**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services to ensure residents received care to prevent development of pressure ulcer(s) for one resident (Resident # 3- R3) in a survey sample of 5 residents, resulting in harm for R3. Findings included: For R3, the facility staff failed to implement interventions to prevent the development of and failed to identify and treat a pressure injury until at an advanced stage of wound deterioration, requiring sharps debridement (cutting the dead tissue out), which constituted harm. Review of the clinical record was conducted on 6/17/2024 -6/18/2024 and 6/20/2024. R3 was admitted on [DATE] with diagnoses including but not limited to: Cerebral infarction, difficulty in walking, muscle wasting and atrophy, type 2 diabetes mellitus without complications, hyperlipidemia, and essential (primary) hypertension. R3 was discharged from the facility on 4/29/24. R3's admission MDS (Minimum Data Set - assessment tool) with an ARD (Assessment Reference Date) of 4/14/2024, coded R3 as having had range of motion impairments bilaterally in upper and lower extremities. R3 was coded as having been dependent in all ADLs (Activities of Daily Living), except eating and oral hygiene. This assessment had no coding for a pressure wound noted but R3 was coded to be at risk for development of pressure ulcer/injuries, based on formal assessments and clinical assessments. R3's baseline care plan did not address any skin breakdown and/or wound. The only notation regarding skin was an approach that read as follows: . SKIN: Resident will be provided skin care to prevent skin breakdown. Review of R3's progress notes and assessments revealed no documentation of any skin issues being present upon admission. On 4/10/24, R3 had labs drawn. A CBC (complete blood count) and CMP (complete metabolic panel). R3's prealbumin, albumin and protein were within normal limits and R3's physician gave no new orders in response to the lab values. According to R3's Braden scale for predicting pressure sore risk assessment, conducted on 4/16/24, R3 was assessed having a score of 12, which indicated high risk for pressure ulcer development. In the section for interventions, nothing was checked/selected. Under the section for plan of care, nothing was checked. On the same day, a weekly skin observation was conducted and documented no skin issues noted. On 4/23/24, R3 had another Braden scale for predicting pressure sore risk assessment conducted. R3 was assessed as having a score of 13, which indicated a moderate risk. Under the interventions section, it noted, skin and ulcer/injury treatments, which included but were not limited to: pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care ., none of which were selected. This assessment's alternative option, none of the above were provided, was selected. On the same day, 4/23/24, a weekly skin observation was conducted at 3:07 p.m. and noted no skin issues noted. On 4/30/24, a Braden scale for predicting pressure sore risk was completed, which was the day following R3's discharge home. This assessment identified R3 as being high risk and the interventions of pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, and application of dressings to feet, were all selected. R3's physical therapy notes dated 4/22/24, read in part, .Directed pt [patient] in rolling bilaterally w/ [with] total A [assistance] w/ pt observed to moan in pain throughout. Pt's wife was present this date and reported that pt has significant skin breakdown on his sacral/buttocks region which causes him pain w/ movement. Repositioned pt in R [right] side lying to offload his sacral/buttocks region. Then immediately reported the wife's concerns to the nurse who reports that the wound care nurse will assess and provide tx [treatment] as needed . On 4/22/24, R3 was seen by the nurse practitioner. The NP's note read in part, Chief complaint/Reason for this visit: . Has an abrasion on coccyx . Has a small abrasion on sacral area about 3 cm circular with superficial depth. Pink with granulation tissue in base. No drainage or erythema. Will change daily and refer to wound team . On 4/25/24, R3 was seen by a wound specialist. The wound specialist's note read in part, . pt [patient] was noted a few days ago to have some peeling of the skin and discoloration at his sacral region. Aid was present today and reported that when she was cleansing the pt the skin peeled at there was an ulceration underneath . Sacrum (+) full thickness ulceration that measures 5.4 x 5.5 x 0.2 cm. wound base 40% intact, 20% slough, 5% deep purple, 35% granular before debridement . Performed excisional debridement [cutting dead tissue out] of sacrum wound(s) consisted of: Ulceration site(s) was/were prepped and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic [dead] tissue with a 5mm curette [sharp cutting tool]. There was scant bleeding that quickly subsided with light pressure and cleansing. Patient appeared to tolerate procedure without pain or signs of discomfort . The wound specialist also documented that the wound to be a stage 3 pressure injury. Orders from the wound specialist for treatment of the wound were to -Cleanse site with normal saline or sterile water (Do not use wound cleanser, this may decrease effectiveness of Santyl (collagenase), Apply Santyl (collagenase) ointment (nickel thickness) to wound base- (tx for enzymatic debridement), Cover with foam dressing, provide this care daily and as needed for saturation or soilage . On 04/27/2024 at 7:24 a.m., a late entry was made for 04/23/2024 of a nursing note about R3 that that read, CNA [certified nursing assistant] reported open area to sacrum. Nurse approximated edges 2cm x 1 cm no depth. Wound base red in color. Small amount of serous drainage noted. Area cleansed with wound cleanser; zinc-based cream applied. Speaking with CNA and looking through chart resident is eating less than 25% at meals. NP aware of findings. Air mattress and wedge for turning and repositioning in place. On 4/27/24, a wound management detail report was entered into R3's chart, by the wound treatment nurse. This document noted the following: Pressure Ulcer: wound type: pressure ulcer, wound location: sacrum, Date/time identified: 4/23/24 13:00, Present on admission/re-entry? No . Observation: Date/time observed pressure ulcer: 4/25/24 at 7:08 a.m. length: 5.4 cm, width: 5.5 cm, can depth be measured? Yes, depth: 0.2, exudate: moderate, . stage: Stage III, tissue type: slough, percent of wound covered by granulation tissue: 35, percent of wound covered by eschar tissue: 5, percent of wound covered by clean, non-granulation tissue: 40, wound edges/margins: edge attached to base, skin surrounding wound: pink/normal, wound healing status: declining, created date/time: 4/27/24 7:14 a.m The above noted form went on to note a second observation that was listed as the following: date/time observed pressure ulcer: 4/23/24 13:00, length: 2 cm, width 1 cm, can depth be measured: no, exudate: light, exudate color and consistency: serous (clear, amber, thin and watery), tissue type: closed/resurfaced, percent of wound covered by clean, non-granulation tissue: 100, wound edges/margins: edge attached to base, skin surrounding wound: assess within 4 cm of wound edge: pink/normal, wound healing status: stable, created date/time: 4/27/24 at 7:08 a.m According to R3's physician orders, on 4/27/24, orders were entered that read, Air mattress to bed, and wedge in place for turning and repositioning, with an effective date of 4/23/24. According to the MAR (medication administration record), neither were signed off as being in place until the night shift on 4/26/24. On 4/23/24, R3 was ordered and started on pro-stat, vitamin C, and zinc for wound healing. The were no record of these interventions prior to R3's wound development, including being in place as preventative measures. According to the medication administration record, R3 had heel protectors bunny boots ordered 4/27/24. Based on the Braden assessments, R3 was identified to be at high risk for development of pressure ulcer development, but there was no evidence of any interventions other than routine care and services provided to all residents. Additionally, R3 had no orders for any wound care implemented until 4/26/24. On 6/17/24 at 3:17 p.m., an interview was conducted with LPN #1. LPN #1 recalled R3 and said, He was very debilitated and was completely dependent on staff for bathing and even eating . he didn't get out of bed daily . he did have a problem on his bottom. When asked if it was present on admission, LPN #1 said, I don't believe it was present on admission. When asked if R3 was on an air mattress, LPN #1 said, We were trying to do turning and repositioning as he would allow, and we put an air mattress on after the wound. LPN #1 confirmed the air mattress was in response to the wound and not placed prior to wound development as a preventative measure. On 6/18/24 at 9 a.m., the facility administrator and Director of Nursing (DON) were asked to provide any evidence they had for consideration of past non-compliance, in light of these findings. They provided a binder that they said was their risk documents. The surveyor asked them to provide a summary of what they found to be the deficient practice, what they did, and when they felt they were in compliance. The facility administrator returned and said, There wasn't any deficient practice, and provided a statement that read as follows, [R3's name redacted]- open area identified. On 4/23/24 CNA reported to nurse that while she was bathing resident his skin peeled off on his sacrum. Nurse cleansed area with wound cleanser and treatments put in place. MD notified. Treatment initiated. Seen by wound provider on 4/25. Treatment changed. 4/26 nurse notified wound provider. Sacral wound worsening. Requesting telehealth visit for 4/29 to determine if sacral may be a KTU [Kennedy terminal ulcer] vs. PI [pressure injury]. Patient discharged prior to telehealth visit. Date of compliance 5/23/24. Ongoing monitoring of any impaired skin integrity. Within this facility provided risk binder with regards to R3, it included staff education and sign-in sheet that had written, pressure ulcer prevention/basic skin care education. Included were documents that read, basic skin care for the CNA/STNA [certified nursing assistant/state tested nurse aide]. It was noted that 28 of the nursing staff had not signed as having received the education. Also within this facility provided risk binder with regards to R3, there was a document titled, Facility Acquired Injuries Investigation Tool, which read in part, Date ulcer identified: 4/23/24, Ulcer us [sic] properly diagnosed as a pressure ulcer? yes . Is the new ulcer in a site of a previously healed ulcer of any type? no. Location of ulcer: Sacrum. Stage of PU [pressure ulcer] at discovery: 3, Is the resident diabetic? no. Prevention strategies that were in place prior to ulcer development: air mattress, turning and repositioning program, heels floated, chair cushion, heel protector/prevalon boots. Nutritional Interventional: multivitamins, Vitamin C, zinc, pro stat 30 ml BID [twice daily] and boost . Is nutritional intake what registered dietician recommends? yes . Another exerpt from this facility acquired injuries investigation tool document went on to read, 1. Is the injury to the patient's skin a pressure ulcer? yes . 3. Discovery date and stage of facility acquired pressure ulcer; 4/23/24, stage 3. 4. document details of event: CNA reported doing incontinence care . Root cause identified for pressure ulcer development? no responses were recorded; this section was blank. What the pressure injury: avoidable or unavoidable (Circle) was blank, with neither option circled. Action Plan for Improvement/Treatment of Pressure Injury, was blank with nothing listed. This document was signed by the facility's wound treatment nurse and dated 4/23/24. On 6/18/24 at 1:56 p.m., the wound treatment nurse was interviewed. The wound treatment nurse reported that the residents' have their skin assessed on admission and then weekly thereafter. The wound treatment nurse said that if a wound is noted, staff would let her know, she woud have the wound specialist see the resident to stage the wound, and get an order from the resident's doctor for treatment, until the wound specialist sees the resident. The wound treatment nurse went on to say that she rounds with the wound specialist, who would tell me what she wants for orders, and we discuss it during our at-risk meeting. The wound treatment nurse also said, If at risk, we put things in place like air mattress, turn and repositioning, and talk to the dietician about vitamins, prostat, etc. During this interview, the treatment nurse was asked about the turning and repositioning and barrier cream, which she confirmed is routine care for all residents. When asked to describe what additional measures were put in place, since R3 was total care, unable to reposition to alleviate pressure, and had a Braden score that identified him to be high risk for wound development, the treatment nurse asked if she could get back to the surveyor. When asked about the treatment to R3's wound, the wound treatment nurse stated that on 4/26/24, she identified the wound had worsened, and had an onion odor. The treatment nurse stated she called the wound practitioner who gave the order to cleanse with Dakin's. The clinical record revealed that, on 4/27/24, the wound care order was entered as a late entry for 4/26/24, and read, Cleanse stage 3 PI [pressure injury] to sacrum with Dakins, apply Santyl and foam dressing change QD [every day] and PRN [as needed]. According to the medication administration record (MAR), treatment to the wound was not performed until 4/27/24. When asked about these findings, the wound treatment nurse stated that the Santyl had to be ordered and they had to wait for it to arrive. When asked about the late entry, the wound treatment nurse said that at times she gets busy and will remember later and go back in and chart. On 6/18/24 at 3:30 p.m., a follow-up interview was conducted with the treatment nurse. When asked about R3's air mattress, the wound treatment nurse said, We put the air mattress on right after found [referring to the wound]. The wound treatment nurse was shown R3's MAR and asked why the air mattress was showing as having been ordered on 4/23/24 but was not signed off as being in place until 4/26/24. The wound treatment nurse said, I recall putting the air mattress on, on the 23rd, when we found it [the wound], but didn't address that the order had not been entered until 4/27/24. On 6/18/24 at 4:05 p.m., during an end of day meeting, the facility's administration and corporate staff were made aware of the above findings. They were asked to provide any additional information to the survey team upon their return on 6/20/24. On 6/20/24 at 9:04 a.m., the facility's director of nursing (DON) provided the survey team with documentation of the specifications of the mattress that they had on R3's bed. The DON said, it is a pressure relieving mattress and he [R3] was being turned and repositioned, was getting up into recliner chair with a cushion and therapy was working with him. When asked if they had documentation/evidence of the turning and repositioning, the DON said they did not. On 6/20/24 at 9:44 a.m., an interview was conducted with LPN #3, who was the unit manager where R3 resided. LPN #3 explained that Braden scales are conducted on admission to identify if a resident is at risk for development of pressure ulcers. LPN #3 went on to say, At that time we can put stuff in place to prevent that, we would have them on an air mattress, on a turn and repositioning, and use barrier cream. LPN #3 confirmed that turning and repositioning and barrier cream are standard and routine care practices used for all residents who are incontinent. On 6/20/24, interviews were conducted with the treatment nurse and LPN #6. Both confirmed that all the mattresses in use at the facility are pressure reducing and are standard for all residents, as well as the use of barrier cream for incontinent residents. Each of them also confirmed that turning and repositioning is part of routine care. On 6/20/24 at 2:45 p.m., an interview was conducted with CNA #2. CNA #2 reported that R3 had peeling skin on his buttocks, and she was going to put cream [she clarified to be barrier cream] on the bleeding spot that had been there a couple of days. CNA #2 said, The peeling wasn't where the bleeding spot was. CNA #2 explained when she moved her hand, R3's skin stuck to her glove and came off. CNA #2 said that the area started to bleed and she notified the nurse immediately. CNA #2 reported that R3 would get up around 10:30 a.m. to 11 a.m., into a recliner chair daily, would be returned to bed for incontinence care around 3-3:30 p.m., would be gotten back up following the incontinence care until after supper, and would be put back to bed for the day around 6 p.m. CNA #3 said towards the end of his stay at the facility, R2 would want to stay in bed more and once in a while would say his bottom was hurting. When asked about R3's bed and if an air mattress was on the bed, CNA #3 reported that the air mattress was put on the bed sometime after the incident on 4/23/24, indicating maybe the following day but wasn't sure. On 6/20/24 at approximately 5:30 p.m., a phone interview was conducted with the wound specialist. The wound specialist stated that when she saw the wound .it was irregular shaped, the tissue loss was not the whole wound, but it was 20% and it was deep purple. The wound specialist was unable to say how long it would take for such a wound to develop but said that upon her assessment of R3, she would not have anticipated the wound to deteriorate rapidly and did not feel the resident was in organ failure or significantly compromised. On 6/20/24, a review was conducted of the facility's 24-hour nursing reports. R3 was not noted on any of the reports during his stay at the facility. When a resident with the same first initial and last name was noted with a right leg wound, a clinical record review confirmed it was not R3, which the Regional [NAME] President of Operations also confirmed that it was not R3. On 6/20/24, a review was conducted of the facility's at-risk meeting minutes for the time frame R3 was a resident of the facility. R3 was not noted on any of the documents. On 6/20/24 at approximately 4:30 p.m., a meeting was held with the Regional [NAME] President of Operations (RVPO). When asking if the survey team was going to accept past non-compliance, the RVPO asked if he had seen the evidence provided to the survey team, he said he had not. The RVPO then joined the surveyor in the conference room and was given the facility's Risk binder with regards to R3. Upon being handed the binder, the RVPO said, well, I'm used these binders being about this thick [and noted about an inch- inch and 1/2 thick, with a hand gesture] and said, I see what you mean. The RVPO began looking through the binder and identified that many of the facility staff had not signed the education. The RVPO was also notified that when asked what the deficient practice was that had been identified and put a plan in place to correct, the facility administrator told the survey team, no deficient practice was noted. The RVPO was then notified that past non-compliance had not been achieved. Review of the facility policy titled, Skin and Wound Care Best Practices, was conducted. This policy read in part, 1. Skin care and pressure injury prevention: provide pressure reduction/redistribution for those at risk: offload/suspend heels for at risk residents, reposition at a frequency determined by risk assessment to avoid pressure to bony prominences, provide pressure redistribution/relief devices according to interdisciplinary assessment and recommendation . The facility policy titled, Pressure Injury Prevention and Treatment Policy, was reviewed. This policy read in part, Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable .Residents will be assessed for pressure injury risk on admission . using the Braden Scale for Predicting Pressure Ulcer Risk . The policy titled, Resident Review Meeting Best Practice, was reviewed. The policy read in part, The interdisciplinary team will meet on a weekly basis to conduct a review of all residents who have experienced a change in condition, weight loss, acute infections, skin conditions, falls during the week and/or ongoing behaviors. The team will conduct a comprehensive review of the resident's clinical record to ensure develop and implementation of the necessary interventions to address each resident's specific risk has taken place and is appropriate for the resident F. The residents risk assessments will be reviewed, and re-assessment will be completed as deemed necessary . On 6/20/24, during an end of day meeting, the facility's director of nursing and corporate staff was made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interviews, clinical record and facility documentation, the facility staff failed to provide pain management, resulting in numerous instances of untreated pain, which constituted harm for one resident (Resident #2 - R2), in a survey sample of five residents. The findings included: For R2, who had a right hip fracture of unknown origin, the facility staff failed to respond to and treat the resident's documented complaints of unrelieved pain on 12 occasions, which adversely affected her level of physical functioning in therapy and constituted harm. Resident #2 (R2) was admitted to the facility on [DATE]. Diagnoses for R2 included, but were not limited: to cerebral infarction unspecified, muscle weakness and unspecified fracture of the lower end of left radius. R2's quarterly Minimum Data Set (MDS), (an assessment protocol) with an Assessment Reference Date of 4/14/23 coded R2 with a BIMS (brief interview for mental status score) of 7, which indicated severely impaired cognition. R2's most recent MDS, with an ARD of 3/13/24, noted R2 had a BIMs of 0. According to the MDS completed in April 2023, R2 required extensive assistance of staff for activities of daily living (ADLs), to include walking, and R2 was noted to have no limitation in her range of motion in her lower extremities. On 6/17/24, during the surveyor's investigation of an injury of unknown origin, a clinical record review was being conducted. According to the physician orders, on 5/24/23, an order was made for an x-ray of the right hip that read, x-ray of right hip. Unable to walk with therapy . There was a nursing note entry dated 5/25/23, that read, Spoke with nurse [name redacted] at [hospital name redacted]. Resident admitted to 5 east with right hip fx [fracture]. Nurse stated ortho recommended surgical intervention. According to R2's nursing progress notes, there was no indication of pain or events leading to the fracture prior to the order for the x-ray. There was a progress note from the nurse practitioner dated 4/27/23, R2 was seen for CC: [chief complaint] Trouble with right foot bending back under wheelchair when husband was pushing her along in the hall. Assisted them back to room. According to the progress note from the NP, both R2 and her roommate, who is her spouse have cognitive impairments. According to the note, it read in part, ROS: [review of systems] UTO [unable to observe] due to confusion. The note indicated a physical exam was conducted which included: vital signs, general, eyes, ENT [ears, nose, and throat], Neck, Respiratory system, CV [cardiovascular], Abdomen, skin, neurological, psychological, and musculoskeletal systems. The musculoskeletal section read, no contractures, nml [normal] muscle tone, symmetrically reduced strength. There was no indication that the R2's range of motion was assessed for her right foot, nothing about pain, nor any orders or communication to nursing to monitor for changes or pain. On 6/17/24, the director of nursing (DON) was asked to provide any facility documentation with regards to incidents involving R2, prior to the hip fracture. The DON reported there were no incidents/events. On 6/18/24 at 1:50 p.m., an interview was conducted with the NP, who had witnessed R2's incident of having her right foot dragged under the wheelchair on 4/27/23. The NP said that she had a vague recollection of the incident. The NP stated, They [R2 & R5] were between the chapel and the front offices in the facility. The NP stated that she had been walking behind them and noticed that R2's right foot was bent backwards under the wheelchair. The NP stated that she stopped the couple in the hallway and fixed R2's foot and assisted the couple back to their room. When asked if she assessed R2, the NP said that she did not assess at that time because she did not think it was a serious incident, she just helped them back to the room. When asked if she reported the event to nursing, she stated the day the incident happened was her first day at the facility and that she hadn't known anyone and did not report it to anyone. On 5/20/23, the medical doctor (MD) saw R2 for chronic care management discussion. The physician's note documented that urinary retention was addressed, a urinary catheter was reinserted, and noted that a urology consult was pending. On 5/24/23, the NP's note documented that she saw R2 due to physical therapy's report that R2 had not been able to do therapy due to complaints of right hip pain, that an x-ray of the right hip was ordered, and that results showed right hip fracture, for which the NP ordered R2 be sent to the emergency department for evaluation. On 5/26/23 the NP saw R2 for re admission back to the facility after R2's hospital stay. The NP's note had that the family opted for conservative nonsurgical treatment and that R2's pain was being controlled with the current medications. On 6/17/24, an interview was conducted with R2. R2 was noted with cognitive impairments and when asked about the incident from April 2023, and the hip fracture from May 2023, R2 had no recall of either events. On 6/18/24, an interview was conducted with certified nursing assistant, (CNA3). CNA3 was asked about R2 and if she had noticed any changes in the resident prior to the discovery of the hip fracture. CNA3 reported that R2 was moving slow in the mornings and was having some discomfort. CNA3 went on to say that R2 was not putting her right foot down when pivoting/turning, and said, I could tell she was in pain. When asked, what she does when she notices this, CNA3 said that she tells the nurse. The facility had no documentation/evidence of what CNA's report to the nurses to provide to the survey team. On 6/18/24 at 10:00 a.m., an interview was conducted with license practical nurse #9 (LPN9). LPN9 said, If the patient had a decline or change in status, we notify the nurse practitioner, (NP) or the medical doctor, (MD). If the NP or MD is on the unit that we would tell them of the concerns. If the NP or the MD is not in the facility, a communication sheet was filled out or a phone call was made to the provider. LPN9 verbalized that no daily report is received from therapy and that .the therapy staff does not communicate much with nursing department . If therapy staff had a concern that the NP or MD needed to be made aware, then therapy would communicate that with nursing. On 6/18/24, the communication book for R2's providers (doctor and nurse practitioner) was reviewed. The communication book did not have any information dating back to April and May 2023. The Director of Nursing was asked to provide the communication sheets from April and May 2023, but stated that she was not able to find them. On 6/18/24 at 10:15 a.m., an interview was conducted with OS4, one of the therapy staff, who had worked with R2. OS4 verbalized that a combination of things happened to contribute to R2's decline in therapy, including that R2 verbally refusing and that R2 was having pain that proceeded over a period of days to weeks. When questioned further, OS4 stated that she would talk with aides and nursing about pain medication. OS4 verbalized that if a resident was having pain that after a period of days, would have them put on the short list, which is the MD sheet, to be seen. OS4 verbalized that if it was something she could physically see, I would report it to the nurse on the floor and to the unit manager so the resident can be seen. No documentation was found to evidence this was done. On 6/18/24, an interview was conducted with the DON and the acting administrator. The acting administrator verbalized that the expectation is for anyone to report incidents, assess the resident for injury, assess the resident for pain, and to report any instances of pain so follow up can be done by nursing. The DON said that the purpose of the incident forms was to be completed, so follow up and ongoing monitoring could be completed by nursing. On 6/20/24, a clinical record review of R2's occupational therapy (OT) notes was conducted, which revealed the following: 1. On 5/4/23, the OT note documented that R2 had pain at 5/10 static sitting and 10/10 [severe pain] with standing and weight bearing. The note had no intervention for the pain or that nursing or the provider was made aware of the pain. 2. On 5/8/23, the OT note read in part, .pt [patient] not tolerating tx [treatment] session well this date 2nd to pain and fatigue . patient experienced pain? yes to right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 3. On 5/11/23, the OT note documented that R2 was experiencing pain to right lower leg, had right lateral leaning present, and was needing maximum assistance. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 4. On 5/16/23, the OT note documented that R2 refused to stand, was non-weight bearing to right lower extremity (leg), and that R2 had pain in the right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 5. On 5/17/23, the OT note documented R2 had increased pain with movement and extension and that R2 had pain to right hip. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 6. On 5/18/23, the OT note documented that R2 had pain that was at 10/10 (severe) to right lower leg and indicated OT spoke with physical therapy about right lower extremity contracture. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. On 6/20/24, a clinical record review of R2's physical therapy (PT) notes was conducted, which revealed the following: 1. On 5/1/23 at 4:03pm, the PT note documented .patient refused to transfer to chair or to ambulate and that patient had experienced pain to right lower extremity [leg]. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 2. On 5/2/23, the PT note documented patient refused to perform exercises due to all over pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 3. On 5/4/23, the PT note documented that R2 required cues to place right foot on the floor to accept weight. The note also documented that R2 displayed limited standing, weight shift, and had pain to right lower extremity. 4. On 5/5/23 at 4:41 p.m., PT note documented that R2 displayed leaning to the left, refused to put weight on right lower extremity, and with each sit to stand, pain worsened in weight bearing to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. (Tylenol was administered at 10:01 p.m., according to the MAR.) 5. On 5/9/23, PT note documented .patient requested to lay down due to pain and fatigue . The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 6. On 5/11/23, the PT note documented that R2 had pain to right lower extremity but had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 7. On 5/12/23, the PT note documented that R2 was leaning to the left, avoiding full weight on right lower extremity, required cues to weight bear, and was experiencing pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 8. On 5/16/23, the PT note documented that R2 had patient experienced pain to right lower extremity and communicated with nursing symptoms that supported the need to check R2 for urinary tract infection. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 9. On 5/17/23, the PT note documented that R2 was unable to stand, patient needing max assistance and was able to balance on left lower extremity only, as R2 was . not wanting to put weight through RLE [right lower extremity] due to pain. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 10. On 5/18/23, the PT note documented that R2 had pain and tightness to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 11. On 5/19/23, the PT note documented that R2 was having right hip pain and was avoiding weight to right lower extremity. The note had no intervention for the pain or any indication that nursing or the provider was made aware of the pain. 12. On 5/22/23, the PT note documented that R2 required constant cues to place right lower extremity flat on floor, to accept weight to the right leg, and that R2 experienced pain to right lower extremity. The PT note documented that nursing was asked to look at patient's right hip due to pain and discharged R2 from physical therapy. On 6/20/23, a clinical record review was conducted on the medication administration record (MAR), which includes a routine pain assessment every shift. The MAR revealed that R2 was assessed as having pain for 16 days from 5/1/23 - 5/24/23 and was given pain medications on six of those days from the nursing pain assessments. Pain medication, which was Tylenol, was administered on 5/1/23, 5/5/23, 5/15/23, 5/19/23, 5/21/23, and 5/24/23, but did not align with the times that therapy documented R2 was having pain. Occupational therapy documented pain on 5/3/23, 5/4/23, 5/5/23, 5/8/23, 5/11/23, 5/15/23, 5/16/23, 5/17/23, and 5/18/23, while Physical therapy documented pain on 5/1/23, 5/2/23, 5/4/23, 5/5/23, 5/9/23, 5/11/23, 5/12/23, 5/16/23, 5/17/23, 5/18/23, 5/19/23 and 5/22/23. On 5/14/23 and 5/18/23, R2's pain was documented as 10/10 or severe in the therapy notes, but according to the MAR, R2 did not receive any pain medications on those days. On 5/5/23, when therapy documented that R2 refused to put weight on right leg and pain worsened with weight bearing, R2 did not receive any medication to relieve that pain, according to the MAR. On 5/12/23, when therapy documented that the resident was unable to bear weight on right lower leg and was experiencing pain, R2 received no pain medication that day, according to MAR. On 5/17/23, when therapy documented that R2 was unable to stand and was experiencing pain, R2 received no pain medications that day, according to the MAR. On 6/20/24 at 3:45, an end of day meeting was held with the DON, the regional director of clinical services (RDCS), and the regional vice president of operations. The concerns for potential harm were discussed regarding staff's failure to assess/monitor for pain/injury after observing R2's right foot being dragged on 4/27/24, as well as the numerous instances therapy documented pain but failed to ensure relief or interventions were provided. No new information was provided. On 6/20/24 at 6:33 p.m. an exit conference meeting was conducted. The DON, RDCS, and the regional vice president of operations was in the meeting and no other information was provided at this time.