a diagnosis of dementia and that the resident wandered. The facility identified there was no indication that there was a risk of elopement at that time. The form revealed the investigation did not include any interviews or statements from staff or law enforcement, did not include any corrective actions taken to keep the resident safe, and did not include how the facility ensured no other residents were at risk of elopement. An undated [Facility Name] Admit Check-Off List revealed in a section titled DO: ASSESSMENTS (SHOULD AUTOMATICALLY POPULATE) that the admitting nurse should have completed a Wandering Risk Assessment for each new admission. During an interview on 10/17/2024 at 1:53 PM, the MDS Coordinator stated she was unable to find any wandering or elopement risk assessments for Resident #190. During an interview on 10/16/2024 at 11:22 AM, the Administrator stated he did not maintain any documentation regarding the incident in question and simply inputted the information into the reports that he sent to the state. He stated he could see that by not having the documents, it did not look like a full investigation. The Administrator stated, If it wasn't documented, it didn't happen. During a follow-up interview on 10/16/2024 at 1:33 PM, the Administrator stated he understood the importance of being able to show their full investigation, including any interviews conducted, skin assessments conducted, and any interventions added as a result of the incident, as well as any training of staff. During an interview on 10/16/2024 at 6:15 PM, Certified Nursing Aide (CNA) #8 stated Resident #190 would try to leave and was very physical. She stated she remembered a couple of instances where the resident would wander off during the daytime but would not wander at night. CNA #8 stated the resident was very nervous and kept asking where they were and where their children were. During an interview on 10/16/2024 at 6:37 PM, Licensed Practical Nurse (LPN) #19 stated Resident #190 was very anxious and just wanted to leave, but mentally was not in a state to do that. LPN #19 stated facility staff had the doors locked but forgot about the loading dock (this statement is in contrast to the DLBC - Form 358: Facility Reported Incidents that revealed Resident #190 eloped from the facility through a back door where the alarm sounded). LPN #19 stated it was just one of those things that happened, noting Resident #190 was so desperate that the resident tried every door. LPN #19 stated they called the police. LPN #19 stated the resident ran and the police found Resident #190 two to four blocks away. LPN #19 stated it took them a while to convince Resident #190 to come back inside. LPN #19 stated it was evening shift, not dark out yet, and might have been right around shift change. LPN #19 stated a lot of care was given to try to ease the resident's fears. LPN #19 stated that after the incident they always made sure the door in question was locked. LPN #19 stated it was Resident #190's first day in the facility. LPN #19 stated Resident #190 was strong-willed and decided they were not going to stay. LPN #19 stated the police department was struggling with the resident not wanting to come back into the facility, so LPN #19 tried to make them understand the resident did not have a choice, and they called their Captain who reassured them that the facility was responsible for the resident. LPN #19 stated she thought she was the charge nurse the night Resident #190 eloped but was not sure. She stated she did not know much about the resident, only that Resident #190 did not want to be there, and the family had admitted the resident. She stated the family could not handle the resident anymore and the resident was doing things that they were concerned about for the resident's safety. LPN #19 stated the facility's doors were locked and a code was needed to get out. During an interview on 10/16/2024 at 6:59 PM, CNA #11 stated that when she worked at the facility, Resident #190 was trying to leave and did escape sometimes (other dates of elopement, if any, were not able to be ascertained) when the nurse would unlock the door, or the resident would try to get out another door that was not locked. She stated she did not remember how long after admission the resident escaped. She stated that there were times when the resident was especially confused, and during these times staff provided one-to-one oversight. CNA #11 stated the CNAs took turns watching the resident so one person did not have to spend the whole shift with Resident #190. During an interview on 10/17/2024 at 11:15 AM, RN #16 stated they had to lock the front door because Resident #190 would try to go out the door. RN #16 stated there was a time, maybe twice, the resident climbed the fences and was found by the cops in the community (other dates of elopement, if any, were not able to be ascertained). During an interview on 10/17/2024 at 3:46 PM, the MDS Coordinator stated she documented in the MDS if the resident had been wandering, but she did not do a formal assessment. She stated she did the care planning for the residents. The MDS Coordinator stated the Director of Nursing (DON) usually told her if a person had been wandering, and they could develop a care plan. She stated that she thought the facility used a wandering assessment, but did not know if there was an elopement assessment. The MDS Coordinator stated the charge nurses completed the admission assessments. The MDS Coordinator reviewed Resident #190's electronic medical record (EMR) and said she did not see an elopement assessment. The MDS Coordinator stated that she did not generally conduct those assessments. During an interview on 10/17/2024 at 3:24 PM, RN #4 stated that when a resident was admitted , the nurses did a thorough head-to-toe skin assessment for any issues, checked for edema, reconciled the medication list with the resident/representative, and asked orientation questions. RN #4 also stated a baseline care plan was always completed and done within two hours of admission. She stated she brought a laptop to a resident's room and completed any needed assessments. RN #4 stated that, every time she did an admission, she completed a wandering risk assessment. RN #4 stated that the wandering risk assessment did not auto-populate for assessments, but it was on the admission check list staff had. During an interview on 10/18/2024 at 8:15 AM, the Maintenance Manager stated he remembered when Resident #190 got out of the facility. He stated the resident did not go out the loading dock door. The Maintenance Manager stated the resident went out the kitchen door (this statement is in contrast to the DLBC - Form 358: Facility Reported Incidents form that revealed Resident #190 eloped from the facility through a back door where the alarm sounded). The Maintenance Manager stated that, at the time, they did not keep the kitchen door locked when the dietary staff went home. The Maintenance Manager stated the resident walked through the kitchen door and right out the back door. The Maintenance Manager stated the door was not locked at the time and was not alarmed. During a telephone interview on 10/18/2024 at 9:20 AM, RN #5 stated she thought a wandering/elopement assessment was on the list of assessments that admitting nurses were supposed to do. She stated she did not complete a wandering/elopement assessment for Resident #190 because the resident did not really exhibit an issue until the resident eloped. RN #5 stated the wandering/elopement assessment was not on the list of assessments required to be completed upon admission (this statement is in contrast to the [Facility Name] Admit Check-Off List that revealed the admitting nurse should have completed the Wandering Risk Assessment for each new admission). RN #5 stated the wandering assessment did not populate in the EMR as a required assessment. During an interview on 10/18/2024 at 9:42 AM, the DON stated the charge nurses had a check list in their admission packet that included skin assessments, immunizations, nursing assessments, and vital signs. The DON stated the nurse completed a wandering assessment. The DON stated no one audited or monitored to verify the assessments were completed. The DON stated Resident #190 could not understand why their family left them there and the resident was agitated and immediately was exit-seeking. The DON stated they were supposed to do a wandering/elopement assessment, and she just saw that RN #5 missed it. The DON stated the assessment was one that popped up in the EMR. The DON stated it was after noon when the resident was admitted , though she did not remember the exact time, knowing only that it was in the late afternoon. The DON stated when the family left, the resident was actively exit-seeking. The DON stated when Resident #190 ran out the kitchen door, all she heard was that the resident got out; the resident had gone around and checked all the doors until finding the kitchen door was open and then went out the door. The DON stated they called the Administrator, and he called the police. The DON stated the resident was wandering around the building, and staff tried to call the family, who did not answer. The DON stated the family was very hard to contact. The DON stated someone should have been with Resident #190 to help calm the resident. The DON stated they did not receive a lot of information about Resident #190 as the resident was not a direct placement from the hospital. The DON stated they did not have the staff to do one-on-one monitoring, but they knew they had to keep an eye on Resident #190. The DON stated they tried to keep the resident in the common area and keep the resident distracted. The DON stated there was no other instance that the resident eloped that she was aware of. The DON stated the information should have been passed on that Resident #190 was recently admitted and was exit-seeking, and it should have been passed on in report. She stated that she did not know how often the wandering assessments should be completed, but thought they should be done quarterly, especially if they had a resident who was actively wandering. The DON stated wandering assessments were not currently being done quarterly. She stated the kitchen door was supposed to be locked. The DON stated an investigation should start as soon as staff sent the information to the Administrator. She stated the staff did not call her; they called the Administrator. She stated the Administrator told her he would handle it, so she did not come to help. The DON stated they did not do a root cause analysis that she was aware of, but there should have been one completed. She stated she expected some resolutions to be found before an elopement could happen again. She stated she expected staff to find ways to educate, redirect, and distract the resident and to keep them calm and inside the facility. The DON stated wandering assessments needed to be done. The DON stated the resident's elopement investigation needed to be more thorough, with more detail, and documented. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated that what was listed on the admission checklist should be completed. The Administrator stated a wandering assessment was not completed for Resident #190. The Administrator stated staff should have completed a wandering/elopement assessment after Resident #190's elopement. The Administrator stated when Resident #190 was admitted to the facility, the resident wandered, but they did not know that at first. The Administrator stated the family just dropped the resident off and left without even saying goodbye and did not give much history (this statement is in contrast to the admission summary Progress Notes dated 08/05/2023 at 1:43 PM that revealed the family reported that there had been multiple incidents when the resident left the house and no one could find them, and the police would get involved). The Administrator stated it was a new building to the resident, who was just looking for a way out. The Administrator stated Resident #190 was able to get out the side door, the alarm sounded, then the resident was out the door and out of the area (this statement is in contrast to the DLBC - Form 358: Facility Reported Incidents that revealed Resident #190 eloped from the facility through the back door where the alarm sounded). The Administrator stated the sheriff was called immediately and was trying to find the resident as well. He stated deputies were out looking for the resident; there was someone down the road who called, and the deputies brought the resident back. The Administrator stated it took a lot of convincing to get Resident #190 back into the building. The Administrator stated deputies were there the entire time and finally got the resident to come back in. The Administrator stated he left when they were finally able to get the resident calm and back in the facility. The Administrator stated Resident #190 was fine the rest of the night. The Administrator stated the resident did not go out the dock doors. The Administrator stated the resident went out the kitchen door. The Administrator stated staff were in the kitchen; he was not sure how the resident made it out without them knowing. The Administrator stated the resident was found a few minutes after it happened. The Administrator stated this happened on the resident's second day at the facility. The Administrator stated after the incident they probably placed the resident on one-on-one monitoring, but he did not remember specifically. He stated he could see that it would be helpful to have a full investigation documented with a summary so if someone asked about it, they would be able to explain what happened at the time. He stated he did not want any of this to happen. He stated the facility needed to be doing the preventive measures to be sure it did not happen. He stated that he expected to be better at investigating to ensure the investigations were thorough and to ensure the staff were trained on what needed to be done. On 10/16/2024 at 10:40 AM, 10/17/2024 at 12:55 PM, and 10/18/2024 at 9:15 AM, calls were placed to the county sheriff's office with return calls requested. As of the time of exit conference, no calls were received from the county sheriff's office. Due to discrepancies identified between information contained in documents and interviews conducted with staff, the specific date(s) of any elopement(s) involving Resident #190 was/were unable to be determined. Based on observation, interview, facility document review, and facility policy review, the facility failed to put interventions in place to prevent future falls for 2 (Resident #35 and Resident #27) of 2 residents reviewed for falls. The failure resulted in Resident #35 sustaining falls on 11/04/2023 which resulted in a laceration to the resident's head, 12/19/2023, 02/23/2024 which resulted in a right clavicle fracture, 05/21/2024 which resulted in an abrasion to their left knee, 07/12/2024, 07/22/2024 which resulted in swelling to the face and an abrasion on the nose, 07/27/2024, and 08/06/2024 with no evidence the facility initiated interventions after the falls to prevent future falls. Additionally, the facility failed to complete wandering assessments, ensure a resident was safe from eloping from the facility, and failed to investigate to find the root cause of an elopement for 1 (Resident #190) of 3 residents reviewed for elopement; and failed to ensure they assessed for resident safety before leaving medications at a resident's bedside for 1 (Resident #4) of 1 resident reviewed for accident hazards. Findings included: 1. A facility policy titled, Falls-Clinical Protocol, revised 09/2012, indicated, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. The policy also indicated that based on assessment, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. An admission Record indicated the facility admitted Resident #35 on 10/06/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, seizures, bipolar disorder, and anxiety disorder. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 07/16/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had disorganized thinking that fluctuated, had no limitation in range of motion, and did not use mobility devices. The MDS indicated the resident was independent with rolling left and right in bed and required supervision to move from sitting to lying or standing. Resident #35's care plan, included a diagnosis area initiated on 10/23/2023, that indicated the resident was at very high risk for falls with fractures related to seizure disorder, osteoarthritis, and confusion. A risk management form, dated 11/04/2023 at 7:30 PM, indicated Resident #35 fell in the common area when they got up from a recliner. The form revealed the resident hit their head on the floor, causing a 4-centimeter laceration. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. Resident #35's Progress Notes, dated 12/19/2023 at 9:14 AM, indicated Resident #35 was found sitting on the floor next to their bed and had spilled their juice on the floor next to them. The notes revealed the resident had no injury. The Progress Notes and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 02/23/2024 at 1:30 PM, indicated Resident #35 was found on the floor next to their bed. The form revealed the fall resulted in a right clavicle fracture that required a sling, and an orthopedic doctor follow-up. The form revealed no evidence there were interventions initiated related to this fall. Resident #35's care plan was updated to include details about the fall; however, the care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 05/21/2024 at 8:45 PM, indicated Resident #35 tripped as they were coming in from outside. The form revealed the resident stated they tripped on their boot or slipper. The form revealed the resident had an abrasion to their left knee that measured 2 centimeters by 1 centimeter. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/12/2024 at 8:00 PM, indicated Resident #35 was found sitting on the floor in their room. The form revealed the resident stated they did not know what happened. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/22/2024 at 7:24 PM, indicated Resident #35 fell outside and reported they had possibly had a seizure. The form revealed the resident had swelling to the face and an abrasion on the nose. The form revealed no evidence there were interventions initiated related to this fall. Resident #35's care plan was updated to include details about the fall; however, the care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 07/27/2024 at 9:50 PM, indicated Resident #35 fell in their room and had no injuries. The form revealed the resident was placed in the common area for monitoring. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. A risk management form, dated 08/06/2024 at 12:15 AM, indicated Resident #35 fell in their room next to the bed. The form revealed the resident had no injury. The form and Resident #35's care plan revealed no evidence there were interventions initiated related to this fall. During an interview on 10/17/2024 at 9:12 AM, the Director of Nursing (DON) stated she expected fall interventions to be put in place to help potentially prevent falls. The DON stated that for Resident #35's fall on 07/27/2024 the risk management form indicated there was poor lighting in the room, so the intervention was for the bathroom light to remain on for lighting. The DON stated, however, the intervention for the bathroom light to remain on for lighting was not documented in the resident's progress notes or on the resident's care plan. The DON stated there was a lack of fall interventions. During an interview on 10/16/2024 at 1:47 PM, Certified Nursing Aide (CNA) #1 stated the nurses completed the fall investigations. CNA #1 stated the nurses, and the DON implemented fall interventions. During an interview on 10/16/2024 at 2:16 PM, Registered Nurse (RN) #12 stated when a resident fell, the nurses completed a risk management form in the computer that tracked the falls. RN #12 stated the nurses were responsible for updating the care plan with new interventions. RN #12 stated the MDS Coordinator also checked the care plan for interventions. During an interview on 10/16/2024 at 2:26 PM, RN #4 stated when a fall occurred the nurses were to write an incident note and then complete a risk management form that tracked falls. RN #4 stated the nurse had to review the care plan to implement more personalized interventions. During an interview on 10/17/2024 at 9:42 AM, RN #6 stated the nurse on duty and management were responsible for completing fall investigations. RN #6 stated the nurse on duty would implement an intervention and then update the care plan after a fall. During a telephone interview on 10/17/2024 at 11:34 AM, RN #17 stated the nurses completed a risk management form for a fall, and then document a nurses note. RN #17 stated the DON and the Administrator went through the risk management forms to determine interventions. During an interview on 10/17/2024 at 12:08 PM, the MDS Coordinator stated the care plan was completed after the MDS assessment. The MDS Coordinator stated other staff also updated care plans, and the nurses would update fall care plans, as the fall happened. During an interview on 10/18/2024 at 9:35 AM, the DON reviewed falls for Resident #35 for 07/12/2024 and 05/21/2024 and stated she did not see any interventions for the falls. The DON stated the forms should have been completed better. The DON stated that staff knew Resident #35 was a frequent faller who had seizures and maybe just thought falls were a common occurrence. The DON stated she read through the incident reports but did not review the care plan to make sure interventions were placed. The DON stated the nurses were responsible for investigating the root cause of a fall and to put new interventions in place. The DON stated she expected the nurses to look for a root cause, to place an intervention, and let the CNAs know the intervention. The DON stated she expected for everybody to follow through to keep the residents safe and that it was documented. During an interview on 10/18/2024 at 11:28 AM, the Administrator stated the nurses should investigate, put in a risk assessment and then implement interventions for a fall. The Administrator stated he and the DON were responsible for reviewing falls in morning meetings and in Quality Assurance Performance Improvement meetings. The Administrator stated they tried to determine what caused the fall. The Administrator stated he had not looked to ensure an intervention was in place. The Administrator stated that fall investigations and interventions were to protect the resident. The Administrator stated he expected staff to document everything and to look deeper into the incident to put things in place to best protect Resident #35. 2. A facility policy titled, Self-Administration of Medications, revised 02/2021, indicated, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy also specified, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. An admission Record indicated the facility admitted Resident #4 on 10/03/2019. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 19 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. One resident had to be transported to the emergency room on two occasions after sustaining lacerations that required sutures. In addition, a resident was not provided adequate supervision during smoking. Resident identifiers: 6 and 10. Findings include: 1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but not limited to atrial fibrillation, fall on same level from slipping, tripping and stumbling without subsequent striking against object, strain of muscle, fascia and tendon of lower back, laceration without foreign body of other part of head, weakness, presence of artificial knee joint, long term (current) use of anticoagulants, and major depressive disorder. Resident 6's medical record was reviewed on 6/17/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 6 was requiring extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and locomotion on and off the unit. Resident 6 was not steady, only able to stabilize with human assistance during surface to surface transfer (transfer between bed and chair or wheelchair). A Quarterly MDS assessment dated [DATE], documented that resident 6 had a Brief Interview for Mental Status (BIMS) score of a 5. A BIMS score of 0 to 7 indicates a severe cognitive impairment. A Care Plan Diagnosis initiated on 1/18/21, documented The resident is at risk for falls r/t (related to) Confusion and history of falls at home. The Goal initiated on 1/18/21 and revised on 4/16/21, documented The resident will be free of falls through the review date. The Interventions initiated on 1/18/21, documented Anticipate and meet needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). On 2/2/21 at 9:22 AM, a Nurses Note documented Resident fell in room at 0850 (8:50 AM) found by Aid (Certified Nursing Assistant) [name removed]. Resident appeared to have fallen from wheelchair onto floor underneath bed. Resident had bleeding and skin tear to face on nose and complained of pain to back, hips, and B (bilateral) legs. Vital signs taken at 0855 (8:55 AM):temp (temperature) 98.6, 02 (oxygen) 78, pulse 44, and BP (blood pressure) 113/67, respirations of 18. 02 rechecked at 97% and pulse of 81. Ambulance contacted, daughter [name removed], and [local hospital name removed]. Resident transported to ER (Emergency Room) by ambulance. DON (Director of Nursing) notified. [Note: No new fall interventions were implemented.] On 2/2/21, resident 6 was categorized high risk for falling with a score of 75 on the Nursing Morse Fall Scale Form. On 2/5/21, a Patient Discharge Summary Report from the local hospital documented laceration without foreig (sic) as one of the secondary encounter diagnoses. On 2/6/21 at 8:30 AM, an Incident Report documented Aide (Certified Nursing Assistant) was walking passed resident room and noticed resident on floor. Emergency call light was pushed. Went into room and observed resident on floor at the end of his bed. Resident denied any pain but does have bruise under left eye. Resident denies falling, stated he slipped out of chair. [Note: No new fall interventions were implemented.] On 2/6/21, resident 6 was categorized high risk for falling with a score of 55 on the Nursing Morse Fall Scale Form. On 2/16/21 at 9:11 AM, a Skin/Wound Note documented Took 2 sutures out of right side of nose. No steri stripes needed. Clean and dry. No signs of infection. On 5/12/21 at 2:00 PM, a Nurses Note documented Resident had unwitnessed fall in room from motorized wheelchair to floor at 1400 (2:00 PM). Aide [name removed] came and reported this to RN's (Registered Nurses) [names removed]. Resident hit head off of heater and has 3-4 moderate sized open and bleeding lacerations to L (left) side of face. Resident reports no other pain or injuries on any other parts of body besides head and face. Resident's post fall vitals are as followed: BP 125/66, pulse 95, RR (respiratory rate) 18, and 02 94% on 3L (liters) NC (nasal cannula). Resident alert and oriented x4 (person, place, time, situation). Pupils equal and reactive to light. Resident cognition baseline. [Name of Medical Director (MD) removed], DON, and ADON (Assistant Director of Nursing) notified and resident taken to [name of local hospital removed] ER in ambulance. [Name of local hospital removed] called and given report of resident's current condition. Risk management completed. Resident's son notified and at facility when resident was taken by ambulance. [Note: No new fall interventions were implemented.] On 5/12/21 at 5:00 PM, a Nurses Note documented Resident arrived back to the facility after visit to [name of local hospital removed] ER due to fall in resident's room at 1400. Resident arrived back to facility via ambulance in stable condition via stretcher. Resident received 6 stitches to facial lacerations and got CT (computed tomography) of Brain and Head w/o (without) contrast which was negative findings. On 5/12/21, resident 6 was categorized high risk for falling with a score of 75 on the Nursing Morse Fall Scale Form. On 5/25/21 at 11:46 AM, a Nurses Note documented Bee aware program implemented. On 6/17/21 at 10:17 AM, an interview was conducted with resident 6. Resident 6 stated he had the seat belt so he did not fall out of his motorized wheel chair. Resident 6 stated if he did fall the chair would fall him. On 6/17/21 at 10:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 6 had the seat belt in his motorized wheelchair because he would fall out of his wheelchair. CNA 1 stated once a month during a CNA meeting she had training on the seat belt, restraints, and safety. CNA 1 was not aware of any special requirements with the seat belt. CNA 1 stated resident 6 had the seat belt on the motorized wheelchair when he was at home prior to coming to the facility. CNA 1 stated that resident 6 was unable to toilet himself and he wore briefs. CNA 1 stated that resident 6 was in his motorized wheelchair from approximately 7:00 AM until 7:00 PM or 8:00 PM. An observation was made of resident 6 self releasing the seat belt without assistance from CNA 1. CNA 1 stated the seat belt had been a problem in the past because resident 6 would self release the seat belt, put his feet on the floor, put the wheelchair in reverse, and the wheelchair would come out from underneath resident 6 and resident 6 would fall out of the wheelchair. On 6/17/21 at 11:30 AM, an interview was conducted with RN 1. RN 1 stated resident 6's motorized wheelchair that he brought from home did not have the seat belt attachment. RN 1 stated the facility tried to put resident 6 in a standard wheelchair for safety reasons but resident 6 was unable to get around the facility in the standard wheelchair. RN 1 stated resident 6's family requested that resident 6 have the motorized wheelchair back so he was able to get around. RN 1 stated the facility got resident 6 a motorized wheelchair with the seat belt attachment. RN 1 stated that resident 6 preferred to spend most of the day in his room looking out the window but he did come to the dining room for meals. RN 1 stated if resident 6 was in his room the staff would ensure resident 6 had his seat belt on, glasses, oxygen, bed side table, and call light within reach. RN 1 stated resident 6 was on the Bee Program. RN 1 stated the if a resident had a lot of falls they would have a bee placed outside of their door. RN 1 stated the bee was to remind the staff to look in on the resident each time they passed the room. RN 1 stated if a resident had a fall the CNAs were to notify the nurse and vital signs were done with a complete assessment. RN 1 stated if the resident could tell her they hit their head or the fall was not witnessed neurological checks would be initiated. RN 1 stated if the resident had hit their head she would notify the family and send the resident to the hospital unless the family said no. RN 1 stated the DON implemented a Bee Aware program where staff could make suggestions on how to prevent falls and the DON would pick the best suggestion. RN 1 stated residents have there own individualized care plans in the medical record. On 6/17/21 at 12:04 PM, an interview was conducted with the DON. The DON stated the MDS Coordinator updated the resident care plans with interventions. The DON stated the team meets every Thursday to discuss care plans and the team meets with resident families once a month. The DON stated last month there were a lot of resident falls. The DON stated when a resident had a fall the staff would complete a 72 hour charting and the resident would be on the bee aware program. The DON stated residents with cognitive issues would be brought to the day room so the staff could watch them. The DON stated the higher fall risk residents were on the same hall. The DON stated residents had individualized fall interventions. The DON stated a fall intervention implemented for resident 6 was the bee program but resident 6 required a lot of communication. The DON stated resident 6's family wanted the seat belt on the motorized wheelchair but resident 6 would take off the seatbelt and reach to turn up the heater. The DON stated residents were generally checked every 2 hours and resident 6 was on a hourly check and he was brought to the dining room for meals. The DON stated resident 6 was to be checked more frequently because he would remove his oxygen and his oxygen levels would decrease. The DON clarified during the interview the MDS Coordinator did not update resident care plans with interventions. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness, essential hypertension, schizophrenia, hereditary and idiopathic neuropathy, cerebral infarction, and generalized edema. On 6/14/21 at 2:32 PM, an interview was conducted with resident 10. Resident 10 stated he had a burn on his finger. Resident 10 stated it was an old burn from smoking cigarettes. Prior to exiting resident 10's room a cigarette butt was observed on the floor under resident 10's bed. Resident 10's medical record was reviewed on 6/16/21. An admission MDS assessment dated [DATE], documented that resident 10 was requiring supervision with setup help only for bed mobility, transfers, walk in corridor, locomotion on and off the unit, dressing, and eating. Resident 10 was requiring limited assistance of one person for walk in room, toilet use, and personal hygiene. Resident 10 was not steady, but able to stabilize without human assistance during transitions and walking. An admission MDS assessment dated [DATE], documented that resident 10 had a BIMS score of 13. A BIMS score of 13 to 15 indicates a intact cognitive response. a. A Care Plan Diagnosis initiated on 5/4/21, documented The resident is at risk for falls r/t Confusion, incontinence. The Goal initiated on 5/4/21, documented The resident will be free of falls through the review date. The Interventions initiated on 5/4/21, documented Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Follow facility fall protocol. On 4/24/21 at 12:42 PM, a Nurses Note documented Resident had a witnessed fall/ tipped over sideways in chair in dining area at 1245 (12:45 PM) while trying to move independently from wheeled walker to dining room chair. Resident appeared to miss chair and fell onto L side, appearing to hit head on floor.Resident (sic) denies any pain or discomfort, examined for injuries, none at this time. Neuro (neurological) exam WNL (within normal limits): BP 156/91, HR (heart rate) 94, R (respirations) 18, and temp 98.2. Neuro sheet initiated. [Note: A fall care plan was not developed until 5/4/21, for resident 10.] On 4/24/21, resident 10 was categorized high risk for falling with a score of 90 on the Nursing Morse Fall Scale Form. On 5/17/21 at 2:26 PM, a Nurses Note documented Cleaning heard a noise at approximately 1330 (1:30 PM) and went to check residents room, resident was on floor next to sink. Cleaning pushed emergency call light. Aids and I went into room to find resident on floor as well sitting on buttocks. Resident is alert andoriented (sic) X4. Resident stated that he hit head and that his neck was sore but his head did not hurt. He did not complain of any other injuries at this time. Did residents vitals at time of fall, all within normal limits. Started neuros. Helped resident back up. Gave him Tylenol for neck pain. Will continue neuros. [Note: No new fall interventions were implemented and a Morse Fall Scale Form was not completed reassessing resident 10's fall risk.] On 5/25/21 at 11:45 AM, a Nurses Note documented Bee aware program implemented. On 5/31/21 at 8:35 AM, a Nurses Note documented Resident had an unwitnessed fall outside while smoking on smoking deck with other resident. Kitchen Aide [name removed] heard resident fall onto ground from chair to butt and came to get floor nurse. Nurse assessed resident for any injuries,head (sic) injuries, or bruising. Resident reports he did not hit head, has no pain, only slight redness to R (right) side of neck. Resident reports he fell from his butt off of chair to the ground landing on his butt, denying hitting his head at all. Neuro exam performed, PERRLA (pupils are equal, round, and reactive to light and accommodation), pupils reactive, grasps equal, resident's A/O (alert and oriented) x4. Contacted resident's emergency contact/ sister [name removed], left message. Messaged DON, ADON, and [MD name removed]. Resident refused to have neuro fall sheet vitals performed stating he 'did not hit hishead (sic) and would not be having that done.' Post fall vitals: BP 138/70, P (pulse) 88, o2 90% on RA (room air), and RR 18. [Note: No new fall interventions were implemented and a Morse Fall Scale Form was not completed reassessing resident 10's fall risk.] b. A Care Plan Diagnosis initiated on 4/22/21, documented The resident is a smoker. The Goal initiated on 4/22/21 and revised on 4/26/21, documented The resident will not suffer injury from unsafe smoking practices through the review date. The Interventions initiated on 4/22/21, documented Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. The resident's smoking supplies are stored at the nurses station. On 3/31/21, a Nursing admission Assessment documented No open wounds or skin issues at this time. Burn (blister) to R pointer finger at home, bandaid in place. On 4/5/21 at 10:33 AM, a Nurses Note documented . Resident has onewound (sic) on right hand on first finger that looks like a burn. It is completely closed. On 4/19/21 at 9:10 AM, a Nurses Note documented . Resident has one wound on right hand on first finger that looks like a burn, this was previous to admit. On 4/22/21 at 2:34 PM, a Plan of Care Note documented . Yesterday, RA (Resident Advocate) spoke with his sister, [name removed] and she addressed his smoking and would like him to have a patch. She is worried his smoking will get out of hand and won't be able to afford his habit. RA informed her that his cigarettes are kept at the nurses desk and they try monitoring them. RA also told her when he doesn't have a smoke he continually picks up butts off the ground and smokes them. [Name removed] asked about a patch, DON advised her that they are unable to put a patch on as long as he continues smoking and picking up butts. Sister said she was going to talk with Resident and tell him only 3 cigarettes a day. RA will continue to encourage Resident to smoke lightly. On 5/11/21, an admission Smoking - Safety Screen was completed. Resident 10 was documented as Safe to smoke without supervision. Resident 10 needs to store cigarettes and lighter at the nurses station. Resident 10 forgets and lights cigarettes in his room. Safe and stable outside. On 5/12/21 at 11:15 PM, a Nurses Note documented SMOKING/FIRE INCIDENT: [Resident 10] came in the door after going outside to smoke. As soon as he entered through the door, I was able to smell something burning. Aide [name removed] went out the door to investigate and returned stating the burning smell was only right here in the entry and hallway nearby. I stated that it smells like clothes are on fire. We both promptly followed [resident 10] down the hall. We were able to see embers moving down the inside of [resident 10's] pant leg and with the dimly lit hallway it was very visible. His sweatpants were immediately removed and stomped on. We shook out the pant legs and out fell a dry wipe that still had embers glowing. His sweatpants were charred. We asked resident if he got burned, he stated that he did not. Upon inspection,there (sic) were no burn marks on the skin of the resident's right leg. [Note: No new smoking interventions were implemented.] On 6/11/21, a Quarterly Smoking - Safety Screen was completed. Resident 10 was documented as Safe to smoke without supervision. Resident 10 able to light his own cigarette and smoke without any complications. On 6/17/21 at 11:40 AM, an interview was conducted with RN 1. RN 1 stated resident 10 used a wheeled walker and required safety reminders. RN 1 stated since resident 10's urinary catheter had been removed he had been better as far as falls and safety. RN 1 stated she provided resident 10 a lot of education regarding falls and safety. RN 1 stated that resident 10 was safe to smoke most of the time. RN 1 stated If resident 10 ran out of cigarettes he would try and find cigarette butts and then resident 10 was not safe. RN 1 stated she had to remind resident 10 not to look for cigarette butts and smoke them. RN 1 stated that smoking aprons were available for the residents and they had tried to implement them in the past but the residents would not wear them. On 6/17/21 at 11:45 AM, an interview was conducted with CNA 2. CNA 2 stated she frequently checked on resident 10 every 2 hour. CNA 2 stated when resident 10 was in the day room she would remind resident 10 to use his walker. CNA 2 stated she would look out the window at the smoking area to check on resident 10 to ensure that he was safe and resident 10's cigarettes were at the nurses station. On 6/17/21 at 11:52 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated she would keep an eye on resident 10 every two hours. NA 1 stated she had been given no instructions on watching resident 10 in the smoking area. On 6/17/21 at 12:22 PM, an interview was conducted with the DON. The DON stated resident 10 required constant reminders regarding fall safety and he had advanced schizophrenia. The DON stated that resident 10 worked with Physical Therapy because he had a shuffle gait. The DON stated resident 10 would get excited and the shuffle gait would become worse. The DON stated resident 10's sister was medical Power of Attorney and did not want resident 10 smoking. The DON stated a nicotine patch was tried on resident 10 but he would smoke with the patch on. The DON stated resident 10's cigarettes were kept at the nurses station desk. The DON stated resident 10 was a safe smoker except when he tried to smoke the little cigarette butts. The DON stated resident 10 would go outside and pick cigarette butts off the ground and would light them. The DON stated the maintenance worker was going to hire an assistant to help clean up the cigarette butts. The DON stated she had tried putting buckets and cigarette receptacles in the smoking area but resident 10 would dig in them to look for the cigarette butts when he was out of cigarettes. The DON stated resident 10 was only unsafe smoking when he was out of cigarettes. The DON stated it would probably help to have a staff member outside to watch resident 10 while he smoked. The DON stated the smoking incident with resident 10 was caused when resident 10 walked in the facility with his cigarette and tried to put it in his pocket. The DON stated smoking assessment were completed on admission and quarterly. The DON was not sure why resident 10's admission smoking assessment was not completed until 5/11/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record the review it was determined, for 1 of 19 sample residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident that complained of pain was unable to get a change in pain relief from the facility Medical Director (MD) for a week. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included but not limited to acute and chronic respiratory failure, senile degeneration of brain, post-traumatic stress disorder, morbid obesity due to excess calories, chronic kidney disease stage 4, lichen sclerosus et atrophicus, essential hypertension, mood disorder due to known physiological condition, persistent mood [affective] disorder, chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, obstructive sleep apnea, and type 2 diabetes mellitus with other specified complication. On 6/15/21 at 10:36 AM, an interview was conducted with resident 17. Resident 17 stated that her pain was not managed but the nursing staff had tried. Resident 17 stated she had asked the staff to call the doctor and they had tried twice and the doctor would not call the staff back. Resident 17 stated her pain was located on her right side under her abdominal pannus. Resident 17 stated the pain was relieved when she lied down but she preferred not to be in bed all day. Resident 17 stated the doctor would not pay attention or listen to her when she complained about pain. Resident 17 stated the doctor came in to visit her when she had covid19 but would not address her pain issue. Resident 17 was observed during the interview to attempt to shift her position and resident 17 facial grimaced during the interview. Resident 17 verbally expressed pain during the interview. Resident 17's medical record was reviewed on 6/15/21. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented resident 17 had scheduled pain medications, as needed pain medications, and non-medication interventions for pain. A pain assessment interview was completed and revealed resident had occasional pain. Resident 17's pain intensity was a numeric rating of a 10 on a scale of 00 - 10. A Care Plan Diagnosis initiated on 1/29/20, documented The resident has chronic pain r/t (related to) obesity, joint pain and diabetic pain. The Care Plan Goal initiated on 1/29/20 and revised on 5/5/21, documented The resident will not have an interruption in normal activities due to pain through the review date. Some of the Interventions initiated on 1/29/20, documented Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on condition. Identify, record and treat the resident's existing conditions which may increase pain and or discomfort. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record pain characteristics PRN (as needed): Quality (e.g. sharp, burning): Severity (1 to 10 scale): Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors, Chart in MAR (Medication Administration Record) as well as progress notes. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The June 2021 MAR was reviewed and documented the following physician's orders: a. On 1/27/20, Tramadol 50 milligrams (mg) 2 tablets every 4 hours as needed for pain r/t idiopathic peripheral autonomic neuropathy. [Note: Out of 84 opportunities resident 17 requested Tramadol on 46 occasions. Pain ratings were a 7 or greater. On one occasion the pain rating was a 5.] b. On 1/28/20, Meloxicam 15 mg daily for pain c. On 12/7/20, Lidocaine Gel 2% apply to affected areas topically every 4 hours as needed for rash with pain. d. On 4/3/21, Gabapentin 300 mg daily for diabetic neuropathy e. On 6/12/21, Tylenol 325 mg every 4 hours as needed for pain On 6/15/21 at 3:26 PM, a Nurses Note documented Resident stated having pain underneath perineal area and pannus. NA (Nursing Assistant) [name removed] helped me while I assessed. Resident has a 2x2 cm (centimeter) wound, a 1x1 cm wound, and about a 1 inch slit underneath pannus. I cleaned and dried wounds. There was some bloody drainage. I put nystatin on perineal area and under pannus. ABD (abdominal) gauze placed under pannus to help with moisture. Resident stated she was in pain but tolerated it well. Will continue to monitor. On 6/16/21 at 9:38 AM, a Nurses Note documented Sent a msg (message) to [MD name removed] about increasing pain in right hip area on 06-11. He stated that we could give her PRN tramadol until Monday. Called and advised nurses. Text [MD name removed] again on Monday 06-15-2021 about increasing pain as I still had not heard from him. The end of the day he sent me a text to talk with his nurse that he was at the hospital. Sent another message to his nurse in his office. Will continue to monitor. RN's (Registered Nurses) are keeping area dry, applying cream and keeping gauze in area to keep dry. Will continue to monitor. On 6/16/21 at 3:39 PM, an Order Note documented Oxycodone 10 mg every 6 hours as needed for pain. On 6/15/21 at 3:49 PM, an interview was conducted with RN 2. RN 2 stated the new MD came in once every other week on Fridays. RN 2 stated the old MD was responsive to the nursing staff calling for orders or concerns; the new MD was not responsive when the nurses called and he was not willing to make adjustments that the nursing staff felt were appropriate. RN 2 stated the MD did not answer quickly regarding issues at the facility and the MD was not really involved. RN 2 stated regarding pain medications the MD was often very resistant to making pain medication changes sometimes the physician just won't do it and then if he doesn't come into the facility that week then it cannot be done; sometimes the MD may even just do the opposite of what the nursing staff asked for. RN 2 stated that resident 17 wanted something more for pain, but the MD did not respond when he had asked to provide her more pain medications. RN 2 stated resident 17's pain was due to wounds in the perineal area and pannus; she becomes more aggressive and agitated because she is in pain. On 6/16/21 at 8:57 AM, an interview was conducted with RN 3. RN 3 stated if she was unable to get a hold of the MD she was able to get a hold of his nurse. RN 3 stated the MD came to the facility every other Friday. RN 3 stated the MDS Coordinator would do rounds with the MD and would input any new physician's orders in the electronic medical records. RN 3 stated resident 17 had been complaining of increased pain for about a week, to a week and a half. RN 3 stated she had been giving resident 17 pain medications as frequently as she could have them. RN 3 stated resident 17 did not like to rotate as often as she should to alleviate pain. RN 3 stated the nystatin powder did not help but resident 17 did have Lidocaine gel at bedside and that seemed to help at times. RN 3 stated that resident 17 liked to lie in bed but staff encouraged resident 17 to be up more. RN 3 stated resident 17's pain did restrict her but resident 17 was not very active prior. RN 3 stated there was not a big difference in resident 17's restriction but resident 17 did vocalize it was harder to do things with the pain. RN 3 stated the Director of Nursing (DON) was the last to send a message to the MD regarding resident 17's pain and the MD replied that he was going to do something on Monday (6/14/21) but RN 3 was not sure if anything had been changed. On 6/16/21 at 9:39 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident 17 had expressed on occasion prior to a shower refusal that she was in pain. On 6/16/21 at 2:07 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 17 would refuse showers frequently due to pain. CNA 1 stated resident 17 was working with restorative at the beginning of June and CNA 1 would assist resident 17 with her showers a couple days a week. On 6/16/21 at 12:46 PM, an interview was conducted with the DON. The DON stated if the nursing staff called the facility MD he would get back to the them hours later. The DON stated the MD did not respond in a timely manner if the MD responded at all. The DON stated the MD's clinic was priority. The DON stated resident 17 had chronic pain issues and last week resident 17 had developed a new sore under her pannus down the right side that caused neuropathy pain. The DON stated the staff have tried to bandage the area to keep it dry and apply powders. The DON stated resident 17 had Lidocaine gel at bedside to help numb the neuropathy. The DON stated RN 2 sent the MD a message on Tuesday, 6/8/21, and the MD never responded. The DON stated she had sent the MD a message on Thursday, 6/10/21, and the MD never responded. The DON stated she had sent the MD a message on Friday, 6/11/21, and the MD responded . Hate tramadol. Use it until. The DON stated the MD was not in his office or where he could write a paper order for pain medications. The MD responded Only thing we can do now. Fix it Monday. The DON stated on Monday, 6/14/21, she had to message the MD to follow up regarding resident 17 and the conversation they had on Friday. The DON stated she had received no response from the MD and sent another message on Tuesday, 6/15/21, the MD responded to message his office the information on resident 17. The DON stated she had to message the MD again today about the pain medication for resident 17. [Note: The DON provided copies of cell phone messages .]