Every finding on record at Autumn Care Of Biscoe

Based on observations and staff interviews the facility failed to ensure a resident room was in good repair for 4 of 6 residents (Resident #35, #30, #76, and #77) observed for a safe, clean and homelike environment. Findings included:An initial observation was conducted of 500 hall on 06/21/26 from 10:29 AM through 10:45 AM. The following observations were made: a. The wall visible upon walking into Resident #77's room (the wall straight in front of door that included the window) where the wall and ceiling met had a noted gap measuring approximately 1/4 inch wide and approximately 7 to 8 inches in length from the right corner of the wall. The area to the right and left of the gap had a white substance between the ceiling and top of drywall. The right corner of the room where the two walls and ceiling met revealed the paint was bubbled up and appeared as being pulled in opposite directions from the ceiling to the floor. b. The wall visible upon walking into Resident #30's room (the wall straight in front of door that included the window) from right to left where the wall and ceiling met had a noted gap measuring approximately 1/4 to 1/2 inch across the length of the wall where the drywall met the ceiling. c. The wall visible upon walking into Resident #76's room (the wall straight in front of door that included the window) from right to left where the wall and ceiling met had a noted gap measuring approximately 1/4 to 3/4 inch for the entire length of the wall. The right and left corners of the room where the two walls and ceiling met revealed the paint was bubbled up and appeared as being pulled in opposite directions from the ceiling to the floor. d. The wall visible upon walking into Resident #35's room (the wall straight in front of door that included the window) from right to left where the wall and ceiling met had a noted gap measuring approximately 1/4 to 1 inch for the entire length of the wall and ceiling revealed the paint was bubbled up and appeared as being pulled in opposite directions from the ceiling to the floor. The ceiling appeared to be uneven, angled/slanted approximately 1 foot out from the wall to the right. An observation and interview were conducted on 06/21/26 at 2:30 PM with the Maintenance Director. He observed and stated he was aware of the gap between where the ceiling and the wall should meet and the bubbled up paint that appeared as being pulled in opposite directions from the ceiling to the floor. The Maintenance Director also observed an area to the right of Resident #35's room where the two walls and ceiling met the ceiling appeared to be angled approximately 1 foot out from the wall to the right. The Maintenance Director then observed and verified he was aware of the same issues (gap where ceiling and wall met and the lifted bubbled up paint to both corners) in Resident #76's room. The Maintenance Director also observed Resident 30's and 77's rooms. The Maintenance Director explained that he had been working at the facility for approximately 2 years and that the Resident rooms had been in this condition and that he had applied caulking to the open areas. When asked when the last time was that he applied caulking to the gaps the Maintenance Director did not respond. The Maintenance Director then explained he felt the issues with the walls were caused by the building settling and it was expected from a building that was built in 1962. He went on to state the walls won't fall in or anything and indicated this was not a concern. The Maintenance Director indicated he had looked at the outside wall for cracked foundation but did not see any. An interview and observations of the residents' rooms were conducted on 06/23/26 at 3:25 PM with the Administrator. The Administrator indicated she was not aware of the needed repairs to the rooms. She stated it was important for the environment to be well repaired and homelike. She also stated the Maintenance Director was responsible for the concerns.

Based on record reviews and staff interviews, the facility failed to provide the resident and responsible party (RP), written notification of the reason for a hospital transfer for 4 of 4 residents reviewed for hospitalization (Residents #19, # 44, #61 and #4). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. Resident #19's medical record revealed she was transferred to the hospital on [DATE] and 12/31/24 for mental status changes. There was no documentation that a written notice of transfer was provided to the resident and RP for the reason for the transfer. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was cognitively intact. On 3/5/25 at 10:13 AM, an interview occurred with Unit Manager #2, who stated when a resident was transferred to the hospital a copy of the face sheet, a copy of the Complete Clinical Data sheet, any Do Not Resuscitate (DNR) information if present, and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Regional Director of Clinical Services was interviewed on 3/5/25 at 12:25 PM and stated the facility was not sending the written notice of transfer as required. RPs were notified by phone when a resident was sent to the hospital. She stated there was some confusion over whether nursing or the Social Worker was to send them out, but a plan would be put into place moving forward. On 3/5/25 at 1:00 PM, the Social Worker was interviewed and stated she had been employed at the facility since 10/2023. She stated she had not been sending out the written notice of transfer to the resident and RP when a resident was sent to the hospital and was unaware, she was to be doing this task. The Administrator was interviewed on 3/6/25 at 10:08 AM and verified she was aware of the regulation regarding the need for written reason for hospital transfer to be sent to the resident and RP, but it was not being done at the facility. She was unable to offer a reason. 2. Resident #44 was admitted to the facility on [DATE]. An admission MDS assessment dated [DATE] indicated Resident #44 had moderately impaired cognition. Resident #44's medical record revealed she was transferred to the hospital on 2/23/25 for respiratory distress and did not return to the facility. There was no documentation that a written notice of transfer was provided to the RP for the reason for the transfer. On 3/5/25 at 10:13 AM, an interview occurred with Unit Manager #2, who stated when a resident was transferred to the hospital a copy of the face sheet, a copy of the Complete Clinical Data sheet, any Do Not Resuscitate (DNR) information if present, and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Regional Director of Clinical Services was interviewed on 3/5/25 at 12:25 PM and stated the facility was not sending the written notice of transfer as required. RPs were notified by phone when a resident was sent to the hospital. She stated there was some confusion over whether nursing or the Social Worker was to send them out, but a plan would be put into place moving forward. On 3/5/25 at 1:00 PM, the Social Worker was interviewed and stated she had been employed at the facility since 10/2023. She stated she had not been sending out the written notice of transfer to the resident and RP when a resident was sent to the hospital and was unaware, she was to be doing this task. The Administrator was interviewed on 3/6/25 at 10:08 AM and verified she was aware of the regulation regarding the need for written reason for hospital transfer to be sent to the resident and RP, but it was not being done at the facility. She was unable to offer a reason. 3. Resident #61 was admitted to the facility on [DATE]. Resident #61's medical record revealed he was transferred to the hospital on 7/5/24 and 9/11/24 due to falls. There was no documentation that a written notice of transfer was provided to the resident and RP for the reason for the transfer. A significant change in status MDS assessment dated [DATE] indicated Resident #61 had moderately impaired cognition. On 3/5/25 at 10:13 AM, an interview occurred with Unit Manager #2, who stated when a resident was transferred to the hospital a copy of the face sheet, a copy of the Complete Clinical Data sheet, any Do Not Resuscitate (DNR) information if present, and the Bed Hold policy was sent with them. The RP was notified by phone of the change and reason for the hospital transfer. The Regional Director of Clinical Services was interviewed on 3/5/25 at 12:25 PM and stated the facility was not sending the written notice of transfer as required. RPs were notified by phone when a resident was sent to the hospital. She stated there was some confusion over whether nursing or the Social Worker was to send them out, but a plan would be put into place moving forward. On 3/5/25 at 1:00 PM, the Social Worker was interviewed and stated she had been employed at the facility since 10/2023. She stated she had not been sending out the written notice of transfer to the resident and RP when a resident was sent to the hospital and was unaware, she was to be doing this task. The Administrator was interviewed on 3/6/25 at 10:08 AM and verified she was aware of the regulation regarding the need for written reason for hospital transfer to be sent to the resident and RP, but it was not being done at the facility. She was unable to offer a reason. 4. Resident #4 was admitted to the facility on [DATE]. Resident #4's medical record revealed she was transferred to the hospital on [DATE] for worsening leg wounds. There was no documentation that a written notice of transfer was provided to the resident and RP. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact. On 03/05/25 at 10:13 AM, an interview occurred with Unit Manager #2, who stated when a resident was transferred to the hospital the RP was notified by phone of the change and reason for the hospital transfer. On 03/05/25 at 1:00 PM, the Social Worker was interviewed and stated she had been employed at the facility since 10/2023. She stated she had not been sending out the written notice of transfer to the resident and RP when a resident was sent to the hospital and was unaware, she was to be doing this task. The Regional Director of Clinical Services was interviewed on 03/05/25 at 12:25 PM and stated the facility was not sending the written notice of transfer as required. RPs were notified by phone when a resident was sent to the hospital. She stated there was some confusion over whether nursing or the Social Worker was to send them out, but a plan would be put into place moving forward. The Administrator was interviewed on 03/06/25 at 10:08 AM and verified she was aware of the regulation regarding the need for a written reason for hospital transfer to be sent to the resident and RP, but it was not being done at the facility. She was unable to offer a reason.

Based on record review, and staff and resident interviews, the facility failed to report to the Administrator/Abuse Coordinator and Adult Protective Services the theft of residents' money and personal property for 3 of 4 residents reviewed for misappropriation of resident property (Resident #16, Resident #64 and Resident #60). The facility failed to submit a 5-day investigation report to the state survey agency for 1 of 4 residents (Resident #16). Findings included: Facility Resident Abuse Policy: Abuse, Neglect and Exploitation policy, revised 7/11/24 was reviewed. Policy stated It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Once the Administrator and Department of health are notified, an investigation of the allegation or suspicion will be conducted. The investigation must be completed within five working days from the alleged occurrence. Final Report will be submitted to applicable State agency, after the investigation is completed, but no later than five working days from the alleged occurrence. 1. Resident #16 was admitted to facility on 9/27/16. Resident #16 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #16 was cognitively intact and with no behaviors. An interview was conducted with Resident #16 on 3/3/25 at 11:45 am. Resident #16 stated that on 2/8/25 someone took her lock box that contained money, and a personal ring from her room. Resident #16 indicated that she last seen her lock box on 2/7/25 and on 2/8/25 she realized that both the lock box and the lock box keys were missing. Resident #16 revealed that that the lock box contained 30 dollars, and a ring valued at 500 dollars. A phone interview was conducted with Nurse Aide (NA) #3 on 3/5/25 at 1:46 pm. NA #3 confirmed that she worked on 2/8/25 from 7:00 am to 7:00 pm. NA #3 revealed that she went into Resident #16's room to check on her at 4:00 pm. NA #3 stated that Resident #16 indicated that she wanted NA #3 to get her (Resident #16) a drink from the vending machine. NA #3 revealed that Resident #16 had a lock box that was always kept by the window and the keys hung on the wall. NA #3 indicated that when she went to get the lock box for Resident #16 it was not there to be found. NA #3 indicated that Resident #16 did not know where the lock box was. NA #3 further revealed that even the lock box keys were missing. NA #3 indicated that she immediately notified Unit Manager #1 about the missing lock box and lock box keys. NA #3 stated that together with Unit Manager #1 they looked everywhere in Resident #16's room and could not find the lock box or the lock box keys. A phone interview was conducted with Unit Manager #1 on 3/6/25 at 10:51 am. Unit Manager #1 confirmed that she worked on 2/8/25 from 7:00 am to 7:00 pm. Unit Manager #1 revealed that at 4:10 pm, NA #3 notified her that Resident #16 was missing both her lock box and lock box keys. Unit Manager #1 indicated that together with NA #3 they looked everywhere in Resident #16's room and could not find the lock box or the lock box keys. Unit Manager #1 indicated that Resident #16 kept her money in the lock box and used the money to get drinks from the vending machine or anything that she needed staff to assist and get for her. Unit Manager indicated that Resident #16 had reported that she had 30 dollars in the lock box and a personal ring. Unit Manager indicated that she notified Director of Nursing (DON) at 4:30 pm. Unit Manager #1 further revealed that DON informed her to fill out a grievance concern form and place it in the Administrators box in the front office. Unit Manager #1 indicated that she did not notify anyone else about the missing lock box and lock box keys. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 11:35 am. DON indicated that she received notification from Unit Manager #1 on 2/8/25 at 4:35 pm, indicating that Resident #16 was missing her lock box and lock box keys. The DON indicated that she told Unit Manager #1 to notify the Administrator. The DON stated that as far as she knew the Administrator was notified of the missing money that was in the lock box and lock box keys on 2/8/25. An interview was conducted with the Administrator on 3/6/25 at 1:21pm. The Administrator indicated that she was notified on 2/10/25 via phone by Unit Manager #1 about Resident #16 missing 30 dollars. The Administrator also confirmed that adult protective services was not notified. The Administrator confirmed that Resident #16 did not have a 5-day working investigation report submitted to NC DHHS. 2. Resident Number #64 was admitted to facility on 1/31/24. Resident #64 annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 was cognitively impaired but was able to make himself understood (ability to express ideas and wants) and had no behaviors. An interview was conducted with Resident #64 on 3/3/25 at 12:49 pm. Resident #64 indicated that he had 240 dollars stolen from him. Resident #64 indicated that the money was inside his wallet that was inside the top drawer of his bedside dresser, and it went missing. A phone interview was conducted with NA #4 on 3/5/25 at 1:57 pm. NA #4 confirmed that she worked on 2/8/25 from 7:00 am to 7:00 pm. NA #4 revealed that Resident #64 reported to her that he was missing money. NA #4 confirmed that Resident #64 did have money in a wallet that he would use to get drinks from the vending machine. NA #4 stated that she notified Unit Manager #1 on the morning of 2/8/25 at 8:00 am. NA #4 indicated that she looked everywhere in Resident #64's room and could not find the missing wallet that had money in it. A phone interview was conducted with Unit Manager #1 on 3/6/25 at 10:51 am. Unit Manager #1 confirmed that she worked on 2/8/25 from 7:00 am to 7:00 pm. Unit Manager #1 indicated that she was notified about Resident #64 missing 200 dollars from his wallet on 2/8/25. Unit Manager #1 indicated that she was notified by Nurse #3 via phone, because she (Unit Manager #1) had already left work. Unit Manager #1 indicated she was notified while at home by Nurse #3. Unit Manager #1 further revealed that she told Nurse #3 to fill out a grievance form, and place it in the administrators box by the front office and notify DON. Unit Manager #1 indicated that she followed up and called the DON as well and notified her of Resident #64's missing money. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 11:35 am. The DON indicated that she received notification from Unit Manager #1 on 2/8/25 at 4:35 pm, indicating that Resident #64 was missing his wallet. The DON indicated that she told Unit Manager #1 to notify the Administrator. The DON further stated that as far as she knew the Administrator was notified of the missing money that was in the wallet on 2/8/25. Review of the 5-day working day investigation report for Resident #64 was submitted on 2/17/25 at 4:59 pm and adult protective services were not notified. An interview was conducted with the Administrator on 3/6/25 at 1:21pm. The Administrator indicated that she was notified on 2/10/25 via phone by Unit Manager #1 about Resident #64's missing money. The Administrator also confirmed that adult protective services were not notified. 3. Resident #60 was admitted to facility on 3/8/19. Resident #60 significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #60 was cognitively intact and had no behaviors. An interview was conducted with Resident #60 on 3/3/25 at 12:03 pm. Resident #60 indicated that his money had been stolen. Resident #60 revealed that his money was inside a lock box that was placed inside the top drawer of his bedside dresser. Resident #60 indicated that the whole lock box was missing, which had 600 dollars. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 11:35 am. DON indicated that she did not receive notification from any staff about Resident #60 missing money. The DON indicated that she was notified of Resident #60 missing money on 2/10/25 by Unit Manager #2 while in the facility. The DON indicated that the Administrator was also notified. Review of the 5-day working day investigation report for Resident #60 was submitted on 2/17/25 at 5:02 pm and adult protective services were not notified. An interview was conducted with the Administrator on 3/6/25 at 1:21pm. The Administrator indicated that she was notified on 2/10/25 via phone by Unit Manager #1 that Resident #60 was missing money. The Administrator also confirmed that adult protective services were not notified.

Based on staff interviews, resident interview, and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of medications and dental status for 2 of 22 (Residents #2 and # 29) residents reviewed for MDS accuracy. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of Resident #2's January 2025 physician orders included an order for insulin lispro 100 unit/ml (milliliter); administer per sliding scale before meals and at bedtime. Review of Resident #2's January 2025 medication administration record revealed insulin lispro was received on 7 days during the look back period. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the medications section was coded as 0 out of 7 days that injections of any type were received, and 0 out of 7 days insulin injections were received during the lookback period. An interview was conducted on 03/05/25 at 3:59 PM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that she did not code the insulin injections that were received for 7 days during the lookback period. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. She stated she expected the MDS assessments to be coded accurately. 49295 2. Resident #29 was admitted to facility 4/9/24, with diagnosis that included diabetes, chronic obstructive pulmonary disease, depression, heart failure and hypertension. Resident #29 Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #29 had no oral or dental problems. An observation was made on 3/3/25 with Resident #29 at 11:53 am. Resident #29 was observed to have missing upper and lower teeth, with only 4 remaining upper teeth, and at least 5 remaining lower broken teeth. The 4 remaining upper teeth were noted to have decay and discoloration. On 3/6/25, at 9:36 am, an observation was made with MDS Nurse #1 while she (MDS Nurse #1) was examining Resident #29's mouth, doing an oral assessment. MDS Nurse #1 indicated that Resident #1 was noted to have five lower bottom teeth that were broken, and 4 upper teeth that had visible decay. An interview was conducted with MDS Nurse #1 on 3/6/25, at 9:36 am. MDS Nurse #1 indicated that she did not accurately reflect Resident #29 dental status on the significant change assessment dated [DATE]. MDS Nurse #1 further indicated that Resident #29's should have been coded as having obvious or likely cavity on the assessment. MDS Nurse #1 stated she would complete a modification to ensure that the assessment accurately reflected Resident #29's dental status. An interview was conducted with the Director of Nursing (DON) on 3/6/25 at 11:35 am. The DON indicated that she required assessments accurately reflected a resident's dental status.

Based on record review, observations and staff interviews, the facility failed to develop an individualized person-centered care plan in the area of nutrition for 1 of 2 residents reviewed for nutrition (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA) and cognitive communication deficit. Resident #2's active orders included an order dated 12/26/24 for adaptive equipment: Divided Plate. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2's cognition was severely impaired. She required setup/cleanup assistance with meals. Review of Resident #2's active care plan, last reviewed on 02/06/25, revealed a care plan focus for nutritional status that read Resident #2 was at an increased nutritional risk due to dysphagia, congestive heart failure, age-related physiological decline, impaired mobility, diabetes mellitus, and weight loss. The care plan focus did not include an intervention for a divided plate during meals. Observation made in the dining room on 03/04/25 at 8:20 AM of Resident #2 eating breakfast from a divided plate. Observation made in the dining room on 03/05/25 at 12:05 PM of Resident #2 eating lunch from a divided plate. An interview was conducted on 03/05/25 at 3:59 PM with the Minimum Data Set (MDS) Nurse #1. She verified there were no areas on Resident #2's care plan for a divided plate during meals and there should have been an intervention added to the nutrition focus area. She explained dietary completed the focus care area for nutrition and should have added the intervention for the divided plate, but it was a group effort. A phone interview was conducted on 03/05/25 at 5:22 PM with the Registered Dietitian (RD). She stated Resident #2 did have an order for a divided plate with meals and that it should have been included in the care plan. She indicated she should have added the divided plate to the care plan focus for nutrition. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. She stated she expected Resident #2's care plan should have included the divided plate during meals.

Based on record review, resident, Physician and staff interviews, the facility failed to act on a hospital discharge order for a nephrology follow up appointment for Resident #60 that resulted in her requiring antibiotics to treat UTIs on 5/26/23, 10/11/23, 10/28/23, 1/18/24 and 2/25/24. This was for 1 of 2 residents reviewed for urinary tract infections (UTIs). The findings included: Resident #60 was admitted on [DATE] with cumulative diagnoses of congestive heart failure and chronic kidney disease. Review of Resident #60's hospital discharge summary dated 3/13/23 included an order for a nephrology consult in 2-4 weeks. Resident #60 was care planned on 10/12/23 for current and/or a history of UTIs. Interventions included antibiotics as ordered. Review of Resident #60's electronic medical record read she was treated for UTIs on 5/26/23, 10/11/23, 10/28/23, 1/18/24 and 2/25/24. Review of Resident #60's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact, dependent on staff for toileting, moderate staff assistance with personal hygiene and always incontinent of bladder. Review of Resident #60's electronic medical record from 3/13/23 to 3/6/24 did not include any documentation of any nephrology or urology consultations. An interview was completed on 3/5/24 at 1:40 PM with Resident #60. She stated she had a history of UTIs that caused her dysuria (painful urination). She stated she was not experiencing dysuria at present and was recently treated with an antibiotic for a UTI. She stated she did not recall seeing a nephrologist or urologist for her history of UTIs. Review of Resident #60's March 2024 Physician orders included an order dated 3/5/24 for a renal ultrasound due to urinary retention. Review of a nursing note dated 3/6/24 at 12:53 AM read Resident #60 displayed an altered mental status and complained of discomfort to her suprapubic area. The on-call Physician was notified and new orders were given for a post void in and out catheterization. Review of a nursing note dated 3/6/24 at 1:20 AM read a post void in and out catheterization was completed with the result of 700 cubic centimeter (cc) of urine drained. The note read the on-call Physician ordered Resident #60's Physician to be notified of her post void results. Review of Resident #60's March 2024 Physician orders include new orders dated 3/6/24 for a urinary catheter placement and a urology consult. An interview was completed on 3/6/24 at 11:35 AM with the Physician. She stated Resident #60 had a history of UTIs and urinary retention. The Physician stated she expected any orders for consultation with a nephrologist or urologist be scheduled and completed as ordered. An interview was completed on 3/6/24 at 1:52 PM with the Administrator. She stated Resident #60's nephrology appointment order from the hospital discharge paperwork dated 3/13/23 was never done and there was new orders obtained today for a urology consultation. A telephone call was attempted on 3/6/24 at 3:37 PM with Nurse #5 who no longer worked at the facility. Nurse #5 entered Resident #60's admission orders on 3/13/123 into the electronic medical record. The surveyor was unable to leave a message for Nurse #5 to return the call. An interview was completed on 3/7/24 at 9:50 AM with the Administrator. She stated she expected all admission orders to be entered into the electronic medical record correctly with a careful review of all hospital discharge orders to ensure no orders were missed.

Based on observations, record review, and interviews of residents and staff, the facility failed to provide a clean, home-like environment in the main dining room as evidenced by a dirty, sticky floor and a dirty window and failed to repair a leaking roof. Findings included: 1 On 3/4/24 at 12:00 pm the initial resident dining observation was done. The entryway floor with vending machines, food serving cabinets and entry into the kitchen was noted to have a moderate amount of brown soil which was sticking to the shoe. This was a high-traffic area with staff, residents, and visitors walking. The window in this area had a large amount of spider webs with black soil affecting visibility to the outside. On 3/5/24 at 1:30 pm an observation was done of the dining room and the floor and window remained the same. On 3/6/24 at 1:35 pm an observation was done of the dining room and the floor and window remain unchanged. On 3/6/24 at 1:54 pm an interview was conducted with the lead Housekeeper. She stated housekeeping was responsible to clean the floor and dust in the main dining room each day. She stated the floor was mopped each day. She stated she was not aware the floor had not been mopped since before Monday and was sticky. She stated she would mop the floor now and clean the dirty window. Housekeeping and maintenance manage cleaning the facility windows. 2. A vendor estimate dated 10/3/23 to repair the areas of active leak or the entire roof was obtained by the facility and a copy was provided on 3/7/24. E-mail communication dated 10/16/23 between the facility Administrator and Corporate Office documented there were roof leaks that affected the following areas (copy provided 3/7/24): Resident rooms 109 202, 206, 209, 212, 301, 302, 2307, 310, 401, 402, 403, 406, 407, 410, 412, 502, 503, 504, 506, 507, 508, 510, 516, 608 614, 620, 622, and 625. 600 nurses' station 600 nutrition room 600 medication room 600 living room 600 soiled utility room Director of Nursing's office Unit manager's room Conference room Laundry room vents Front dining room A capital purchase request dated 10/16/23 was provided to the Corporate Office for roof repair or replacement by the Administrator and copy provided on 3/7/24. The facility had leaking areas patched by the vendor. On 03/06/24 at 12:20 pm an interview was conducted with the Maintenance Manager. The Manager stated he was the only person completing repairs. The roof has been leaking for months in the past and patched by the vendor. He was currently waiting for the entire roof replacement bid to be approved by the home office. There was currently other random roof leaks after patches were placed that he was fixing. On 3/7/24 at 9:00 am an interview was conducted with the Administrator. She stated that the Corporate Office was provided the vendor quote for patch and repair and approved patch repair and there had been new leaks that had popped up throughout the building. The Corporate Office was aware of the leaks and had the roof replacement estimate, but there was no decision at present. The facility maintenance staff had attempted to repair the leaks, but there were new leaks. She stated new areas of leak had opened recently and residents had to be moved to other rooms. There was a current roof leak in resident room [ROOM NUMBER], which had leaked before. The Administrator stated the roof needed to be replaced, patching the roof was not working at this time. On 3/7/24 at 9:30 am an observation was completed of resident room [ROOM NUMBER]. It was raining and there was a small amount of water on the floor next to the outer wall. The ceiling above had a small area of stain and small blister in the drywall. On 3/7/24 at 10:00 am an observation of resident rooms on Halls 100 - 600 was completed. The rooms were checked for roof leak and none were observed. On 3/7/24 at 9:30 am an interview was conducted with Resident #24. The resident resided in room [ROOM NUMBER]. The resident stated the roof was leaking again. She had been moved from another room before when the roof was leaking. The ceiling was coming down and no one had come to repair the leak. On 3/7/24 at 9:35 am an interview was conducted with Resident #58. Resident #58 resided in room [ROOM NUMBER]. She stated the ceiling was stained and sagging and there was a small amount of water leaking onto the floor near the window and this was not the first time. An observation revealed the leak was in front of the drawers where the residents' clothes were stored. On 3/20/24 at 9:40 am an interview was conducted with the Administrator. The Administrator stated the Corporate Office made the decision of how to manage the roof leak. The roof leak was patched last week, resident room [ROOM NUMBER] no longer had a leak, and future leaks would be patched. The roof would not be replaced at this time.

Based on observation, record review and interviews of residents and staff, the facility failed to provide dependent residents with nail care for 6 of 6 residents reviewed for activities of daily living (ADL) [Resident #s 14, 20, 35, 61, 76, and 92]. Findings included: 1. Resident #14 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. Resident #14 had a care plan for activity of living deficit. He required assistance as needed and help with his dentures. Review of Resident #14's ADL sheets for February and March 2024 revealed the staff did not document set up for shower, he had periodic staff assistance with toilet use on all shifts, and there was no documentation of nail care or refusal of care. A review of Resident #14's nurses' notes for February and March 2024 documented the resident required set up help with meals and showers. Showers were scheduled on Tuesday and Friday. On 03/04/24 at 10:40 am Resident #14 was observed to have long dirty nails and was interviewed. The nails had dirt underneath and around the cuticles that was brown to black. The resident was alert and oriented, he looked at his long, dirty nails and shrugged his shoulders and said it's okay. I am independent with most things. The resident had limited dexterity to his hands, with gross movement to pick up items. The resident had limited range of movement to his neck and torso and sat in his wheelchair leaning over to his left leaning on the side arm. On 3/4/24 at 10:55 am an interview was conducted with Nurse #4. Nurse #4 stated she was assigned to Resident #14 and knew him well. She stated the resident refused to have his nails cut, but the nails/hands should be washed when he was set up for his shower or meal. The resident was set in his ways. Nurse #4 was not aware the resident had soiling around the nail cuticle and underneath and his nails were long. On 3/5/24 at 11:20 am an observation was completed of Resident #14. His nails remained in the same condition. On 3/5/24 at 2:50 pm Nursing Assistant (NA) #5 was interviewed. NA #5 stated she was assigned to all halls. The residents were to have nail care as needed unless unable then the nurse was to be informed of the resident's needs. Resident's nails were cared for during bathing or showers. If the resident refused, the nurse was to be informed. The NA did not know why some of the residents on Hall 500 had long dirty nails and would check. If the nails were long and dirty, the care was not done and should have been reported to the nurse. On 2/5/24 at 3:24 pm an interview was conducted with Nurse #4. Nurse #4 stated she was assigned to Hall 500 residents. She stated if the residents' nails were long and dirty, care was not completed, and the NA had not informed her. Nurse #4 stated Resident #14 would probably not allow staff to cut his nails, but his hands/nails should be washed. The resident had not refused care before. She expected the NA to provide nail care with the shower or bath and as needed or let the nurse know if unable or the resident refused. On 3/6/24 at 8:45 am an observation was completed of Resident #14. His nails were observed to be cut and clean this morning. Resident #14 commented staff assisted him with his nails. On 3/6/24 at 2:05 pm an observation was done of Resident #14. He used his hands to feel through the wheelchair pocket and it was noted that his fine dexterity was limited and had gross use of his fingers. On 3/6/24 at 10:40 am an interview was conducted with Nurse Consultant #2. She stated facility staff noticed some issues with the residents' nail condition and directed the staff to audit all residents' fingernails and provide care around 5:00 pm yesterday, 3/5/24. 2. Resident #20 was admitted to the facility on [DATE] with the diagnoses of schizoaffective disorder and weakness. A review of Resident #20's ADL sheets for February and March 2024 documented he received a bath with assistance from staff almost every day. No refusals were documented. There was no nail care documented. Resident #20's care plan dated 2/13/24 documented Resident #20 had an ADL self-care deficit. Staff were to assist with ADL care as needed. Resident #20's quarterly Minimum Data Set, dated dated dated [DATE] documented his cognition was intact. The resident had little interest in doing things every day, was depressed, and had trouble falling asleep 2 to 6 days per week. The resident was moving and speaking slowly, had no behaviors, and no rejection of care. On 03/4/24 at 2:08 pm an observation was completed of Resident #20. His nails were long and dirty under the nail bed and around the cuticle. On 3/5/24 at 12:30 pm an observation was completed of Resident #20 and his nails remained unchanged. Some nails had jagged edges, especially on his dominant hand the second finger. On 3/5/24 at 2:50 pm Nursing Assistant (NA) #5 was interviewed. NA #5 stated she was assigned to all halls. The residents were to have nail care as needed unless unable then the nurse was to be informed of the resident's needs. Resident's nails were cared for during bathing or showers. If the resident refused, the nurse was to be informed. The NA did not know why some of the residents on Hall 500 had had long dirty nails and would check. If the nails were long and dirty, the care was not done and should have been reported to the nurse. On 2/5/24 at 3:24 pm an interview was conducted with Nurse #4. Nurse #4 stated she was assigned to Hall 500 residents. She stated if the residents' nails were long and dirty, care was not completed, and the Nursing Assistant (NA) had not informed her. Nurse #4 stated Resident #20 had not refused care and should have had nail care when assisted with his shower. She expected the NA to provide nail care with the shower or bath and as needed or let the nurse know if unable or the resident refused. On 3/7/24 at 10:15 am Resident #20 was interviewed. The resident was able to state yes when asked if staff assisted him with nail care last evening. The resident was slow to respond. On 3/6/24 at 10:40 am an interview was conducted with Nurse Consultant #2. She stated facility staff noticed some issues with the residents' nail condition and directed the staff to audit all residents' fingernails and provide care around 5:00 pm yesterday, 3/5/24. 3. Resident #61 was admitted to the facility on [DATE] with the diagnosis of dementia. A review of Resident #61's weekly skin assessment dated [DATE] documented no skin issues with no mention of fingernails. Resident #61's care plan dated 1/31/24 documented an ADL self-care deficit and to assist with ADLs as needed. Resident #61's admission Minimum Data Set, dated dated dated [DATE] documented he had a moderately impaired cognition. The resident had no refusal of care and bathing required maximal assistance and all other care required partial-moderate assistance of 1 staff. A review of Resident #61's ADL for February and March 2024 documented he required bathing assistance with part of the bathing by 1 staff member. The resident had Tuesday and Friday showers scheduled. He required total dependence for most days and 1-day partial assistance. March 2024 bathing varied from dependence to assistance by 1-staff member. There was no documentation of nail care or refusal. On 3/05/24 at 1:29 Resident #61 was observed sitting in his wheelchair in the front lobby. The resident was alert to self and situation. The resident's nails were noted to be long, broken (right pointer finger) and dirty under the nails and fingers. The resident was interviewed and stated he would like nail care. He had no nail care since he got here (1/31/24). On 3/5/24 at 2:50 pm Nursing Assistant (NA) #5 was interviewed. NA #5 stated she was assigned to all halls. The residents were to have nail care as needed unless unable then the nurse was to be informed of the resident's needs. Resident's nails were cared for during bathing or showers. If the resident refused, the nurse was to be informed. The NA did not know why some of the residents had had long, dirty nails on Hall 500 and would check. If the nails were long and dirty, the care was not done and should have been reported to the nurse. On 2/5/24 at 3:24 pm an interview was conducted with Nurse #4. Nurse #4 stated if the residents' nails were long and dirty, care was not completed, and the NA had not informed her. Nurse #4 stated residents should have had nail care when assisted with their shower or bath. She expected the NA to provide nail care with the shower or bath and as needed or let the nurse know if unable. On 2/7/24 at 10:20 am an observation was completed of Resident #61. He was sitting in his wheelchair on the hall. His nails were cleaned, and some were cut. On 3/6/24 at 10:40 am an interview was conducted with Nurse Consultant #2. She stated facility staff noticed some issues with the residents' nail condition and directed the staff to audit all residents' fingernails and provide care around 5:00 pm yesterday, 3/5/24. 4. Resident #76 was admitted to the facility on [DATE] with the diagnosis of dementia. Resident #76's annual Minimum Data Set, dated dated dated [DATE] documented the resident had a severely impaired cognition, no psychosis, no behavior, or refusal of care. The resident was dependent for personal care. The documented care plan dated 2/12/24 for Resident #76 revealed she had an ADL care deficit. On 03/04/24 at 12:35 pm an observation was done of Resident #76. Resident #76 was dressed and sitting in her wheelchair in her room. Her nails were long and dirty, and she was unable to state whether she wanted them to be cut and cleaned. The resident was pleasantly confused but oriented to self. A review of Resident #76's orders revealed she was receiving longevity care as of 9/25/23 (managed palliative care). A review of ADL documentation for February and March 2024 revealed Resident #76 received bathing each day and one shower on 3/5/24 during March and bathing each day during February 2024. The resident was dependent of 1 staff for care with no refusals and no behaviors. There was no documentation of nail care. The multi-disciplinary meeting for Resident #76 on 2/14/24 documented the resident no longer had behaviors or refusal of care. Physician note dated 2/14/24 documented Resident #78 was seen for her regulatory visit. The resident had a history of late onset Alzheimer's dementia without behavioral disturbances. Staff reported no new behaviors or concerns. A review of Resident #78's ADL documentation for February 2024 revealed she was bathed every day. The resident was dependent and had showers on Tuesday and Friday. There was no nail care, behaviors, or refusals documented. On 3/5/24 at 2:50 pm Nursing Assistant (NA) #5 was interviewed. NA #5 stated she was assigned to all halls. The residents were to have nail care as needed unless unable then the nurse was to be informed of the resident's needs. Resident's nails were cared for during bathing or showers. If the resident refused, the nurse was to be informed. The NA did not know why some of the residents had had long, dirty nails on Hall 500 and would check. If the nails were long and dirty, the care was not done and should have been reported to the nurse. On 2/5/24 at 3:24 pm an interview was conducted with Nurse #4. Nurse #4 stated if the residents' nails were long and dirty, care was not completed, and the NA had not informed her. Nurse #4 stated residents should have had nail care when assisted with their shower or bath. She expected the NA to provide nail care with the shower or bath and as needed or let the nurse know if unable. Nurse #4 stated Resident #78 had not refused care, no longer had behaviors and would not be able to make her needs known due to dementia. On 3/6/24 at 10:40 am an interview was conducted with Nurse Consultant #2. She stated facility staff noticed some issues with the residents' nail condition and directed the staff to audit all residents' fingernails and provide care around 5:00 pm yesterday, 3/5/24. On 3/6/24 at 11:10 am Resident #76 was observed. She had some remaining brown soil under her fingernails, a couple of nails were cut, and the soil around the cuticle was gone. 5. Resident #92 was admitted to the facility on [DATE] with diagnosis of ataxia, muscle wasting of the hands, and other nervous system deficit. Resident #92's admission Minimum Data Set, dated dated dated [DATE] documented his cognition was intact and he had no behavior or refusal of care. The resident required partial/moderate assist with personal hygiene. Resident #92's quarterly MDS dated [DATE] and due 3/8/24 documented no behaviors or refusal of care. Resident #92's care plan dated 2/21/24 documented he had an ADL deficit secondary to hand atrophy and ataxia. ADL assistance was needed for personal care and meal set up. The resident wore bilateral splints to wrist/hand for carpal tunnel and muscle wasting, which was removed during the day, and used adaptive utensils for meals. A review of the Resident #98's medical chart revealed he had no pain to his hands; he had muscle atrophy and splints at night for carpal tunnel and was receiving therapy services for hand rehab and used adaptive utensils to eat. On 3/6/24 at 11:00 am Resident #92 was interviewed. He stated staff cleaned and cut his nails last evening (3/5/34), and he observed staff provide nail care to his roommate as well. The resident had no pain in his hands and accepted care. On 3/5/24 at 2:50 pm Nursing Assistant (NA) #5 was interviewed. NA #5 stated she was assigned to all halls. The residents were to have nail care as needed unless unable then the nurse was to be informed of the resident's needs. Resident's nails were cared for during bathing or showers. If the resident refused, the nurse was to be informed. The NA did not know why some of the residents had had long, dirty nails on Hall 500 and would check. If the nails were long and dirty, the care was not done and should have been reported to the nurse. On 2/5/24 at 3:24 pm an interview was conducted with Nurse #4. Nurse #4 stated she was assigned to and familiar with Resident #92. The resident had pain in his hands and she would need to see if the resident would allow nail cut. The resident had not refused care. All residents should have their hands and nails washed. If the residents' nails were long and dirty, care was not completed, and the NA had not informed her. Nurse #4 stated residents should have had nail care when assisted with their shower or bath. She expected the NA to provide nail care with the shower or bath and as needed or let the nurse know if unable. On 3/6/24 at 10:40 am an interview was conducted with Nurse Consultant #2. She stated facility staff noticed some issues with the residents' nail condition and directed the staff to audit all residents' fingernails and provide care around 5:00 pm yesterday, 3/5/24. 31227 6. Resident #41 admitted on [DATE] with diagnoses of a cerebral vascular accident (CVA),right side hemiparesis and Diabetes. Review of Resident #41's annual Minimum Data Set, dated dated dated [DATE] indicated he had severe impairment, exhibited no behaviors and was dependent on staff assistance with personal hygiene. Review of Resident #41's comprehensive care plan included a care plan revised on 12/12/23 for staff to check his skin to his right hand with hygiene, before splint placement and removal. There was also a care plan last revised on 10/28/22 for Resident #41's for noncompliance with shaving, weights, showers and medications. Review of Resident #41's cumulative Physician orders included an order dated 1/16/24 for a resting hand splint to his right hand for a contracture. An observation on 3/4/24 at 10:51 AM of Resident #41. He was sitting in a wheelchair in his room. The fingernails to his left hand were long and jagged. Resident #41 opened his right contracted hand slightly enough to observe his fingernails longer than the nails to his left hand. His nails were touching his palm but there was no evidence of any injuries. An observation on 3/5/24 at 9:30 AM was completed of Resident #41. He was lying in bed. The nails to his left hand had been trimmed but his contracted right hand remained unchanged. An interview was completed on 3/5/24 at 9:40 AM with nursing assistant (NA) #6. He stated Resident #41 was a diabetic so the nurses were responsible for trimming his fingernails. He stated he had reported the appearance of Resident #41's fingernails sometime last week or the week before to a nurse but he was unable to recall which nurse it was. NA #6 stated normally the aides completed nail care after showers or bathing and Resident #41 was known to refuse his showers. He stated he was not aware of his refusals of nail care. An observation on 3/6/24 at 10:25 AM was completed of Resident #41. He was sitting in a wheelchair in his room. The fingernails to his right contracted hand were unchanged. Another observation was completed on 3/6/24 at 10:30 AM with the assistant Director of Nursing (ADON) of Resident #41's fingernails on his right hand. The ADON observed his fingernails and confirmed they appeared long. The ADON assessed his palm for injuries and asked if he would allow her to trim his nails and he replied yes. The ADON confirmed Resident #41 was diabetic and stated the nurses were responsible for trimming his fingernails and his fingernails should have not been in the condition observed. An interview was completed on 3/6/24 at 10:32 AM with Nurse #8. She stated nurses trim fingernails of all diabetic residents. She stated this was her first day working in a while and that she did not notice the appearance of Resident #41's fingernails this morning. An interview was completed on 3/6/24 at 10:40 AM with Nurse Consultant #2. She stated the facility noticed some issues with nailcare and she told the staff to audit all the residents fingernails on 3/5/24. Nurse Consultant #2 stated she expected Resident #41's fingernails to have been trimmed yesterday. A telephone interview was completed on 3/6/24 at10:52 AM with Nurse #6. She confirmed she worked with Resident #41 on 3/4/24 and 3/5/24 from 7:00 AM to 7:00 PM. She stated she did not notice his fingernails on either day. Nurse #6 stated she thought an aide trimmed his nails one day last week. When questioned why an aide would trim Resident #41's fingernails, she did not recall that he was diabetic. When questioned if anyone asked her to audit fingernails on 3/5/24, she stated she was not aware of any directive to audit resident fingernails yesterday. A telephone interview was completed on 3/6/24 at 1:54 PM with Nurse #9. She stated she worked 7:00 PM to 7:00 AM on 3/5/24 with Resident #41. She stated she was not aware of any directive to audit resident fingernails. She stated Resident #41 was known to refuse assistance with his activities of daily living (ADLs) and nail care. An interview was completed on 3/7/24 at 9:50 AM with the Administrator. She stated it was her expectation that the nurses provide nail care on Resident #41's hands as indicated on observation.

Based on staff interviews, Medical Director interview, and record review, the facility failed to prevent a significant medication error for 1 of 2 residents reviewed for medication administration when Depakote (valproic acid) Delayed Release (DR) 125 milligrams (mg), (manages bipolar disorder) was not administered per orders for Resident #26. The findings included: Resident #26 was admitted to the facility on [DATE]. Her relevant diagnosis included bipolar disorder, anxiety, and depression. The most recent Minimum Data Set (MDS) coded as an admission assessment on 02/07/24 revealed Resident #26 was cognitively intact. No behaviors coded and no rejection of care were coded. Record review of active medications revealed an order dated 01/03/24 that read Depakote (valproic acid) Oral Tablet DR 125 mg, give 1 tablet by mouth two times a day related to bipolar disorder. The Medication Administration Record (MAR) for February 2024 revealed Depakote (valproic acid) 125mg DR by mouth twice a day was administered. The MAR for March 2024 revealed Depakote (valproic acid) 125mg DR by mouth twice a day was administered from 03/01/24 through 03/04/24. An observation and interview were made on 03/05/24 at 8:39 AM with Nurse #1 during the medication pass. As she prepared medications for Resident #26 an observation was made of one bubble pack card of Depakote (valproic acid) 250 mg DR. tablets. These were the only Depakote (valproic acid) tablets observed on the medication cart for Resident #26. She stated she administered Depakote (valproic acid) 125 mg sprinkles capsule on 03/04/24, however there were no Depakote (valproic acid) 125 mg sprinkle capsules available on the medication cart. Further inspection of the Depakote (valproic acid) 250 mg tablet cards revealed 4 out of 30 tablets were missing. Nurse #1 retrieved the correct dose of 125 mg of Depakote (valproic acid) from the facility back up system and administered it. Pharmacy medication delivery summary for Resident #26 revealed Depakote (valproic acid) 250 mg tablets were received on 02/01/24 and on 03/01/24. Valproic Acid level (measures the amount of valproic acid in the blood) report for Resident #26 dated 03/06/24 revealed the resident had a level of 22.4 micrograms (mcg)/milliliter (ml), the reference range was 50.0-100.0 mcg/ml. On 03/05/24 at 9:39 AM an interview was conducted with Nurse #1. She stated she called the pharmacy to clarify the order on 03/04/24 for Depakote (valproic acid) 125 mg DR tablets and they did not have the correct order. She then stated Depakote (valproic acid) 125 mg DR tablets will arrive at the facility this evening. An interview and observation were conducted on 03/06/24 at 10:44 AM with Nurse #7, she stated she had worked at the facility full time for approximately one year. She indicated she regularly worked first shift (7:00 AM-7:00 PM) on the 400 hall, and the Depakote (valproic acid) 250 mg DR tablets was the dosage that pharmacy had been delivering for Resident #26. She further stated she administered the Depakote tablets that were in the medication cart, which was Depakote 250 mg. She verified the name of the medication compared to the Medication Administration Record (MAR) but stated she did not look at the dosage prior to pulling the medication. An observation conducted with Nurse #7 in the medication room revealed 2 medication cards located in a tote that read, return to pharmacy. Nurse #7 verified the medication cards for Resident #26 were labeled Depakote 250mg tablets and those were the cards that were in the medication cart available for use until they were removed from the medication cart on 3/4/24. An interview was conducted on 03/06/24 at 11:35 AM with the Medical Director. She stated the medications should always be administered per order and staff should compare the medication to the Medication Administration Record (MAR) for accuracy. She also stated she would be ordering a valproic acid level to ensure Resident #26 was at therapeutic level. She further stated no abnormal behaviors had been reported regarding Resident #26. An interview was conducted on 03/06/24 at 1:17 PM with the Director of Nursing (DON). She stated she was not aware the pharmacy had sent the incorrect dose of Depakote to Resident #26 until the error was brought to her attention. She stated nurses were to follow the rights of medication administration when administering any medication, which included the correct dose. A phone interview was conducted on 03/06/24 at 2:52 PM with the Pharmacy Manager. She stated she did not know why Depakote (valproic acid) 250 mg was sent to the facility on [DATE] or 03/01/24. She verified the order they had on file was Depakote (valproic acid) 125 mg twice a day since October 2023. She also stated the facility had not reported the error to them. She indicated when the facility notifies them of an error, they immediately initiate an investigation to include root cause analysis, interviews, and education. An interview was conducted on 03/06/24 at 3:41 PM with the Director of Nursing (DON). She stated that the medications should be given per order. A phone interview was conducted on 03/06/24 at 5:34 PM with Nurse #10. She verified she worked 03/03/24 and 03/04/24 from 7:00 PM-7:00 AM. She stated she was familiar with Resident #26's medication orders. She indicated she normally compares the medication card with the Medication Administration Record (MAR) but there was a possibility that she did not verify the Depakote (valproic acid) dosage amount. She verified she did not withdraw any medications from the backup system for Resident #26, she administered the Depakote tablet that was in the medication cart. An interview was conducted on 03/07/24 at 9:12 AM with the Administrator. She stated she expects nurses to administer medications following the rights of medication administration, which includes the ordered dose.

Based on observation, record review and interviews of staff, the facility failed to: 1) label, date and discard expired food items observed in the walk-in refrigerator for 1 of 1 refrigerator observed; 2) enforce hair restraint during meal preparation and food plating in the kitchen for 2 of 4 staff observed; 3) keep milk at 41 degrees Fahrenheit or below during meal service; and 4) repair the kitchen ceiling which was observed to have paint and drywall flaking and peeling above the cooking, serving, preparation and general areas of the kitchen. Findings included: 1. On [DATE] at 10:00 am the initial kitchen observation was conducted with the Dietary Manager. During observation of the walk-in refrigerator, the following was observed to be expired or not dated and opened: Turkey sandwich meat had no date, was opened, and the plastic was not covering the meat. Cooked ham was wrapped in plastic and labeled with a discard date of [DATE], which was expired. Shredded cheese was opened and not dated. Sliced cheese was not completely wrapped and not dated. There were 2 containers of chocolate pudding. One had a discard date of [DATE] and one had a discard date of [DATE] respectively. Both items were expired. On [DATE] at 10:00 am an interview was conducted with the Dietary Manager. The Dietary Manager stated the Cook was responsible for discarding expired food and labeling food items. The Cook was not available for interview during the survey. The Dietary Manager stated all opened food should be dated after opening and all food checked daily for expiration and discarded accordingly. On [DATE] at 10:20 am the Administrator was interviewed. The Administrator stated she was not aware opened and expired food was not discarded or label dated for the discard date. The cook was responsible for daily food check and labeling. 2.On [DATE] at 10:00 am an observation was completed of dietary staff. The Dietary Manager (DM) was noted to have multiple hair braids half-way down her back. She had a hair net on her scalp only and not over her braids as evidenced by free movement and a lack of netting during movement throughout the kitchen and storage initial observation. Food was being prepped at this time. On [DATE] at 12:20 pm an observation was completed of lunch food plating by the Dietary Manager. The Dietary Manager was observed from the kitchen door during dining room meal observation to have long braids that were not covered by a hair net. The braids were observed to swing freely and the scalp was covered with a hair net. On [DATE] at 12:25 pm an observation and interview was done with Dietary Aide #2. Dietary Aide #2 was observed to assist lunch plating and was present during meal prep. He had long curls approximately 12 inches down his back and not in a hair net. His hair net covered the scalp only. Dietary Aide #2 stated he was not aware a hair net was required to cover his curls. The facility in-service for protecting food during preparation documented (no date) hair restraints as part of physical contamination prevention. On [DATE] at 3:10 pm the Dietary Manager was interviewed. The Dietary Manager stated she was not aware that braided or tied hair (all hair) was required to be placed in a hair net while in the kitchen for all staff. The Dietary Manager stated she was aware Dietary Aide #2 had long curls not inside of a hair net and would follow up. On [DATE] at 10:20 am the Administrator was interviewed. The Administrator stated she was not aware that dietary staff had not covered all hair with a hair net. All hair was required to be covered. 3.On [DATE] at 12:20 pm the temperature check for the lunch meal was observed. After all hot food was checked and reheated as needed, dietary staff was requested to check a milk carton that had been sitting for 15 minutes on a metal tray with ice on top. The drinks were taken from the refrigerator at 12:05 pm and placed on the tray. The staff had not checked any of the cold drinks and were ready to plate. The Corporate Dietary Consultant was asked to check the temperature of a carton of milk, and it recorded 44.5 degrees Fahrenheit after three rechecks. The Consultant commented that the milk temperature had not met the 41 degrees criteria and the cold drinks would need to be returned to the refrigerator. On [DATE] at 10:20 am the Administrator was interviewed. The Administrator stated she was not aware milk cartons stored on ice after being taken out of the refrigerator during plating had not met the temperature criteria and would follow up with the DM. 4. On [DATE] at 12:05 pm an observation and interview was conducted with the Dietary Manager (DM) and Corporate Dietary Consultant. The kitchen ceiling was observed to be peeling in several areas of the kitchen including over the food preparation area, food plating area, steam table, and steam oven, as well as general areas. The Dietary Manager stated she had notified maintenance early last week that the kitchen ceiling needed maintenance which had not been completed to date ([DATE]). The Corporate Dietary Consultant acknowledged the peeling ceiling areas were over open food areas which was a potential for physical food contamination. On [DATE] at 12:20 pm an observation and interview was done with the Maintenance Manager. The Maintenance Manager stated he was provided information early last week that the ceiling in the kitchen needed repair but had no time to evaluate the situation. During observation of the kitchen ceiling, the Maintenance Manager stated the areas of ceiling paint that was peeling was larger and more significant than he thought. He stated that it would need to be fixed immediately because the ceiling was peeling over food preparation areas. The Maintenance Manager stated he was notified last week the kitchen needed maintenance, but the areas were large and involved several areas. He commented that this had been a problem for a while (before early last week). On [DATE] at 10:20 am the Administrator was interviewed. The Administrator stated she was not aware the kitchen ceiling needed repair and would follow up with the Maintenance Manager.

Based on observations, record review, resident and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification survey dated [DATE] for three deficiencies in the areas of safe/clean/comfortable/homelike environment (584), quality of care (690) and label/store drugs and biological's (761). The facility also failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following recertification survey dated [DATE] for one deficiency in the area of quality of life (677). The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This tag is cross referenced to: F584: Based on observations, record review, and interviews of residents and staff, the facility failed to provide a clean, home-like environment in the main dining room as evidenced by a dirty, sticky floor and a dirty window and failed to repair a leaking roof. During a recertification survey dated [DATE] the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) units (a type of heating and air conditioning system used in a single living space) in residents' rooms. F690: Based on record review, resident, Physician and staff interviews, the facility failed to act on a hospital discharge order for a nephrology follow up appointment for Resident #60. This was for 1 of 2 residents reviewed for urinary tract infections (UTIs). During a recertification survey dated [DATE] the facility failed to follow up on a laboratory results for a resident reviewed for urinary tract infections (UTIs). F761: Based on record review, observations and interviews with resident and staff, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents when the nurse left the medications at bedside for 1 of 2 residents (Resident #25). The facility also failed to date multi-use medications upon opening in 2 of 2 medication carts (400 hall and 500 hall medication carts) reviewed for medication storage. During a recertification survey dated [DATE] the facility failed to discard expired multi-dose inhaler and to date multi-dose inhalers and protein supplements. F677: Based on observation, record review and interviews of residents and staff, the facility failed to provide dependent residents with nail care for 6 of 6 residents reviewed for activities of daily living (ADL) [Resident #s 14, 20, 35, 61, 76, and 92]. During a recertification survey dated [DATE] the facility failed to trim and clean dependent residents' nails and failed to ensure a resident was free from unwanted facial hair. An interview was completed on [DATE] at 9:50 AM with the Administrator. She stated the repeat citations were likely due to staff turnover during the pandemic.

Based on record review, resident and staff interviews, the facility failed to treat a resident with dignity and respect when Nurse Aide #2 spoke to a resident (Resident #2) in a disrespectful manner. This was for 1 of 2 residents reviewed for dignity. The findings included: Resident #2 was admitted to the facility on [DATE]. An initial allegation report dated 2/21/23 documented that Resident #2 reported Nurse Aide (NA) #2 was verbally abusive to him on 2/20/23, when he needed toileting hygiene assistance. NA #2 was an agency NA who was removed from the schedule and terminated immediately on 2/21/23. A written statement from Nurse #3 (on duty 7:00 PM to 7:00 AM) dated 2/20/23 indicated that he overheard bickering from NA #2 and Resident #2 using bad language to each other. NA #2 left the building and Nurse #3 approached Resident #2 who stated NA #2 wouldn't clean his buttocks after a bowel movement. She stated to him that he could do it himself and cursed at him. NA #3 assisted Resident #2 with his toileting hygiene. A written statement from NA #2 (who was on duty 3:00 PM to 11:00) dated 2/21/23 read that on 2/20/23 Resident #2 was in the bathroom. She went to help him but couldn't get to him. I handed him the wipes, he got mad, bent over, and patted his buttocks and said to kiss his ass. NA #2 left the room and reported to the nurse what happened. Later that evening Resident #2 called me a stupid bitch and I said that is why you are going to have an itchy ass tonight. A written statement from Nurse #1 (who was the nurse on duty 7:00 AM to 7:00 PM) dated 2/21/23 read that NA #2 came to the desk talking very loudly stating Resident #2 told her to kiss his ass because she wouldn't clean his ass. She stated, since the resident could stand up, he could wipe his own ass. An Interdisciplinary Departmental Team (IDT) meeting was completed on 2/22/23 regarding Resident #2 interaction with NA #2. The investigative report dated 2/27/23 documented that the facility investigation into the incident revealed the exchange did not rise to the level of abuse but was inappropriate. Resident #2 reported that NA #2 called him names, cursed at him, and told him he could provide toileting hygiene himself when he was in the need for assistance after toileting. He was assisted with hygiene from a different staff member as he didn't want NA #2 back in his room. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact and displayed no behaviors. He required moderate assistance with toileting hygiene. An interview occurred with Resident #2 on 3/5/24 at 1:50 PM who was able to recall the incident that occurred on 2/20/23. He explained he was in the bathroom and needed assistance with toileting hygiene. The NA came in, was on her phone and told him if he could stand, he could wipe his own ass. He couldn't recall what else was said but stated the incident made him very mad and he felt she was rude and disrespectful. Resident #2 stated he didn't want her back in his room that evening, so another NA assisted him with his needs. On 3/5/24 at 2:02 PM, an interview occurred with Nurse #1 who recalled the incident on 2/20/23. She stated NA #2 came to the nurse's station, was very loud and stated, I'm not going to wipe his ass, he can do it himself. Nurse #1 stated she went to Resident #2 who stated the aide spoke to him rudely and he didn't want her back in the room. Another NA assisted Resident #2 with his needs. The incident was reported to the Administrator. The Administrator was interviewed on 3/6/24 at 10:23 AM and was able to recall the details of the incident that occurred on 2/20/23. She stated when she arrived to work on 2/21/23 she was made aware of the incident between Resident #2 and NA #2 and initiated the investigation. Resident #2 reported to her that NA #2 cursed at him and wouldn't help him with toileting hygiene. During the interviews it was reported that staff overheard Resident #2 and NA #2 cursing at each other. She was an agency employee and was removed from the schedule. The Administrator stated she would expect staff to treat residents with dignity and respect at all times. Multiple phone calls were placed to NA #2 and Nurse #3 without success.

Based on record reviews, observations, Responsible Party, Physician and staff interviews, the facility failed to provide dietary supplements as ordered (Residents #84 and #67) for 2 of 6 residents reviewed for nutrition. The findings included: 1. Resident #84 was admitted to the facility on [DATE] with diagnoses that included dementia, protein-calorie malnutrition, and adult failure to thrive. A review of Resident #84's physician orders included an order dated 4/24/23 for Magic Cup (a high calorie and protein dessert cup) twice a day with lunch and dinner. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #84 had moderately impaired cognition and required setup assistance for eating. Her weight was coded as 94 pounds. A review of Resident #84's active care plan, last reviewed 1/10/24, included a focus area for increased nutrition/hydration risk related to: received a mechanically altered diet and severe malnutrition requiring high calorie supplements. The interventions included provide diet as ordered and provide supplements per order. On 3/4/24 at 12:34 PM, an observation was made of Resident #84 while she was sitting on the side of the bed with her lunch tray. The meal ticket read that she should have a Magic Cup and soft sandwich present with meal tray. Neither one of these items were present on the lunch tray. Another observation of Resident #84 occurred on 3/5/24 at 12:35 PM, as she was sitting on the side of the bed with her lunch tray. The meal ticket read that a Magic Cup and soft sandwich should be present but neither of those items were present on the meal tray. An interview occurred with Nurse Aide (NA) #1 on 3/5/24 at 12:42 PM who set up the lunch tray for Resident #84. She stated she noticed the Magic Cup wasn't present on the tray but not the soft sandwich. NA #1 explained that those items would be placed on the meal tray from the kitchen staff and was told last week that Magic Cups were not in stock. She added she would call the kitchen to get those items for Resident #84. The Dietary Manager (DM) was interviewed on 3/5/24 at 3:01 PM. She reviewed Resident #84's meal ticket and stated there should be a Magic Cup and soft sandwich on her meal tray at lunch and dinner. She was unaware these items had been missing from the lunch tray on 3/4/24 and 3/5/24. The DM added that Magic Cups were in stock and there were no issues with having it available. The dietary aide was responsible for putting these items on the tray when the meals were being plated. Another interview occurred with the DM on 3/6/24 at 8:15 AM, who stated the Dietary Aides just forgot to put those items on the meal tray for Resident #84 on 3/4/24 and 3/5/24. She stated that each meal ticket should be reviewed at the time of plating to ensure that items are not forgotten. An interview occurred with Dietary Aide #1 on 3/6/24 at 9:27 AM. She explained that any additional items such as Magic Cups and sandwiches are placed on the meal tray based on the meal ticket and that it was an oversight not to have sent those items to Resident #84 on 3/4/24 and 3/5/24. The Physician was interviewed on 3/6/24 at 11:40 AM and stated that she would expect the facility to provide supplements on meal trays as ordered to give Resident #84 the option to consume those items. The Administrator was interviewed on 3/7/24 at 9:03 AM and stated she would expect supplements and additional items listed on the meal ticket to be present as ordered and indicated. 31227 2. Resident #67 was admitted on [DATE] with a diagnosis of a fractured left humerus. Resident #67 was care planned on 1/11/24 for increased nutrient needs related to inadequate oral intake and being underweight. Weight gains were desirable for greater than 90 pounds (lbs.). Resident #67 was prescribed a regular diet. Interventions included serving supplements as ordered. Review of Resident #67's January 2024 Physician orders included an order dated 1/11/24 for a house supplement twice daily. Her admission Minimum Data Set, dated dated dated [DATE] indicated she had moderate cognitive impairment and required set up only for meals. Review of a weight warning note dated 2/6/24 read Resident #67 had unplanned weight loss, her oral intake remained inadequate and her weight continued to decline. The note read she was on a house supplement for weight loss that was increased to three times daily with a trial of fortified pudding with her lunch daily. Review of Resident #67's March 2024 Physician orders included an order dated 2/6/24 for a regular diet with fortified pudding with her lunch daily and weekly weights. An observation was completed on 3/4/24 at 12:40 PM. Resident #67 was eating in her room without staff assistance. Observation of her meal tray appeared that she had eating approximately 25% and there was no fortified pudding on her tray. Her Responsible Party (RP) was in the room . He stated he had not noticed any weight loss for Resident #67 and stated she had always had a minimal appetite prior to her admission. He stated Resident #67's dominant hand was her right one and that the humerus fracture was to her left arm Another observation was completed on 3/5/24 at 12:55 PM. She had eaten approximately 50% of her meal with no observed fortified pudding on her tray. Observation of her tray ticket did not include the fortified pudding with her lunch. An interview was completed on 3/5/24 at 1:20 PM with Nurse #4. She stated the nurses gave Resident #67 her house supplement three times a day in the morning, afternoon and at bedtime. Nurse #4 stated most days she does not finish the house supplement and other days she would drink most of it. Nurse #4 stated Resident #67 had a poor oral appetite since admission and apparently that was not unusual for her according to her family. An interview was completed with the dietary manager (DM) on 3/5/24 at 3:00 PM. She stated the fortified pudding was not listed on her tray ticket because she had not received an order for it and was not aware that it was to be added to her lunch tray. Review of Resident #67's weights since admission revealed weight loss from 71.6 lbs. on 2/5/24 to 67.1 lbs. on 3/6/24. An interview was completed on 3/6/24 at 11:20 AM with nursing assistant (NA) #4. She stated Resident #67's assistance with meals varied. She stated the nurses gave her a house supplement and that she had not seen fortified pudding on Resident #67's lunch tray. NA #4 stated Resident #67 had never had much of an appetite since admission. An interview was completed on 3/6/24 at 11:35 AM with the Physician. She stated Resident #67 had a poor appetite with had poor oral intake since admission. She stated the facility reach out to her RP who stated that was not unusual for Resident #67. The Physician stated she expected any order for supplements were acted on and provided. An interview was completed on 3/6/24 at 12:10 PM with Nurse Consultant #1. She stated the facility identified what happened with the order for the fortified pudding. She stated the original order was entered into the electronic medical record inaccurately and that Resident #67 had never received the fortified pudding with her lunch. An interview was completed on 3/7/24 at 9:50 AM with the Administrator. She stated Resident #67 should have received the fortified pudding with her lunch tray as ordered.

Based on record review, observations and interviews with resident and staff, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents when the nurse left the medications at bedside for 1 of 2 residents (Resident #25). The facility also failed to date multi-use medications upon opening in 2 of 2 medication carts (400 hall and 500 hall medication carts) reviewed for medication storage. Findings included: 1. Resident #25 ' s was admitted to the facility on [DATE] with diagnosis that included hypertension, chronic kidney disease, anxiety, depression, restless legs syndrome, polyneuropathy, and essential tremors. Resident #25 ' s quarterly Minimum Data Set (MDS) assessment indicated her cognition was moderately impaired. No behaviors or rejection of care were coded. On [DATE] at 10:00 AM an observation was made of medications in a medication cup sitting on Resident #25 ' s bedside table. Resident #25 stated the pills had been on the table since before breakfast. Observed breakfast plate sitting on bedside table and Resident #25 stated she had completed her breakfast a while back. She stated she did not know why the pills had been left there, as she did not ask the nurse to leave them. She did not indicate she was going to take the medications. An observation and interview were conducted on [DATE] at 10:01 with AM the Director of Nursing (DON). The DON approached this surveyor in front of Resident #25 ' s doorway and asked if this surveyor needed assistance. The surveyor explained there was a cup of medications at the bedside for Resident #25. The DON verified the medications were at bedside and retrieved them. She stated Nurse #1 should have observed Resident #25 taking the medications and they should not be left at bedside. The DON gave the medications to Nurse #1 as she approached her in the hall. An interview was conducted on [DATE] at 10:02 AM with Nurse #1. She verified she was the nurse that left Resident #25 ' s morning medications on the bedside table for her to take. She stated another resident was in the hall and was attempting to stand up unassisted, so she sat the medications on the table and went to assist the other resident. She further stated she forgot to return to the room to administer the medications after she assured the other resident was safe. She administered the medications to the resident with surveyor and DON present. She further stated the medications should be secured and Resident #25 did not have an order to self-administer medications. The medications left in the medication cup at bedside included the following: extra strength acetaminophen 500 milligram (mg) 2 tablets, senna-s 8XXX,d+[DATE]mg 1 tablet, cranberry capsule 250mg, vitamin-D 1000 units 2 capsules, famotidine 20mg 1 tablet, ferrous gluconate 324mg 1 tablet, Norvasc 2.5mg 1 tablet, gabapentin 100mg 2 capsules, buspirone 5mg 1 tablet, Lisinopril 20mg 1 tablet, Zoloft 25mg 1 tablet, and Zoloft 50mg 1 tablet. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:17 PM. She stated medications should not be left at bedside unsecure unless the resident has an order for self-administration. An interview was conducted with the Administrator on [DATE] at 9:12 AM. She was unaware the medications were left unattended for an extended amount of time. She indicated medications should be locked in the medication cart or taken by the resident in the presence of the nurse and should not be left at bedside. 2. An observation was conducted on [DATE] at 11:05 AM of the 400 Hall medication cart in the presence of Nurse #1. The observation revealed no opened date on the following multi-dose medications: a. One multi-dose open foil package of Levalbuterol 1.25 milligram (mg) nebulizer inhalation solution vials. The manufacturer ' s recommendation was to discard 7 days after opening. b. Two multi-dose open foil packages of Ipratropium Bromide/Albuterol Sulfate 0.5mg/3ml inhalation vials. The manufacturer ' s recommendation was to discard 7 days after opening. Nurse #1 verified the medications were not dated and she removed them from the medication cart and discarded them. She revealed she knew the foil packages were to be dated when they were opened. She indicated nurses were to write the date on all multi-dose medications upon opening and check dates on all medications prior to administration to make sure they were not expired. She then stated she did not realize the medications were not dated. She further stated that the nurses should be checking the medication carts daily prior to administration. 3. An observation was conducted on [DATE] at 11:15 AM of the 500 Hall medication cart in the presence of the Assistant Director of Nursing (ADON). The observation revealed no opened date on two multi-dose open foil packages of Ipratropium Bromide/Albuterol Sulfate 0.5mg/3ml inhalation. The manufacturer ' s recommendation was to discard 7 days after opening. The ADON stated she reviews the medication carts every Monday to check for expired and/or undated medications. She also stated she knew the foil packages were to be dated when they were opened. An interview was conducted with Nurse #4 on [DATE] at 11:23 AM. She verified she was the nurse for the 500 hall. She stated she did not know the foil packages for nebulizer solution vials were to be dated when they were opened. She indicated she was a new nurse and had not been told she needed to date the multi-use packages. An interview was conducted with the Director of Nursing (DON) on [DATE] at 1:17 PM. She stated nurses were to date multi-dose medications upon opening and they should be checking for dates daily prior to administration.

Based on observations, staff interviews, Medical Director interview, and record review, the facility failed to secure Resident #82 in a sit to stand lift per manufacturer's instructions and failed to provide a safe transfer which resulted in a fall. This was for 1 of 8 residents reviewed for accident hazards, supervision, and devices. Resident #82 sustained a left shoulder fracture. After a pulmonary evaluation, it was determined Resident #82's acute on chronic decline was due to her underlining severe Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), complicated by lung collapse likely due to decreased mobility from recent fall and from her baseline muscle weakness from prior stroke. Noninvasive ventilation was used in attempt to bring her back to her baseline; however, Resident #82's respiratory condition was not able to improve. Resident #82 was discharged from the hospital on [DATE] and transferred to hospice due to progressive respiratory failure. Immediate jeopardy began on [DATE] when the facility failed to secure Resident #82 in a sit to stand lift per manufacturer's instructions and failed to provide a safe transfer which resulted in a fall with major injury. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower harm level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure the facility complete all staff training and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's instruction manual for the sit to stand lift revealed the lower leg straps are to be used to ensure the lower parts of the resident's legs stay close to the knee support. The straps pass around the knee supports, then around the resident's lower calves. The foot operated rear [NAME] brakes are to keep the sit to stand lift in position. The support strap should be placed around the resident's lower back. The support strap should be secured by pressing the buckles together. Resident #82 was admitted to the facility on [DATE] with multiple diagnoses that included [CONDITION(S)], disorder of bone density and structure, personal history of COVID-19, chronic respiratory failure, stroke, [CONDITION(S)], and muscle weakness. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact and required extensive assistance with two staff members for transferring. Resident #82 was coded as having no falls since prior assessment. Review of the care plan dated [DATE] revealed Resident #82 had a focus area of having a self-care deficit due to a history of a stroke with left sided muscle weakness. The goal indicated Resident #82's needs would be met daily through the next review. Interventions included assist with activities of daily living which include dressing, grooming, toileting, feeding, oral care as needed as well as resident to be transferred with a sit to stand lift with two staff member assistance. A review of Resident 82's Kardex (an electronic overview of each resident's care needs located on each hallway of the facility) indicated resident requires a lift with the assistance of 2 people. A review of an incident report dated [DATE] completed by Nurse #5 revealed Resident #82 was being transferred via a sit to stand lift by Nurse Aide (NA) #1 when she slid out of the lift and was lowered to the ground by NA #1. No injuries were observed at the time of the incident. A review of the written witness statement by NA #1 dated [DATE] revealed she used the sit to stand lift on Resident #82 to get her up for the morning. It indicated Resident #82 was properly strapped and secured when NA #1 began the transfer. However, Resident #82 slipped out of the sling while she provided personal care to Resident #82. Several attempts to interview NA #1 were unsuccessful. A telephone interview with Nurse #5 on [DATE] at 9:58 AM revealed she was an agency nurse who worked with resident on [DATE]. She stated when she entered the room to assist Resident #82 after she had fallen, she noticed Resident #82 was not strapped into the sit to stand lift properly. She stated the leg straps were not buckled and the sling was loose. She indicated per her care plan Resident #82 required 2-person assistance with the sit to stand lift. She stated NA #1 used the lift by herself to transfer Resident #82. She stated she had sent Resident #82 to the hospital due to Resident #82's oxygen saturations dropping. A review of the hospital records dated [DATE] revealed Resident #82 was admitted to the hospital on [DATE] with a diagnosis of acute on chronic respiratory failure. Resident #82 presented to the emergency room after a reported fall at the facility and noted increased shortness of breath. A chest x-ray determined Resident #82 had a left shoulder fracture, aspiration pneumonia, and pulmonary [CONDITION(S)]. Resident #82's orthopedic evaluation recommended non-operative management for the shoulder fracture. After a pulmonary evaluation, it was determined Resident #82's acute on chronic decline was due to her underlining severe [CONDITION(S)], complicated by lung collapse likely due to decreased mobility from recent fall and from her baseline muscle weakness from prior stroke. Noninvasive ventilation was used in attempt to bring her back to her baseline; however, Resident #82's respiratory condition was not able to improve. Resident #82 was discharged from the hospital and transferred to hospice on [DATE] due to progressive respiratory failure. A telephone Interview with NA #4 on [DATE] at 9:24 AM revealed she was familiar with Resident #82's care needs. She indicated Resident #82 used a sit to stand lift for transfers. She stated any resident who utilized a lift required two-person assistance. She indicated she would always have a Nurse or another NA help with the transfer. A review of the witness statement by the former Assistant Director of Nursing (ADON) dated [DATE] revealed she provided education to NA #1 on the use of a sit to stand lift after the incident. A telephone interview with the former ADON on [DATE] at 11:58 AM revealed NA #1 was educated 48 hours after the incident on how to operate the sit to stand lift and made sure NA #1 was competent to use the lift prior to her going back to work. She indicated NA #1 was also educated on following the care plan. A review of the undated witness statement by the former RN Supervisor revealed NA #1 was educated via demonstration on how to use the sit to stand after the incident. The statement indicated NA #1 failed to lock the [NAME] wheels on the lift as well as failed to utilize the lower leg straps. During the demonstration, NA #1 was educated on the use of a sit to stand lift and education was provided to her regarding the presence of two people when using the lift. Several attempts to interview the former RN Supervisor via phone were unsuccessful. An interview with the Director of Rehab on [DATE] at 2:00 PM indicated the [NAME] wheels on the sit to stand lift are to be locked when the staff member is lifting a resident from a seated position. She stated the resident should be able to bear some weight to be able to use the lift. She further indicated the sling supports the resident's upper body when they stand. She stated lift transfers evaluations are done when ordered if staff feel like a resident requires a lift for transfers. Interview with the facility Medical Director on [DATE] at 1:24 PM revealed she was familiar with Resident #82's medical history and care needs. She stated she was notified by the facility the next business day of Resident #82's fall and was told she was sent to the emergency room for shortness of breath. She stated she saw Resident #82 the day prior to her fall for left knee pain. Resident #82 did not complain of shortness of breath during that time. She indicated Resident #82 was diagnosed with COVID-19 in [DATE], and this could have exacerbated her [CONDITION(S)]; however, Resident #82 was at baseline prior to her fall and could not remember any significant respiratory decompensation. An interview with the Administrator on [DATE] at 11:10 AM revealed NA #1 was trained on how to use the sit to stand lift prior to the incident but did not follow facility policy. She indicated all staff should use the sit to stand according to manufacturer's instructions to ensure safe transfers. She further indicated NA #1 did not follow Resident #82's care plan and all staff were to always follow residents' care plans. Review of the undated Performance Improvement Plan (PIP) related to the incident revealed the resident had a fall from the sit to stand lift which resulted in a left shoulder fracture. Resident #82 was sent to the hospital and was diagnosed with acute on chronic respiratory failure and left shoulder fracture. Staff was reeducated concerning resident handling with specific focus on the use of the sit to stand lift. The PIP did not indicate how the facility would monitor staff regarding use of lifts according to manufacturer's instructions. The Administrator was notified of immediate jeopardy on [DATE], at 11:17 AM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility did not secure Resident #82 in a sit to stand lift per manufacturer's instructions and did not provide a safe transfer which resulted in a fall with injury. Resident was sent to the hospital and was found to have sustained a left shoulder fracture. During her hospitalization , the resident's condition declined and she experienced aspiration pneumonia and pulmonary [CONDITION(S)]. After a pulmonary evaluation, it was decided the resident had acute on chronic decline which was due to her underlining severe Chronic Obstruction Pulmonary Disease, complicated by lung collapse likely due to decreased mobility from her recent fall. Noninvasive ventilation was used in attempt to bring her back to her baseline. The resident's respiratory condition did not improve, and she was transferred to hospice on [DATE] and expired. Residents in the facility that are transferred via lift have the potential to be affected. On [DATE] each Electronic Medical Record was reviewed by the Director of Nursing to ensure the Kardex and care plan reflected the transfer status and the number of staff needed for each lift transfer. On [DATE] the Director of Nursing reviewed all witnessed falls that occurred after [DATE], to determine if any were a result of not using a lift or improper use of a lift. There were no other transfer incidents found during the review. Current residents, that require the use of a lift for transfer, were assessed by the Director of Nursing on [DATE] to ensure there were no injuries of unknown origin that may have been a result of not using the lift or improper use of a lift. There were no injuries of unknown origin found during the assessments. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] all Nursing Assistants and Nurses, to include agency staff, were educated by the Administrative Nursing Team or Rehab staff on proper sit to stand transfers according to the manufacturer's instructions with return demonstration, the facility specific Mechanical Lift Policy and obtaining transfer status (to include the number of staff needed for the transfer and the type of lift or transfer) from the Kardex or Care plan. The Director of Nursing will supply a list of the re-educated individuals to the facility scheduler daily to ensure no licensed individuals work until they have been re-educated and the return demonstration has been validated. All newly hired Nursing Assistants and Nurses will be educated by the Director of Nursing or designee on proper sit to stand transfers according to the manufacturer's instructions with return demonstration, the facility specific Mechanical Lift Policy and obtaining transfer status (to include the number of staff needed for the transfer and the type of lift or transfer) from the Kardex or Care plan prior to taking a resident care assignment. The Regional Director of Clinical Services notified the Director of Nursing on [DATE] on the implementation for new hires. AOC [DATE] On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by observations of a sit to stand lift transfer; multiple interviews with facility staff revealed they received training on how to use a sit to stand lift and were able to describe the facility's policy on where to look for the lift requirements a resident needs; review of the updated facility policy regarding resident handling, body mechanics, and lift transfers; and review of the education sign-off sheets regarding resident handling, proper body mechanics, and resident transfers. Immediate jeopardy was removed on [DATE].

Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours, 7 days a week for 3 of 30 days reviewed for staffing. The findings included: A review of posted daily Nurse Staffing sheet from 9/29/2022 through 10/17/2022 revealed the facility had not provided the required RN coverage (at least 8 consecutive hours per day 7 days a week) on the following dates: Thursday 9/29/2022; Thursday 10/13/2022; and Saturday 10/15/2022. On 10/20/22 at 9:26 am an interview was conducted with the Administrator. The Administrator reviewed the dates in question and confirmed there was no RN coverage on 9/29/2022, 10/13/2022, and 10/15/2022. She stated she completed the staff posting and staffing sheets since the previous DON left in mid-August. She further stated the facility used agency RNs to meet the 8-hour requirement and when they call out, she has no RN coverage. The Administrator stated the facility was in the process of orienting new staff, including RNs.

Based on record review and staff interview, the facility failed to hold the blood pressure medication for 14 days as ordered for 1 of 5 sampled residents reviewed for unnecessary medications (Resident # 51). Findings included: Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including hypertension. Resident #51 had a doctor's order dated 5/19/22 for Lisinopril (blood pressure medication) 20 milligrams (mgs) by mouth in the morning for hypertension - hold for systolic blood pressure (SBP) of less than 120. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #51's cognition was intact. Resident #51's Medication Administration Records (MARs) were reviewed. The MARs revealed that Lisinopril was administered when the SBP was less than 120. The September and October 2022 MARs revealed that Lisinopril was administered on: 9/18/22 - SBP of 118/66 9/20/22 - SBP of 117/60 9/15/22 - SBP of 115/56 10/5/22 - SBP of 108/58 10/8/22 - SBP of 119/63 10/9/22 - SBP of 110/58 10/10/22 - SBP of 110/60 10/11/22 - SBP of 108/59 10/14/22 - SBO of 109/58 10/15/22 - SBP of 110/61 10/16/22 - SBP of 118/60 10/17/22 - SBP of 107/59 10/19/22 - SBO of 113/62 10/20/22 - SBP of 108/60 Nurse #1 was interviewed on 10/20/22 at 11:16 AM. Nurse #1 was assigned to Resident #51 on 10/5/22, 10/10/22, 10/11/22, 10/14/22, 10/15/22, 10/16/22, 10/19/22 and 10/20/22. He reviewed Resident #51's doctor's orders and stated that he was not aware that there was an order to hold the Lisinopril when the SBP was less than 120. He added that the order was transcribed to the MAR, but he missed to read the parameter to hold if the SBP is less than 120 and he administered the Lisinopril by mistake. Attempted to interview Nurse #4, assigned to Resident #51 on 9/25/22, 10/9/22 and 10/17/22 but she was not available. The Administrator was interviewed, in the absence of the Director of Nursing (DON), on 10/21/22 at 9:55 AM. The Administrator stated that she expected the nurses to follow doctor's orders in holding blood pressure medications with parameters.

Based on record review, observation and resident and staff interview, the facility failed to review and revise the care plan for 3 of 16 sampled residents reviewed (Residents # 18, # 51 & #13). Findings included: 1. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including 0bstructive sleep apnea. Resident #18 had a doctor's order dated 3/3/20 for Continuous positive airway pressure (CPAP), a machine that uses mild air pressure to keep breathing airways open while you sleep and used to treat obstructive sleep apnea, on at bedtime and off in the morning. This order was discontinued on 7/13/21. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18's cognition was intact. Resident #18's care plan with the revision date of 8/1/22 was reviewed. One of the care plan problems was the resident has altered respiratory status/difficulty breathing related to sleep apnea and uses CPAP. The goal was resident will maintain normal breathing pattern as evidenced by normal respirations, skin color and respiratory rate/pattern. The approaches included to clean CPAP as ordered, and CPAP setting per order. Resident #18 was interviewed on 10/21/22 at 9:10 AM. He reported that he was using a CPAP machine in the past but that was discontinued last year. Nurse #2 was interviewed on 10/21/22 at 9:12 AM. She stated that Resident #18 was not using a CPAP machine. The MDS Nurse was interviewed on 10/21/22 at 9:38 AM. She reported that the previous MDS Nurse had reviewed the resident's care plan on 8/1/22 and she should have resolved/deleted the care plan for the use of the CPAP, but she did not. The MDS Nurse verified that the CPAP had already been discontinued and she would delete the care plan for the use of CPAP. The Administrator was interviewed, in the absence of the Director of Nursing (DON), on 10/21/22 at 9:55 AM. The Administrator stated that she expected the care plans to be reviewed and revised as needed. She reported that one MDS Nurse had resigned in August 2022, and she just hired a brand new MDS Nurse who was still in training. 2.Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure with hypoxia. Resident #51 had a doctor's order dated 6/25/22 for oxygen at 2liters (L) per minute via nasal canula and to change the canula/tubing and clean the filter weekly. This order was discontinued on 8/29/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #51's cognition was intact. Resident #51's care plan with the revision date of 9/3/22 was reviewed. One of the care plan problems was resident is on oxygen therapy for shortness of breath (SOB). The goal was resident will be free from signs and symptoms of hypoxia. The approaches included administer oxygen as ordered, assess pulse oximetry as indicated, oxygen care as ordered and provide portable oxygen for ambulatory resident. Resident #51 was observed on 10/19/22 at 12:40 PM and on 10/20/22 at 12:36 PM, he was not on oxygen. On 10/21/22 at 9:01 AM, Resident #51 reported that he was on oxygen in the past and the oxygen was discontinued since he did not need it anymore. Nurse #2, assigned to Resident #51, was interviewed on 10/21/22 at 9:15 AM. The Nurse stated that Resident #51 did not have an order for oxygen. The MDS Nurse was interviewed on 10/21/22 at 9:38 AM. She reported that the previous MDS Nurse had reviewed the resident's care plan on 9/3/22 and she should have resolved/deleted the care plan for oxygen, but she did not. The MDS Nurse verified that the oxygen had already been discontinued and she would delete the care plan for the use of oxygen. The Administrator was interviewed, in the absence of the Director of Nursing (DON), on 10/21/22 at 9:55 AM. The Administrator stated that she expected the care plans to be reviewed and revised as needed. She reported that one MDS Nurse had resigned in August 2022, and she just hired a brand new MDS Nurse who was still in training. 40197 3. Resident #13 was originally admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and history of a stroke. A nursing progress note dated 9/6/22, revealed Resident #13 had pulled out his feeding tube and the physician ordered to leave the tube out due to increased oral intake and weight gain. A review of Resident #13's active care plan, last reviewed on 10/11/22 by the Minimum Data Set (MDS) Nurse, included a problem area for required a feeding tube. An interview was conducted with Nurse #4 on 10/18/22 at 12:20 PM and confirmed Resident #13 no longer had a feeding tube and received all meals, snacks, fluids, and medications orally. The MDS nurse was interviewed on 10/20/22 at 10:20 AM and reviewed Resident #13's active care plan and medical record. She indicated the care plan should have been revised since the resident no longer had a feeding tube and felt it was an oversight.

Based on record reviews, resident and staff interviews, the facility failed to follow up on laboratory results (Resident #50) for 1 of 6 reviewed for urinary tract infections. The findings included: Resident #50 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Resident #50's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, required extensive assistance with all activities of daily living, toileting, and personal hygiene. The resident was coded as always incontinent of urine and received diuretics 7out of 7 days during the assessment period. Resident #50 was interviewed on 10/18/22 at 11:08 AM. She stated she did not feel well and thought she had a urinary tract infection (UTI). When asked if the staff had checked her for a UTI, she nodded yes. The resident stated the nurse did not know the results. The resident's son was bedside and stated he inquired about the resident's results on 10/17/2022 and Nurse #3 stated she would look for the results. The resident's medical record indicated Nurse #2 noted the resident had increased confusion and restlessness on 10/16/2022 at 3:00 PM. Nurse #2 made the Medical Director (MD) aware and received new orders for urine analysis and culture with sensitivity. Nurse #2 documented she collected the sample and sent the sample to the laboratory. 10/20/22 09:33 AM interview was conducted with Nurse #3 who was assigned to resident on 10/17/2022 and 10/18/2022. She stated she was made aware on the morning of 10/17/2022, during shift report, the resident had labs completed on 10/16/2022 and the results had not been faxed to the facility. She stated urine analysis results usually post the same day and the results are faxed to a machine in the medication room. She stated she did check the fax on 10/17/2022 and 10/18/2022 but never saw any results for Resident #50. She stated she called the hospital lab on 10/18/2022 after a family member inquired about the results. Nurse #3 stated she called the MD with positive results and made the family aware the resident had a UTI on the afternoon of 10/18/2022. Review of faxed results indicated the sample was received in the laboratory at 3:15 PM and resulted at 8:35 pm on the same day 10/16/2022. The urine analysis revealed nitrites (used to diagnose bacterial infection) and white blood cells (indicate inflammation of the urinary tract). On 10/21/2022 at 9:34 AM a phone interview was conducted with the MD. She stated expected the nurse to have followed up on the urine analysis on 10/17/2022. If the results were not faxed, she should have called the laboratory. The resident was started on antibiotics for her UTI on 10/18/2022. The MD stated the resident was doing well but anytime an elderly individual has a UTI that goes untreated, there is the risk of sepsis. An interview was conducted with the Administrator on 10/21/2022 at 9:50 AM. She stated it was her expectation nurses follow up on laboratory results in a timely manner. Urine analysis results are typically resulted the same day. She stated Nurse #3 was a contract nurse and may not have understood the procedure for following up on results.

Based on record reviews, staff and pharmacist interviews, the facility failed to acknowledge and act on the Consulting Pharmacist's recommendations for 2 of 6 residents (Resident #16, #51) reviewed for unnecessary medications. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #16's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, required extensive assistance with all activities of daily living, and received antianxiety, antidepressant, and antipsychotic medications 7 out of 7 days during the assessment period. Resident #16's medical record revealed a monthly medication review was conducted by the consulting pharmacist on 9/29/2022 and recommendations were made. Pharmacy recommendations for the 9/29/2022 review could not be found in the medical record. On 10/19/2022, the facility provided surveyors a paper copy of the monthly medication review (MMR) completed by the pharmacist on 9/29/2022. The pharmacist recommended Resident #16's Risperdal (used to treat agitation) 0.5mg be reduced to 0.25mg at night with the goal of discontinuation. The recommendation was acknowledged on 10/19/2022 (the date it was requested by surveyors) and indicated the Medical Director (MD) agreed to lowering the Risperdal to 0.25mg. On 10/21/2022 at 9:40 AM a phone interview was conducted with the MD. She stated she did not see the MMR dated 9/29/2022 until 10/19/2022. She stated she did expect to get pharmacy recommendations in a timely manner. An interview was conducted with the Administrator on 10/21/2022 at 9:52 AM. She stated the MMRs got lost in the shuffle. They were found in the DON's office. The 9/29/2022 pharmacy recommendation was not addressed until 10/19/2022. 14652 2. Resident # 51 was admitted to the facility on [DATE] with multiple diagnoses including anxiety. Resident #51 had a doctor's order dated 5/18/22 for Xanax (an antianxiety medication) 0.5 milligrams (mgs) by mouth twice a day for anxiety. Resident #51's medication regimen was reviewed by the Consultant Pharmacist on 8/23/22 and 9/28/22. On both reviews (8/23/22 and 9/28/22), the Consultant Pharmacist had recommended to the attending physician to consider decreasing the Xanax to 0.25 mgs in the morning and 0.5 mgs in the afternoon as it possibly causing or contributing to his falls on 8/20/22 and 9/17/22. Review of the Consultant Pharmacist's consultation report dated 8/23/22 and 9/28/22, the Attending Physician did not address the recommendations regarding the dose reduction of Xanax. The Administrator was interviewed, in the absence of the Director of Nursing (DON), on 10/21/22 at 9:55 AM. The Administrator stated that the DON was responsible for ensuring that the Pharmacist Consultation reports were responded/addressed by the physician. The Administrator reported that since the DON had resigned in August of 2022, the pharmacist's consultation reports were lost in the shuffle.

Based on observations, staff, Physician and Responsible Party (RP) interviews and record review , the facility failed to prevent falls as evidenced by not ensuring call bell was within reach (Resident #175) and not ensuring a resident's wheelchair was safe for use (Resident #66). The facility also failed to analyze and identify the root cause of the falls and failed to implement effective interventions to prevent further falls (Residents #175). Resident ##175 sustained a left wrist fracture and Resident #66 sustained a right ankle sprain from the falls. This was evident for 2 of 5 sampled residents reviewed for accidents. The finding included: 1. Resident #175 was admitted on [DATE] with cumulative diagnoses of [CONDITION(S)], dementia and a history of falls. Review of Resident #175's hospital Discharge Summary 7/27/21 indicated she was admitted to the hospital due to multiple falls at home due to gait instability. Review of Resident #175's cumulative fall care plan initiated on 7/27/21 included the following interventions on admission: encourage resident to call for assistance, encourage the use of nonskid footwear, encourage resident to keep the bed in the low position, implement preventative fall interventions/devices, maintain her call light in reach and educate resident on how to use the call light. Additional interventions implemented on admission included maintaining needed items within reach, therapy evaluation and educate Resident #175 and her family regarding the fall interventions/devices and safety devices. Resident #175's admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment and she exhibited no behaviors. She was coded for extensive assistance of two staff for bed mobility and transfers, frequently incontinent of bladder and always incontinent of bowel. She was also coded for falls prior to admission to the facility. Review of a Fall Risk Evaluation dated 8/3/21 indicated a fall risk score of 24 (high risk). Review of a fall incident dated 8/6/21 indicated Resident #175 was found on the floor in front of her wheelchair at 4:50 PM. One side of her wheelchair brakes were unlocked. She stated I was trying to go to bed. There were no injuries. The report read she was wearing nonskid footwear and last toileted at 2:45 PM. The new interventions was Dycem (nonskid pad) under her wheelchair cushion to prevent sliding. Review of a fall incident dated 8/20/21 indicated Resident #175 fell at 12:30 AM. The report read a noise was heard from the hall and discovered Resident #175 was laying on the floor. Swelling and bruising was noted to her left wrist and she complained of left hip pain and x-rays were ordered by the Physician. She was incontinent of stool at the time of the fall. The report indicated Resident #175's call light was in the nightstand drawer. Resident #175 stated I was trying to reach my call light but it was in the drawer. I had to get up. The report also indicated the facility implemented a fall mat on the floor at the bedside for the new intervention. Review of a nursing note written by Nurse #3 dated 8/20/21 at 6:13 AM indicated the facility were still awaiting the results of the x-rays In a telephone interview on 10/20/21 at 2:25 PM, Nurse #3 stated NA #2 notified her that Resident #175 was lying on the floor beside her bed. She stated she went into the room to assess her for injuries. She stated she was not moved until she did her assessment. She noted her left wrist was swollen but on assessment, she did not see evidence of a possible hip fracture. Nurse #3 stated Resident #175 initially complained of wrist, hip and ankle pain to her left side. She was given Tylenol at the time for pain. Nurse #3 stated during her neurological checks during the night, Resident #175 did not complain of worsening pain. She stated when she went into the room to assess her, she did not notice that Resident #175's call light was in her nightstand drawer. Nurse #3 stated no member of management asked her about the fall. Resident #175 was capable of using the call light but sometimes she forgot. Review of a nursing note Nurse #1 dated 8/20/21 at 7:03 AM, read the nurse was informed in morning report that Resident #175 fell during third shift and resident was now complaining of left hip and left wrist pain. The facility was still awaiting the x-ray results. The note read Resident #175's left leg was rotated inward and her left wrist was swollen and bruised. She sent Resident #175 to the emergency room for an evaluation. Her RP was notified at this time. An interview was conducted on 10/19/21 at 12:10 PM with Nurse #1. She stated upon coming in on 8/20/21 for first shift, Nurse #3 reported Resident #175 sustained a fall on third shift and still awaiting the results of the x-rays. Nurse #1 stated on assessment of Resident #175, her left wrist there was noted swelling and discoloration and she also complained of left hip pain. She notified the Physician and orders were given to send her to the hospital for an evaluation. An interview was conducted on 10/20/21 at 3:15 PM with NA #2 who was assigned Resident #175 on 8/20/21 second shift. NA #2 stated she placed Resident #175's call light inside her nightstand table drawer on second shift on 8/20/21. She stated she did this because Resident #175 was restless on second shift and her call light and bed control would not stay on the bed. She further stated she thought Resident #175 could reach her call light and she left her drawer partially open so she could see where her call light was. She stated when the other aide came in at 11:00 PM, she turned Resident #175 over to NA #6. She stated early on third shift, NA #6 left the facility to go pick up dinner and she was watching her residents until she returned. She stated it was during this time that NA #6 left to get her dinner. NA #6 returned in time to assist with the transfer of Resident #175 back to bed after she was evaluated by Nurse #3. NA #2 stated she was aware that she was not supposed to put a resident's call light in the nightstand drawer and stated no member of management asked her about what happened on that night. NA #2 stated prior to her fall with fractures, she was ambulatory and was known to wander about in her room and she did not always remember to use her call light. In an interview on 10/20/21 at 1:10 PM, Nursing Assistant (NA) #1 stated when Resident #175 was admitted , she recalled that the family had stressed and communicated the need for close observation because of her multiple falls at home. She stated prior to her fall, she was good about using her call light but would forget on occasion. NA #1 stated the family had stressed to the staff the need for close observation. In an interview on 10/21/21 at 10:25 AM, NA #4 stated she assisted Resident #175 and she would use her call light if it was with visible reach or put in her hand. NA #4 stated prior to the fall on 8/20/21, Resident #175 was ambulatory with the use of a walker and able to transfer unassisted. An interview was conducted on 10/21/21 at 10:45 AM with the Director of Nursing (DON) and the Nurse Consultant. The DON stated all resident falls were discussed daily in their morning meetings and the Interdisciplinary Team (IDT) met once a week to discuss the falls. The DON stated the IDT did discuss and investigate Resident #175's fall on 8/20/21 but they forgot to write a note. Review of Resident #175's nursing notes did not reveal documented evidence that the Interdisciplinary Team (IDT) reviewed and addressed the circumstance of the fall that occurred on 8/20/21. In an observation on 10/18/21 at 11:00 AM, Resident #175 was sitting up in bed. She was pleasantly confused and unable to recall the fall on 8/20/21. Her bed was in the low position with a floor mat at her bedside and her call light was wrapped around the grab bar on her bed. There was no cast observed to her left wrist. A telephone interview was conducted on 10/18/21 at 2:17 PM with Resident #175's RP. He stated she had a history of falls at home and the family decided that Resident #175 needed a higher level of care prior to admission to the facility. He stated the facility was made aware of her history of falls at home and thought more interventions would have been put in place prior to her fall on 8/20/21. The RP stated the fall on 8/20/21 resulted in a fracture of her left wrist and left hip but he was not made aware of any of the circumstances regarding the fall and only notified when she was sent to the hospital for an evaluation. An interview was conducted on 10/20/21 at 2:20 PM with the Physician. She stated she was not aware that Resident #175 fell while reaching for her call light. She stated she expected resident's call lights to always be in reach and visible. The Physician stated the fall and injuries could have possibly been prevented. Review of the facility staffing assignments indicated NA #6 was assigned Resident #175 on 8/20/21. Multiple telephone attempts were completed to reach NA #6 were unsuccessful and the voice mailbox was full. An interview was conducted on 10/21/21 at 10:45 AM with the Director of Nursing (DON) and the Nurse Consultant. The DON stated she did not discuss with NA #2 the fact that Resident #175's was located in her nightstand drawer. She further confirmed the facility had no evidence of re-education or in-servicing regarding call light accessibility. The DON stated she did speak to Nurse #3 regarding her assessment and action at the time of the fall on 8/20/21. They have the floor nurse doing post fall huddle form, incident statement by NA #2 and a communication form the MD. That was the extend of the documentation about the fall. An interview was conducted on 10/21/21 at 12:15 PM with the DON and Administrator. The Administrator stated she expected Resident #175's call light to remain in her reach and visible. She further stated the fall that occurred on 8/20/21 that resulted in her injuries should have been thoroughly investigated, staff re-educated and staff in-serviced regarding call light accessibility. 2. Resident #66 was admitted on [DATE] with cumulative diagnoses of [CONDITION(S)], [CONDITION(S)] and dementia. Resident #66's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and she exhibited no behaviors. She was coded for limited assistance of one staff member with bed mobility and transfer, incontinent of bladder and bowel and she was coded for 2 or more falls without injury. Review of a fall incident report dated 9/18/21 at 9:30 PM read Resident #66 was found on the floor in the sitting position in front of her wheelchair. She stated she was sitting in her chair and trying to lock her wheelchair brakes. She stated she moved forward and slid out of her wheelchair. The report read Resident #66 was not wearing nonskid socks, a new wheelchair cushion was recommended along with assessment of the anti-rollback brakes (devices used to ensure a wheelchair user who forgot to lock the manual hand brakes would remain safe). The report read the wheelchair cushion possibly contributed to the fall. Resident #66 had no injuries. Review of and Interdisciplinary Team (IDT) meeting progress note dated 9/22/21 at 11:48 AM read Resident #66's wheelchair cushion was reviewed and changed to reduce risk. The note read Resident #66 was out of the bed daily as desired, often moved personal items in her room and did not use her call light or request staff assistance. Review of a fall incident report dated 9/27/21 at 5:20 AM read staff heard a loud noise and went to Resident #66's room. Resident #66 was on the floor blocking the entrance. The room was accessed using her roommates bathroom door. Resident #66 stated she was standing in front of her closet and she went to sit down in her wheelchair and the wheels were not locked when she slid to the floor. Resident #66's anti-rollback brakes were assessed by therapy. An x-ray was ordered on 9/27/21 due to right ankle pain and swelling. The x-ray indicated no fractures. A nursing note dated 9/28/21 at 4:48 PM read she was sent to an orthopedic on 9/29/21 where Resident #66 was diagnosed with a right ankle sprain and an ankle brace was implemented. Review of and Interdisciplinary Team (IDT) meeting progress note dated 9/29/21 at 1:59 PM read Resident #66 had a fall on 9/27/21 and her anti-rollback wheelchair brakes were not working properly. Observation on 10/18/21 at 10:40 AM, Resident #66's door to her room was closed. Inside the room, Resident #66 was self-propelling herself in her wheelchair. She stated she was re-organizing things in her room. An observation and interview was conducted on 10/19/21 at 11:30 AM with Resident #66. She was sitting in her wheelchair coloring a picture on top of 2 plastic storage bins. Her call light was observed wrapped around the left side grab bar on her bed and not within her reach. Resident #66 stated if she needed help, she could get to her call light using her wheelchair. When asked if she could reach her call light if she fell somewhere in her room too far away from her bed and call light, she stated she would just yell for help. She recalled both falls and stated the falls were related to her wheelchair not working right but she stated the wheelchair had been repaired. In an interview on 10/20/21 at 12:10 PM, Nurse #1 stated Resident #66 insisted on keeping her door closed. She stated Resident #66 has had multiple falls, medication adjustments and being treated for a urinary tract infection ([CONDITION(S)]). Nurse #1 stated she was not aware of a problem with her wheelchair cushion but she was aware that it had been replaced. Nurse #1 stated she was not aware that the fall on 9/27/21 was related to her wheelchair brakes. She stated the maintenance department was responsible for repairs to a resident wheelchair. In an interview on 10/20/21 at 10:25 AM, the Rehabilitator Manager (RM) stated it was the responsibility of the maintenance department to ensure all wheelchairs were in good repair and functional. She stated the therapy department did not routinely assess resident equipment unless the resident was on caseload or something was noticed during a therapy screen. The RM stated she was part of the Interdisciplinary Team (IDT) that met weekly and daily for a morning meeting where all resident falls were discussed. She stated the fall related to Resident #66's wheelchair cushion was replaced after her 9/18/21 fall by the therapy department. The RM stated if therapy had discovered the issue with her brakes, a work order would have been completed and given to the Maintenance Director (MD). An interview was conducted on 10/20/21 at 11:15 AM with the MD and Maintenance Assistant (MA). The MD stated he was also over the Housekeeping Department and he had only been working at the facility for a few weeks. The MA stated when problems with wheelchairs were identified by staff or if the Housekeeping Department noted a concern during wheelchair cleaning, a work order was completed and then given to the Maintenance Department. The MA provided documented evidence of work orders for Resident #66's wheelchair cushion and anti-rollback brakes that were both dated 9/27/21. He stated he did not have a work order dated 9/18/21 regarding Resident #66's wheelchair cushion. The MD stated there was no routine assessment or maintenance conducted of the resident wheelchairs. In an interview on 10/20/21 at 1:10 PM, Nursing Assistant (NA) #1 stated if Resident #66's wheelchair cushion or anti-rollback brakes weren't working, there should have been a work order completed as soon as the wheelchair concerns were identified and not after Resident #66 sustained 2 falls related to the function of her wheelchair. In an interview on 10/20/21 at 1:25 PM, Nurse #5 stated Resident #66 exhibited poor safety awareness and insisted on keeping her door closed. She stated Resident #66 often used her call light but she was not aware that Resident #66's wheelchair cushion and her wheelchair brakes were not working properly and contributed to her recent falls. Nurse #5 stated when a staff member identified the need for a repair of resident equipment, they completed a work order and placed it in the maintenance folder and the MD comes around to the nurses station and picks them up daily. Review of the facility staff assignment sheets indicated that Resident #66's assigned NA #7 on 9/18/21 and on 9/27/21. Multiple telephone attempts were completed to reach NA #7 were unsuccessful and the voice mailbox was full. A telephone interview was conducted on 10/20/21 at 1:00 PM with Nurse #4. She was assigned Resident #66 on 9/18/21 and 9/27/21 at the time of her falls. She stated the wheelchair cushion had ties where it could be secured to a wheelchair. She stated she told the therapy department that Resident #66's wheelchair cushion was missing a securement tie on one side of her cushion. Nurse #4 stated therapy replaced her wheelchair cushion after the fall. Nurse #4 stated Resident #66's fall on 9/27/21 was related to her anti-rollback brakes not working on the wheelchair and resulted in Resident #66's fall with an ankle sprain. Nurse #4 stated she notified therapy and notified the maintenance department about repairing Resident #66's wheelchair brakes after the fall. She stated she completed a work order for both occurrences and left them in the folder for maintenance to address. Nurse #4 stated Resident #66's fall on 9/18/21 and 9/27/21 were contributed to her wheelchair because in both instance, the wheelchair contributed to the falls and could have been avoided. An interview was conducted on 10/20/21 at 2:20 PM with the Physician. She stated both falls could possibly been related to Resident #66's wheelchair and she thought that resident equipment was assessed periodically to ensure good working condition. In an interview on 10/21/ at 10:25 AM, NA #4 stated if she noted something wrong with a resident wheelchair, they would tell the nurse and complete a work order. She stated the Housekeeping Department washed the resident wheelchairs weekly and maintenance did all repairs. An interview was conducted on 10/21/21 at 10:45 AM with the Director of Nursing (DON) and the Nurse Consultant. The DON stated she was aware that Resident #66's two falls in September 2021 were related to her wheelchair and she expected that whoever noticed the problems with Resident #66's wheelchair cushion or brakes should have completed a work order when the issues were discovered. The Nurse Consultant stated the facility relied heavily on the staff but there was no expectation that the facility routinely assess resident wheelchairs. In an interview on 10/21/21 at 11:43 AM, Housekeeper #1 stated the wheelchairs were washed according to a schedule by the housekeeping department. She stated she was not aware that a work order was to be completed if something was broken on a wheelchair and not sure if she would be able to identify concerns related to a wheelchair. In an interview on 10/21/21 at 11:45 AM, the MD stated Resident #66's wheelchair was identified to be malfunctioning at the time of the fall on 9/18/21 and 9/27/21, a work order was completed, given to maintenance, repaired and then returned to Resident #66.

Based on observation, medical record review, and staff interviews, the facility failed to implement interventions identified through a fall investigation's root cause analysis for 1 of 3 residents reviewed for accidents. The intervention identified the need to evaluate a room change to improve supervision of the resident who was located at the end of the hall and had a roommate who preferred a closed door. Resident #51 sustained a subsequent fall resulting in a C1 cervical fracture (a [MEDICAL CONDITION] vertebrae of the neck). The findings included: Resident #51 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #51's plan of care, initiated on 12/7/16, indicated he was at risk for falls related to decreased mobility, weakness, impaired vision, [MEDICAL CONDITION], left [MEDICAL CONDITION], muscle weakness, unsteady, debility, short and long-term memory deficiency, and history of falls. The interventions included, in part: - Staff education for toileting prior to meals (initiated on 1/23/17) - Assist with toileting during care rounds and as needed (initiated on 6/30/17) The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51's cognition was moderately impaired. He was assessed as requiring the extensive assistance of 1 staff with bed mobility, transfers, locomotion on the unit, dressing, eating, and personal hygiene. He was dependent on 1 staff for locomotion off the unit and bathing. Resident #51 was not steady on his feet and he was only able to stabilize with staff assistance. He had impairment on one side of his upper and lower extremities and utilized a wheelchair. Resident #51 was frequently incontinent of bladder and bowel (defined as 2 or more episodes of incontinence with at least one episode of continent bladder/bowel movement). He was not on a toileting program. Resident #51 was on [MEDICAL TREATMENT]. A nursing note dated 11/12/17 completed by Nurse #1 indicated the Nursing Assistant (NA) went to answer a call light and upon entering Resident #51's rooms he was noted on the floor. Nurse #1 was called to the room by the NA and Resident #51 was noted to be on the floor seated in an upright position between the bed and wheelchair in the room. Resident #51 stated he was going to the bathroom and a smell of bowel movement was noted by Nurse #1. Resident #51 was assessed with [REDACTED]. An incident report dated 11/12/17 completed by Nurse #1 indicated Resident #51 had an unobserved fall on 11/12/17 at 10:30 AM. He sustained no injuries from the fall. The incident report indicated Resident #51 was found on the floor between the bed and wheelchair. Resident #51 reportedly stated he was going to the bathroom. Resident #51 was noted as oriented to self, confused, impaired memory, gait imbalance, and incontinent. A predisposing situational factor indicated the door to Resident #51's room stayed closed at all times per his roommate's preference and request. The physician and Responsible Party (RP) were notified. The Fall Scene Investigation Report related to Resident #51's 11/12/17 fall completed by Nurse #1 was reviewed. Resident #51 was noted to be alone and unattended at the time of the fall with his assigned NA in another resident ' s room providing care. Resident #51 was last toileted at 8:00 AM and was noted to be incontinent of bladder at that time. Nurse #1 indicated, Roommate prefers door be shut to room therefore unable to hear resident when he calls out. This investigation asked for the initial root cause analysis of the fall as identified by the staff member completing the investigation. The root cause stated, Door closed to room, unable to hear or visually see resident. Needs (evaluation) for room change. The incident report for Resident #51's 11/12/17 fall was updated on 11/14/17 with a note written by the Director of Nursing (DON) that stated, Toileting before/after meals, upon awakening, and prior to bedtime. The plan of care related to the risk for falls was updated on 11/14/17 with the intervention of toileting Resident #51 before and after meals and at bedtime. The NA Tasks (a care guide of tasks for NAs) related to Resident #51 was updated on 11/14/17 to indicate toileting upon rising, toileting at bedtime, and toileting between meals. The record indicated Resident #51's room was located at the end of the hall furthest away from his unit ' s nurse ' s station. Resident #51's room was not changed following the 11/12/17 fall. The quarterly MDS assessment dated [DATE] indicated Resident #51's cognition was severely impaired. He was assessed as requiring the extensive assistance of 1 staff with bed mobility, transfers, dressing, and personal hygiene. He was dependent on 1 staff for locomotion on/off the unit, eating, and bathing. Resident #51 was not steady on his feet and he was only able to stabilize with staff assistance. He had impairment on one side of his upper and lower extremities and utilized a wheelchair. Resident #51 was frequently incontinent of bladder and always incontinent of bowel. He was not on a toileting program. Resident #51 was on [MEDICAL TREATMENT]. A nursing note dated 1/25/18 completed by Nurse #1 indicated she was called to Resident #51's room by an NA. Resident #51 was noted lying on his left side with a large hematoma to his left forehead. Blood was noted on the floor under his head and a laceration was noted in the hematoma. Notification was made to 911 for transfer to the emergency room (ER). Resident #51 was assisted to his back by 3 nurses, pillow placed under head, and ice pack applied to hematoma. The bleeding was stopped. Resident #51 was verbal during the assessment and indicated his head hurt. Emergency Medical Services (EMS) transported Resident #51 to the hospital. The physician and RP were notified. An incident report dated 1/25/18 completed by Nurse #1 indicated Resident #51 had an unobserved fall with major injury on 1/25/18 at 3:15 PM. The incident report indicated Nurse #1 was called to Resident #51's room by NA #1. Resident #51 was noted lying on his left side with a large hematoma to left forehead. Blood was noted on the floor under his head and a laceration was noted in the hematoma. Resident #51 was unable to report what had happened. Resident #51 was noted as oriented to self, had impaired memory, and gait imbalance. A predisposing situational factor indicated Resident #51 was ambulating without assistance. The physician and RP were notified. The Fall Scene Investigation Report related to Resident #51's 1/25/18 fall completed by Nurse #1 was reviewed. Resident #51 was noted to be alone and unattended at the time of the fall with his assigned NA in the shower room providing care to another resident. Resident #51 was believed to be sitting in his wheelchair prior to the fall and got up without assistance. Nurse #1 stated NA #1 was informed by a visitor that a resident was on the floor in a room at the end of the hall. NA #1 immediately found Nurse #1 to assess Resident #51. The Emergency Department Physician Documentation dated 1/25/18 indicated Resident #51 was brought to the ER after a fall out of his wheelchair. Resident #51 hit his head, but had not lost consciousness. He was noted with a hematoma over the left side of his frontal scalp as well as a small laceration to the left forehead. A head CT (computed tomography) and CT of the C-spine (cervical spine) were obtained. There were no acute findings of the head CT, however the CT of the C-spine revealed a C1 ring fracture. The scalp wound was an abrasion and was closed with a suture. A Neurosurgery consultation conducted while Resident #51 was in the ER indicated non-operative intervention of the C1 ring fracture that included a neck collar and follow up with a Neurosurgeon. A nursing note dated 1/25/18 indicated Resident #51 returned from the hospital with a laceration to the forehead and a [DIAGNOSES REDACTED]. A C-spine collar was put in place. Resident #51 reported no pain or discomfort. A physician's orders [REDACTED].#51. The plan of care related to the risk for falls was updated on 1/25/18 with the intervention of Resident #51 being moved to a room closer to the nurse ' s station. The record indicated on 1/26/18 Resident #51's room was changed. He was moved from the room on his hall that was furthest from the nurse ' s station to the room on the same hall that was closest to the nurse's station. The incident report for Resident #51 ' s 1/25/18 fall was updated on 1/26/18 with a note written by the DON that stated, Ice pack and dressing applied to stop bleeding. EMS called for transport to ER. Returned with C1 fracture and collar in place .moved to room closer to nurse's station .had received incontinent care 30 minutes prior to the fall. A Neurosurgery consultation note dated 1/30/18 indicated this was a follow up for a C1 fracture Resident #51 sustained after a fall on 1/25/18. The treatment plan included wearing a cervical collar 24 hours per day for 12 weeks. Resident #51 was to follow up with the neurosurgeon for an assessment of healing at the conclusion of the 12 weeks. A physician's orders [REDACTED].#51 was to wear the cervical collar at all times for 12 weeks. An observation was conducted of Resident #51 on 4/9/18 at 11:56 AM. Resident #51's room was located in close proximity to the nurse ' s station and the door to his room was open. He was in his room seated in his wheelchair wearing a cervical collar. An interview was conducted with the DON on 4/11/18 at 8:35 AM. The incident report and Fall Scene Investigation Report for Resident #51's 11/12/17 fall were reviewed with the DON. Nurse #1 ' s root cause analysis of this fall that stated, Door closed to room, unable to hear or visually see resident. Needs (evaluation) for room change was reviewed with the DON. The DON reported she had reviewed this Fall Scene Investigation Report and Nurse #1 ' s root cause analysis after Resident #51's 11/12/17 fall. She revealed she had not evaluated Resident #51 for a room change after the 11/12/17 fall as recommended by Nurse #1. She stated she instead implemented the intervention of toileting Resident #51 before meals, after meals, upon awakening, and prior to bedtime. The DON was asked how these interventions differed from Resident #51's care plan interventions for toileting that had been in place prior to the 11/12/17 fall (toileting prior to meals, initiated on 1/23/17; toileting during care rounds, initiated on 6/30/17) and she indicated the timing of the toileting was now on a more specific schedule and it was added to the NA Tasks to be checked off after completion. The DON was asked why Resident #51 had not been evaluated for a room change after the 11/12/17 fall as recommended by Nurse #1. She reported she felt the cause of the fall was related to toileting as Resident #51 was incontinent when he was assessed by staff after the fall. She additionally reported it was not always simple to change rooms as there was not always another room available and/or if the resident or RP had not wanted the resident to be moved. The DON was asked if Resident #51 or his RP were asked about a room change and she indicated they were not, as she had not felt this was a contributing factor to the fall. This interview with the DON continued. The incident report and Fall Scene Investigation Report for Resident #51's 1/25/18 fall in which he sustained a cervical fracture were reviewed with the DON. The intervention of Resident #51 being moved to a room closer to the nurse's station was reviewed with DON. The DON was asked why this intervention was implemented for the 1/25/18 fall. She indicated that changing Resident #51's room increased his visibility to staff as the door to his room could remain open as well as there being increased foot traffic going past the new room because it was close to the nurse's station. An interview was conducted with Nurse #1 on 4/11/18 at 10:09 AM. Nurse #1 stated she had worked at the facility for about a year and she worked with Resident #51 frequently. The incident report and Fall Scene Investigation Report for Resident #51's 11/12/17 fall were reviewed with Nurse #1. Her analysis of the root cause of the fall that stated, Door closed to room, unable to hear or visually see resident. Needs (evaluation) for room change was reviewed with Nurse #1. Nurse #1 was asked to explain how she developed her root cause of the 11/12/17 fall for Resident #51. She stated at the time of the 11/12/17 fall, Resident #51 resided in a room at the far end of the hall (furthest from the nurse's station) with a roommate who preferred to keep the door to the room closed at all times. She explained that because the door to the room was always closed, visual checks were limited as well as the ability to hear Resident #51 if he called out verbally. Nurse #1 additionally explained that Resident #51 rarely used his call bell and if he needed assistance he would call out. She indicated in the instance of the 11/12/17 fall it was Resident #51's roommate who had pressed his call bell to alert staff that Resident #51 had fallen. She reported if the call bell had not been pressed by Resident #51's roommate it would have been difficult for staff to hear Resident #51 call out for assistance with the door to the room being shut. She also pointed out that because his room was at the end of the hall there was less foot traffic going past that room than the rooms that were closer to the nurse ' s station. Nurse #1 revealed Resident #51 ' s room was not changed following the 11/12/17 fall. She stated after she completed the Fall Scene Investigation Report it was given to the DON. She reported it was the DON who had the final call as to what interventions were implemented. The interventions of toileting Resident #51 before meals, after meals, upon awakening, and prior to bedtime that were implemented after the 11/12/17 fall were reviewed with Nurse #1. Nurse #1 was asked how these interventions differed from Resident #51 ' s care plan interventions that had already been in place for toileting (toileting prior to meals, initiated on 1/23/17; toileting during care rounds, initiated on 6/30/17). She indicated that the NAs had already been checking on Resident #51 ' s toileting needs about every 2 hours during their normal care rounds, but these interventions had been added to the NA Tasks which required the NA to document their completion following the 11/12/17 fall. This interview with Nurse #1 continued. The incident report and Fall Scene Investigation Report for Resident #51's 1/25/18 fall in which he sustained cervical fracture were reviewed with Nurse #1. She stated she had been in a meeting when NA #1 came and informed her Resident #51 had fallen. She indicated it was a visitor who had informed NA #1 that she saw Resident #51 on the floor in his room. She stated the door to the room happened to be open at the time of this 1/25/18 fall. She reported it appeared Resident #51 had attempted to get up from his wheelchair unassisted and fell head first onto the floor. An interview was conducted with NA #2 on 4/11/18 at 10:52 AM. NA #2 stated she had worked at the facility for about [AGE] years and was familiar with Resident #51. She stated he required assistance with toileting at the time of 11/12/17 fall through present. She indicated Resident #51 was checked for toileting needs about every 2 hours. An interview was conducted with Nurse Unit Manager (UM) #1 on 4/11/18 at 2:00 PM. She stated she had worked at the facility for [AGE] years and had been in her position as UM for about 3 months. Nurse UM #1 was asked who was responsible for completing incident reports and root cause analyses for falls. She stated it was the nurse that was assigned to the resident at the time of the fall as she was normally the staff member who was most familiar with the resident. An interview was conducted with NA #1 on 4/11/18 at 3:05 PM. She stated she began working at the facility in (MONTH) (YEAR) and she had been working with Resident #51 since the end of (MONTH) following his room change on 1/26/18. She reported she was working on 1/25/18 when a facility visitor had informed her she saw Resident #51 on the floor of his room. NA #1 indicated she had not been assigned to Resident #51 at the time of the fall, but she had immediately found Nurse #1 and informed her of Resident #51 being seen on the floor of his room. An interview was conducted with NA #3 on 4/11/18 at 3:15 PM. She stated she had worked at the facility for over 2 years and she had worked with Resident #51 on several occasions. She indicated when she worked with Resident #51 she checked on him about every 2 hours and offered to toilet him. NA #3 reported she recalled no change in Resident #51's toileting schedule before or after his 11/12/17 fall. A phone interview was conducted with NA #4 on 4/11/18 at 3:50 PM. She stated she had worked at the facility for 3 years and she was very familiar with Resident #51. She indicated she recalled Resident #51's 11/12/17 fall and his 1/25/18 fall. NA #4 stated there was no change in Resident #51's toileting schedule after the 11/12/17 fall. She indicated he was checked on during care rounds which were about every 2 hours. NA #4 reported at the time of both falls (11/12/17 and 1/25/18), Resident #51 resided in a room at the end of the hall (furthest from the nurse's station) with a roommate who preferred to keep the door shut. She stated because the door was always kept closed she was unable to see Resident #51 just by walking by the room. She additionally stated that because Resident #51's room was at the end of the hall there was less staff walking by the room. NA #4 revealed she believed Resident #51's room should have been changed prior to the 1/25/18 fall so he was more visible to staff. An interview was conducted with the SDC on 4/12/18 at 9:00 AM. The SDC was asked to explain the purpose of Fall Scene Investigation Reports and root cause analyses. She indicated the purpose was to evaluate the circumstances surrounding the fall, try to identify specific risks, and to develop new interventions based on the identified risks to prevent future incidences. She stated it was important to speak to the resident's nurse and/or NA to get their opinion on the cause of the fall as they were most familiar with the resident. A follow up interview was conducted with the DON on 4/12/18 at 1:47 PM. The DON was asked to explain the purpose of Fall Scene Investigation Reports and root cause analyses. She stated the purpose was to try to identify the cause of the resident's fall, analyze the risks, develop interventions based on the risks, and implement those interventions with the hope of preventing any future incidences. The DON revealed she expected the root cause analysis to be utilized in the development of new interventions.

Based on medical record review, family and staff interviews, the facility failed to complete a head to toe assessment immediately following a fall for one of three residents reviewed for falls (Resident #2). Resident #2 fell on [DATE] and was not assessed at the time of the fall. On 1/1/17, it was determined that she had a fracture of her right femur. The findings included: Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was moderately impaired in cognition. She required extensive assistance of one person for transfers. Rising from a seated position, surface to surface transfers and toilet transfers did not occur during the assessment period. No falls occurred. A nursing note dated 12/31/16 at 6:37PM stated Nurse #1 walked into the shower room to check on the nursing assistant. She found the nursing assistant #1 (NA#1) hanging onto Resident #2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling was under her. Resident #2 was sliding out of the chair. Nurse #1 and NA #1 sat Resident #2 on the floor, then assisted her to the chair the proper way. Resident #2 did not have any shoes or non-skid socks on her feet. The nursing note indicated Resident #2 did not fall. The nursing note did not indicate that a head to toe assessment was completed at the time of the fall. An occurrence report dated 12/31/16 at 6:49PM stated Nurse #1 walked into the shower room to check on NA#1 and found her hanging onto Resident #2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling under Resident #2. Resident #2 was sliding out of the chair. Nurse #1 and NA#1 sat Resident #2 on the floor then assisted her to the chair. Immediate Intervention: Placed back in the shower chair. Resident #2 had right sided weakness. Neurological checks were within normal limits. Resident #2 had no complaints of pain. The form indicated it was an assisted fall. There was no documentation that a head to toe assessment was completed at the time of the fall and prior to moving Resident #2. An incident report dated 12/31/16 at 6:49PM, completed by Nurse #1, stated Nurse #1 walked into the shower room to check on NA#1 and found NA#1 hanging onto Resident#2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling under her and she was sliding out of the chair. Nurse #1 and NA#1 assisted Resident #2 to the floor then assisted her to the chair. No injuries were observed. The incident report stated Resident #2 was alert. Predisposing environmental factors: wet floor; predisposing physiological factors: confused, incontinent. Predisposing situation factors: occurred during transfer. Witness: NA#1. There was no documentation that a head to toe assessment was completed at the time of the fall. An emergency room report dated 1/1/17 stated Resident #2 fell on [DATE] and had continuous right leg pain with external rotation. A review of the x-ray revealed a displaced (not in alignment) distal femoral [MEDICAL CONDITION] leg. Resident was transferred to (name) hospital and was hospitalized from [DATE]-1/3/17. Nurse #1's statement dated 1/4/17 stated she went into the shower room and observed Resident #2 was sliding out of the wheelchair. NA#1 was holding Resident #2 underneath her arms. There was a sling and cover in the wheelchair. They tried to pull Resident #2 back into the wheelchair but the sling and cover came out from under the resident so they eased her to the floor. Nurse #1's statement said Resident #2's left leg was out straight and her right leg was positioned outward and slightly to the side. They straightened Resident #2's legs while she was still in the floor. She showed no signs of pain at that time. At that time, they picked Resident#2 up and put her in the wheelchair, then attempted to use the sit to stand lift to transfer her to the shower chair. Resident #2 could not stand by herself so they stood her and pivoted her to the shower chair. Nurse #1 looked over her skin and rubbed her legs to see if there was any pain. The statement also indicated Nurse #1 was called by the Director of Nursing on 1/1/17 at 8:41AM and Nurse #1 said she did not notice any outward rotation at that time. She filled out an incident report but did not call the physician or notify the family of the fall. A review of the 5 day investigation working report revealed an addendum dated 1/6/17 that stated during the course of the investigation, it was found that Nurse #1 also failed to complete a thorough head to toe assessment. On 1/27/17 at 11:00AM, an interview was conducted with the Administrator and the Regional Clinical Director of Services. They stated they had in-serviced nursing staff and put a POC (plan of correction) in place. He stated the facility had put an audit system into place and some audits had been completed since the incident. The Administrator stated two of the staff members involved in the incident had been terminated--Nurse #1 and NA#2 on 1/6/17. A third staff member who had assisted Nurse #1 and NA#1 at the time of the fall had received re-education and returned to work on 1/6/17. On 1/27/17 at 3:20PM, an interview was conducted with Nurse #3 who stated she worked 7:00AM-7:00PM on 1/1/17 when Resident #2 went to the hospital. She stated she came to work around 6:30AM on 1/1/17 and Nurse #2 asked her at that time to come and assess Resident #2's leg. Nurse #2 told her that Resident #2 had sustained a fall the evening before. Nurse #2 told her she had called Resident #2's family member when she observed that the leg did not look right and had obtained an order for [REDACTED]. The family was called and Resident #2 was taken to the hospital. On 1/27/17 at 5:38PM, an interview was conducted with NA#3. She stated she routinely provided care for Resident #2 and provided care for her on 12/31/16-1/1/17 (11:00PM-7:00AM shift). She stated Resident #2 slept well all night. She checked her twice during the night and she had not been incontinent of bladder or bowel so she let her sleep. At 6:00AM, Resident #2 was wet (incontinent of urine) and she felt Resident #2's bones moved when she went to turn her. She stated she immediately went and got the nurse to come and check resident because she knew that was not normal. NA#3 stated Resident #2 usually helped her with turning but she was unable to help that morning. She said the nurse came immediately and saw that something was wrong. On 1/27/17 at 5:36PM, Nurse #1 was called with no answer and unable to leave a message. On 1/27/17 at 5:40PM, Nurse #2 was called with the phone ringing, then cut off. Unable to leave a message. The corrective action for past non-compliance dated 1/1/17 was as follows: 1. The licensed nurse and the nursing assistant were placed on suspension and then terminated on 1/6/17 after the investigation was completed. The third nursing assistant received re-education and allowed to return to work on 1/6/17. Time of completion 1/6/17. 2. Other residents who had a fall within the past month were reviewed by the Director of Nursing on 1/4/17 and no other deficient practice was identified. Residents who required the use of the mechanical lift had head to toe assessments completed by the licensed nurse. Date of completion: 1/4/17. Falls will be reviewed in the morning risk meeting by the QAPI (Quality Assurance Performance Improvement) team members to ensure falls were investigated and timely notification of physician and responsible party. 3. 100% of all nursing staff (licensed and nursing assitants) were in-serviced by the Staff Development Coordinator and Director of Nursing starting 1/4/17 and employees received all in-services prior to working their assignment. In-services included: What is a fall, procedure to follow when a fall occurs which included that a complete head to toe assessment would be completed by the nurse and to notify the nurse of a fall or any change in transfer ability of a resident. Date of completion: 1/6/17. 4. The Director of Nursing, Staff Development Coordinator or Assistant Director of Nursing will audit 2 falls weekly, if applicable x 3 weeks, then monthly to ensure total mechanical lift is used to lift a resident from the floor after a fall, head to toe assessment completed and timely notification of family and physician. Any area of identified concern will be addressed at the time and continued area of concern will be addressed by QAPI committee for further action plan. As part of the validation process on 1/26/17 and 1/27/17, the plan of correction was reviewed including the re-education of staff. Interviews with nursing staff (licensed and nursing assistants) revealed they were retrained in the areas of falls and doing head to toe assessments on residents who sustained accidents/ falls at the time of the incident. A review of the monitoring tools revealed that the facility completed the audit of falls as noted in their POC. 100% of in-servicing of nursing staff was completed on 1/4/17 including NA#3 who had assisted moving Resident #2 on 12/31/16. A review of the audits revealed audits had been conducted 1/13/17, 1/18/17, 1/20/17, 1/23/17 and 1/24/17. The final correction date was 1/6/17.

Based on observation, record review, family and staff interviews, the facility failed to transfer a resident from the wheelchair to a shower chair based on the resident's care plan requiring a mechanical lift using two people based on the resident's mobility assessment requiring a mechanical lift for one of one residents (Resident #2) resulting in the resident sustaining a fracture of her right femur. After the fall, the resident was manually transferred back into the wheelchair and then manually back into bed. Facility policy for Falls (undated) stated, in part, if the resident is not being sent to the ER (emergency room ), the resident must be gotten off the floor utilizing a total lift (no exceptions). Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 was moderately impaired in cognition. She required extensive assistance of one person for transfers. Rising from a seated position, surface to surface transfers and toilet transfers did not occur during the assessment period. No falls occurred during the assessment period. A care plan dated 12/8/16 indicated that Resident #2 was at risk for falls related to decreased mobility, weakness, dementia, hemiparesis from cerebrovascular accident (CVA), osteoporosis and right femur fracture. Interventions dated 12/8/16 included, in part, out of bed with mechanical lift x two people. Maintain bed rest for comfort. Vital signs as ordered and as needed. Contact physician with any abnormalities. A review of the Resident Mobility/ transfer Profile dated 12/27/16 revealed Resident #2 needed a total lift for transfers. A nursing note dated 12/31/16 at 6:37PM stated Nurse #1 walked into the shower room to check on the nursing assistant. She found the nursing assistant #1 (NA#1) hanging onto Resident #2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling was under her. Resident #2 was sliding out of the chair. Nurse #1 and NA #1 sat Resident #2 on the floor, then assisted her to the chair. Resident #2 did not have any shoes or non-skid socks on her feet An occurrence report dated 12/31/16 at 6:49PM stated Nurse #1 walked into the shower room to check on NA#1 and found her hanging onto Resident #2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling under Resident #2. Resident #2 was sliding out of the chair. Nurse #1 and NA#1 sat Resident #2 on the floor then assisted her to the chair. Immediate Intervention: Placed back in the shower chair. Resident #2 had right sided weakness. Neurological checks were within normal limits. Resident #2 had no complaints of pain. The form indicated it was an assisted fall. An incident report dated 12/31/16 at 6:49PM, completed by Nurse #1, stated Nurse #1 walked into the shower room to check on NA#1 and found NA#1 hanging onto Resident#2 who was sliding out of the wheelchair. The wheelchair had a fleece blanket and the total lift sling under her and she was sliding out of the chair. Nurse #1 and NA#1 assisted Resident #2 to the floor then assisted her to the chair. No injuries were observed. The incident report stated Resident #2 was alert. Predisposing environmental factors: wet floor; predisposing physiological factors: confused, incontinent. Predisposing situation factors: occurred during transfer. Witness: NA#1. An emergency room report dated 1/1/17 stated Resident #2 fell on [DATE] and had continuous right leg pain with external rotation. A review of the x-ray revealed a displaced (not in alignment) distal femoral fracture of the right leg. An x-ray report dated 1/1/17 was reviewed and indicated there was an obliquely (slanted) oriented fracture of the distal third of the femur (end down by the knee) just below the long stem intramedullary rod. Right knee arthroplasty (knee replacement). Mildly foreshortened as well. Diffuse osteopenia (bone loss). Degenerative changes in the hip and knee. Impression: Fracture of the distal third of the femur which is a spiral fracture and occurred just below the intramedullary rod. A diagram dated 1/1/17 completed by Nurse #1 showed Resident #2 was lying with right leg bent back at the knee. She was lying on her back. The diagram indicated that Resident #2 fell from her wheelchair in the bathing room. A review of the fall investigation report completed on 1/3/17 at 1:13PM stated, in part, that there was a fleece type blanket plus lift sling was in the chair which contributed to Resident #2 sliding down in the wheelchair in the shower room. She had no shoes or non-skid socks on at the time of the fall and staff assisted resident to the floor. Interviews conducted by the facility at the time of the investigation were reviewed and revealed the following: On 1/4/17, NA #1's statement stated she worked on 12/31/16 until 7:00PM. She got Resident #2 out of bed using the total lift and put her in the wheelchair. She wheeled Resident #2 to the shower room in the wheelchair without leg rests. Resident #2 started to slide out of the wheelchair (she had a fleece blanket and lift sling under her and did not have any leg rests for foot placement). Nurse #1 came into the shower room. NA#1 had her arms under Resident #2's arms. Nurse #1 said to sit Resident #2 on the floor. Nurse #1 went and got NA#2 and the three of them lifted Resident #2 off the floor and back into her wheelchair. NA#1 stated they tried to stand Resident #2 to transfer her from the wheelchair to the shower chair but that did not work. NA#1 gave Resident #2 her shower and after the shower, Resident #2 was taken back to her room with one staff member holding her legs and transferred back to bed. On 1/4/17, NA#2's statement stated she was asked by Nurse #1 to go to the shower room. When she arrived, Resident #2 was on the floor in front of her wheelchair. She stated she picked up Resident #2's legs and the other staff (Nurse #1 and NA#1) were on each side of the resident and they placed her back in the wheelchair. They attempted to use the sit to stand lift but Resident #2 began to slip so they picked her up and placed her in the shower chair. NA#2 stated, after the shower, they took Resident #2 back to her room with staff holding her feet up and transferred her back to bed. There was no documentation if the total lift was used at that time. On 1/4/17, NA#3's statement stated she worked the night shift (11:00PM-7:00AM) on 12/31/16. She stated she checked Resident #2 during the night and did not have to roll or change Resident #2 until her last rounds at 6:00AM. She said Resident #2 could not help her roll on her side like she normally did and NA#3 noticed Resident #2's leg did not look normal so she informed the charge nurse to come and check Resident #2's leg. Nurse #1's statement dated 1/4/17 stated she went into the shower room and observed Resident #2 was sliding out of the wheelchair. NA#1 was holding Resident #2 underneath her arms. There was a sling and cover in the wheelchair. They tried to pull Resident #2 back into the wheelchair but the sling and cover came out from under the resident so they eased her to the floor. Nurse #1's statement said Resident #2's left leg was out straight and her right leg was positioned outward and slightly to the side. They straightened Resident #2's legs while she was still in the floor. She showed no signs of pain at that time. At that time, they picked Resident#2 up and put her in the wheelchair, then attempted to use the sit to stand lift to transfer her to the shower chair. Resident #2 could not stand by herself so they stood her and pivoted her to the shower chair. Nurse #1 looked over her skin and rubbed her legs to see if there was any pain. The statement also indicated Nurse #1 was called by the Director of Nursing on 1/1/17 at 8:41AM and Nurse #1 said she did not notice any outward rotation at that time. On 1/4/17, Nurse #2's statement stated she worked from 7:00PM-7:00AM on 12/31/16. During shift change report, Nurse #1 stated that Resident #2 had been lowered to the floor in the shower room. Nurse #1 reported no injuries were found at that time. Nurse #2 stated she checked on Resident #2 to make sure her feet were not hanging over the bed and to make sure her mat was between her bed and wall. Nurse #2 did not look under Resident #2's covers. Resident did not show any signs of pain. Resident #2 remained in bed all night. Sometime around 6:00AM, NA#3 informed her that something was not right with Resident #2's leg. Nurse #2 went immediately down to check on Resident #2. Her right foot and leg was rotated outward. Resident #2 grimaced and moaned when Nurse #2 attempted to move her leg. On 1/4/17, NA#3's statement stated she worked the evening shift on 12/31/16. She stated she asked NA#1 if she needed help getting Resident #2 strapped into the total lift. NA#3 said Resident #2 was not in her wheelchair correctly because her right leg was dragging. Her left leg was in a straight position. She said NA#1 asked her for the sit to stand lift because someone told her to use that lift for Resident #2 and NA#3 got the sit to stand lift for her. NA#3 said she told Nurse #1 later in the shift about Resident #2's feet dragging on the floor when NA#1 took Resident #2 to the shower room. NA#3 said she repositioned Resident #2 later in the shift with no complaints by the resident. A review of the 5 day investigation working report revealed an addendum dated 1/6/17 that stated during the course of the investigation, it was found that three employees did not follow facility protocol regarding safe patient transfer. In addition to this the nurse also failed to complete a thorough head to toe assessment. On 1/27/17 at 11:00AM, an interview was conducted with the Administrator and the Regional Clinical Director of Services. They stated they had in-serviced nursing staff and put a POC (plan of correction) in place. The Administrator stated they had also identified some other issues during the investigation and had in-serviced staff on those also. He stated the facility had put an audit system into place and some audits had been completed since the incident. The Administrator stated two of the staff members involved in the incident had been terminated--Nurse #1 and NA#1 on 1/6/17. A third staff member (NA#2) who had assisted Nurse #1 and NA#1 at the time of the fall had received re-education and returned to work on 1/6/17. On 1/27/17 at 2:00PM, an observation of Resident #2 was conducted. She was lying in bed on her back with her eyes closed. Resident #2 was moving her left arm and hand with no other response noted. A family member was in the room with Resident #2 and stated she had not eaten since sometime last week and no longer responded verbally. She stated she was at the facility the night the resident fell and was there until around 6:00PM. She stated the resident was talking at that time but was not able to get out of bed independently---that she had had strokes and it had affected her right side and she could not move her right side. On 1/27/17 at 3:20PM, an interview was conducted with Nurse #3 who stated she worked 7:00AM-7:00PM on 1/1/17 when Resident #2 went to the hospital. She stated she came to work around 6:30AM on 1/1/17 and Nurse #2 asked her at that time to come and assess Resident #2's leg. Nurse #2 told her that Resident #2 had sustained a fall the evening before. Nurse #2 told her she had called Resident #2's family member when she observed that the leg did not look right and had obtained an order for [REDACTED].#3 said, when she looked at Resident #2's leg, she noticed the abnormalities and told Nurse #2 she thought the leg was broken. She said she did not attempt to turn the resident. The family was called and Resident #2 was taken to the hospital. On 1/27/17 at 5:38PM, an interview was conducted with NA#3. She stated she routinely provided care for Resident #2 and provided care for her on 12/31/16-1/1/17 (11:00PM-7:00AM shift). She stated Resident #2 slept well all night. She checked her twice during the night and she had not been incontinent of bladder or bowel so she let her sleep. At 6:00AM, Resident #2 was wet (incontinent of urine) and she felt Resident #2's bones moved when she went to turn her. She stated she immediately went and got the nurse to come and check resident because she knew that was not normal. NA#3 stated Resident #2 usually helped her with turning but she was unable to help that morning. She said the nurse came immediately and saw that something was wrong. On 1/28/17 at 11:05AM, an interview was conducted with NA#4. She stated staff know what type of lift to use and how many people are needed to use the lift by checking in the kiosk. She stated if there were any changes, nursing assistants verbally told each other during shift change report. Observations conducted throughout 1/27/17-1/28/17 revealed total lifts were available and were available for use in the shower rooms. On 1/27/17 at 4:29PM, NA#1 was called. The phone had been disconnected. On 1/27/17 at 5:36PM, Nurse #1 was called with no answer and unable to leave a message. On 1/27/17 at 5:34PM, NA#2 was called and a message was left with no return call on 1/27/17 or 1/28/17. On 1/27/17 at 5:40PM, Nurse #2 was called with the phone ringing, then cut off. Unable to leave a message. On 1/27/17 at 5:45PM, an attempt was made to call the nursing assistant (NA#3) who had also worked on the evening shift on 12/31/16. The telephone was disconnected. The corrective action for past non-compliance dated 1/1/17 was as follows: 1. The licensed nurse and the nursing assistant were placed on suspension and then terminated on 1/6/17 after the investigation was completed. The third nursing assistant received re-education and allowed to return to work on 1.6.17. Time of completion 1/6/17. 2. Other residents who had a fall within the past month were reviewed by the Director of Nursing on 1/4/17 and no other deficient practice was identified. Date of completion: 1/4/17. Falls will be reviewed in the morning risk meeting by the QAPI (Quality Assurance Performance Improvement) team members to ensure falls were investigated and timely notification of physician and responsible party. Also residents who require the use of the mechanical lift had head to toe assessments completed by the licensed nurses on 1/6/17. 3. 100% of nursing staff (licensed and nursing assistants) were in-serviced by the Staff Development Coordinator and Director of Nursing starting 1/4/17 and employees received all in-services prior to working their assignment. In-services included: timely notification of family and physician. What is a fall, procedure to follow when a fall occurs which included use of the total lift regardless of lift status to lift a resident from the floor, how direct care staff are to locate the lift status information, procedure to follow when a change is noted with a resident. , fall scene investigation, use of wheelchair pedals and proper seating surface to prevent sliding when seated in a wheelchair. Date of completion: 1/6/17. 4. The Director of Nursing, Staff Development Coordinator or Assistant Director of Nursing will audit 2 falls weekly, if applicable x 3 weeks, then monthly to ensure total mechanical lift is used to lift a resident from the floor after a fall, head to toe assessment completed and timely notification of family and physician. The Director of Nursing, Staff Development Coordinator will audit 2 residents randomly weekly x 3 weeks, then monthly x 3 months to ensure residents have appropriate seating surface to prevent sliding and proper wheelchair legs. Pedals as indicated. Also, the Director of Nursing or the Assistant Director of Nursing will randomly observe 3 residents weekly x 3 weeks, then monthly x 3 to ensure residents are being transferred as assessed. Any area of identified concern will be addressed at the time and continued area of concern will be addressed by QAPI committee for further action plan. As part of the validation process on 1/26/17 and 1/27/17, the plan of correction was reviewed including the re-education of staff and observations of transfers from wheelchairs to shower chairs. Resident #2 could not be observed for a lift transfer/ transfer to wheelchair or shower chair due to her physical condition and unresponsiveness. Observations of other residents being transferred were conducted on 1/26/17 and 1/27/17 and all were completed correctly. Interviews with licensed staff and nursing assistants revealed they were retrained in the areas of transfers, falls, where to obtain the information of what type of transfer should be used for a resident, notification of physician and family if an incident occurred, to use the proper lift for a resident when transferring them and to use leg rests when transporting a resident in the wheelchair. A review of the monitoring tools revealed that the facility completed the audit of falls as noted in their POC. 100% of in-servicing of nursing staff was completed on 1/4/17 including NA#3 who had assisted moving Resident #2 on 12/31/16. A review of the audits revealed audits had been conducted 1/13/17, 1/18/17, 1/20/17, 1/23/17 and 1/24/17. The final correction date was 1/6/17.

Based on record review and physician and staff interview, the facility failed to inform the physician of the difference in the length, the swelling and the continued and increased intensity of pain on the right leg for 1 (Resident #188) of 1 sampled resident. The findings included: Resident #188 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #188 had intact cognition, had a fall prior to admission and had received a PRN (as needed) medication for pain. The assessment also indicated that Resident #188 had pain present which made it hard for her to sleep at night, limited her day to day activities and the pain intensity was "9 " . The analog pain scale of 0-10 indicated "0" as having no pain and "10" as agonizing pain. The admission nursing assessment dated [DATE] did not indicate that Resident #188's right leg was shorter than the left leg. The assessment also indicated that the resident had [MEDICAL CONDITION] but did not indicate the location. Review of the physician's orders [REDACTED]. The PT (physical therapy) notes dated 4/8/13 were reviewed. The notes indicated that Resident #188 was evaluated and noted that the right leg was shorter than the left leg and the resident had some pain on the right hip with walking. On 5/8/13 at 1:12 PM, therapy staff #4 (PT) was interviewed. She acknowledged that she was the one who evaluated Resident #188 on admission. She indicated that the right leg was shorter about 2-3 inches than the left leg and thought it was not normal after surgery. She indicated that she did not inform nursing about it because the family indicated that the surgeon stated that it was expected after surgery. She also stated that pain was expected in the beginning of therapy and would decrease later on. The nurse's notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" 4 " . The occupational therapy (OT) notes dated 4/9/13 indicated that Resident #188 stated that she was in a lot of pain. The PT notes dated 4/9/13 indicated that the resident stated " my hip hurt pretty bad last night what we are going to do? " The notes further indicated that Resident #188 was in a lot of pain and it was reported to the nurse and a pain medication was administered prior to therapy. The MAR for 4/9/13 revealed that the resident had received [MEDICATION NAME] at 1:32 PM and at 7:52 PM. The OT notes dated 4/10/13 and 4/12/13 indicated that Resident #188 stated that her leg was very sore. The PT notes dated 4/12/13 revealed that Resident #188 was experiencing pain in the right hip with movement and gait. The MAR for 4/10/13 revealed that the resident had received [MEDICATION NAME] for pain rated at " 4 " . The PT notes dated 4/15/13 indicated that the resident was experiencing pain in the right hip with movement and gait, and the resident seemed to hold her breath due to pain. This was reported to the nurse that hip did not seem to be progressing well. The nurse who was informed by the therapist was not available for interview. The MAR for 4/15/13 indicated that the resident had received [MEDICATION NAME] at 10:44 AM and at 9:33 PM. The OT notes dated 4/16/13 revealed that Resident #188 stated " I am still hurting. " The PT notes dated 4/16/13 indicated that the resident stated that my leg is hurting especially in the knee. The notes further indicated that the pain was with movement and gait. The MAR for 4/16/13 indicated that the resident had received [MEDICATION NAME] at 8:20 AM for pain rated at " 5 " . The OT notes dated 4/17/13 revealed that Resident #188 stated " I am hurting so bad. " Resident had increased pain during movement which did not appear to be getting better. The PT notes dated 4/17/13 indicated that Resident #188 stated " I'm hurting bad. " The notes revealed that the resident continued to have much pain. The MAR for 4/17/13 indicated that the resident had received the [MEDICATION NAME] at 12:45 PM and at 9:24 PM. The OT notes dated 4/18/13 revealed that the resident required frequent breaks due to increased pain. The PT notes indicated that the resident stated " my hip is hurting but I will be alright. " The PTA continued to express concern about the resident's pain. The therapy notes revealed that Resident #188 was seen by the physician on 4/18/13. The physician was informed of the pain during therapy and he ordered to give [MEDICATION NAME] 2 tablets prior to therapy. The records did not indicate that the physician was informed of the swelling on the right leg and the leg length difference, right leg shorter than the left leg. The MAR for 4/18/13 revealed that the resident had received [MEDICATION NAME] at 9:20 AM for hip pain rated at " 5 " . The OT notes dated 4/19/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The notes further indicated that the resident had increased pain during movement which did not appear to be getting better. The PT notes revealed that the resident stated " I'm trying but it just hurts so badly. " The resident was in a lot of pain from hip to knee. On 5/8/13 at 3:05 PM, Nurse #1 was interviewed. She stated that she was aware that Resident #188 was in pain due to her surgery. The resident was on pain medication which was effective. She further stated that the physician had ordered to give [MEDICATION NAME] 2 tablets to be given prior to therapy and that seemed to be working. She was not informed that the resident was having a lot of pain during therapy with movement and gait. She indicated that if she had known, she would inform the physician about it. The PT notes dated 4/21/13 indicated that Resident #188 stated " I would like my pain pill before we start. " The nurse was notified and pain medication was administered. The notes further indicated that resident was in a lot of pain from hip to knee with gait. On 5/7/13 at 5:55 PM, Nurse #2 was interviewed. She stated that she was aware that Resident #188 was in pain and she was on pain medication which was effective. She stated that she was not informed that the resident was in much pain during therapy. She also stated that if the resident had complained of continued pain with movement and gait, she would assess the site for swelling and for any increased in pain and would inform the physician. The nurse's notes revealed that the resident's pain was rated at " 8 " on 4/21/13 at 11:12 AM. The PT notes dated 4/22/13 revealed that the resident had worked hard, still having much pain. She pointed the pain across the groin and she was unable to flex her hip and knee. The MAR for 4/22/13 revealed that the resident had received 2 tablets of [MEDICATION NAME] at 8:46 AM. The notes further indicated that the resident stated that her pain was never completely relieved. At 10:25 PM, 1 tablet of pain medication was given due to complain of pain on the right hip rated at " 8 " . There was no indication in the records that the physician was informed of the pain not completely relieved after the pain medication was administered and the increased intensity of pain the resident was experiencing with movement and gait. The PT notes dated 4/23/13 revealed that the resident was assisted on right hip mobility but she could not tolerate it. She complained of pain in groin with movement. She continued to work hard but continued to have difficulty with movement of hip flex and with extreme pain. The MAR indicated [REDACTED]. The OT notes date 4/24/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The records from 4/18/13 to 4/24/13 did not indicate that the physician was informed of the increased intensity of pain during movement and gait, that the resident could not move her leg anymore and that the pain medication did not completely relieve the pain.. On 4/24/13, Resident #188 went to the orthopedic surgeon for her follow up appointment. The progress notes from the orthopedic surgeon dated 4/24/13 was reviewed. The notes indicated that an x-ray of the hip was taken and demonstrated an oblique [MEDICAL CONDITION] femur. Resident #188 was transported to the hospital from the clinic on 4/24/13 for surgery. The hospital notes with the admission date of [DATE] indicated that Resident #188 had sustained a peri prosthetic fracture (fracture around joint replacement prosthetics/implants) of the right hip. The notes revealed that the resident had sustained the fracture while doing physical therapy. She was admitted from the office to the hospital for surgical repair of her peri prosthetic fracture. She underwent open reduction and internal fixation and implant revision of her right hip hemi arthroplasty. On 5/8/13 at 9:10 AM, therapy staff #1 (PTA) was interviewed. She acknowledged that she was assigned to work with Resident #188 during her stay at the facility. She admitted that the resident was having pain so bad during therapy. She revealed that the resident's right leg was swollen since she was admitted . She also stated that her right leg was shorter than the left leg. She indicated that she had informed the nurse about her pain and a pain medication was administered. She also stated that in 2 weeks, it was not unusual for a resident to be experiencing pain and swelling and she did not think that something was wrong because the resident did not have any incidents that happened On 5/8/13 at 9:15 AM, therapy staff #2 (OTA)was interviewed. She stated that she had worked with Resident #188 during her stay at the facility. The resident was having hard time moving her right leg due to pain. She stated that nursing was aware of the resident's pain and pain medication was administered and was effective. She also stated that pain was not unusual for a resident with a fractured leg. On 5/8/13 at 9:35 AM, therapy staff #3 (OT)was interviewed. She stated that pain was expected in about 2 weeks and the orthopedic appointment should be made with in 2 weeks after surgery. She stated that she was aware that the resident was having pain but the pain was relieved with the pain medications. On 5/8/13 at 10:35 AM, administrative staff #1 was interviewed. She stated that she was aware that the resident was having pain and the pain medication was effective. She was not aware that the pain was on going and was increasing during therapy. She also was not aware that the right leg was shorter than the left leg and was swollen. She expected that the therapy staff should communicate with nursing when the resident continuously experiencing pain during therapy and any abnormality so nursing could inform the physician. On 5/8/13 at 2:10 PM, the physician was interviewed. He stated that he had seen the resident once and that was on 4/18/13. The notes for that visit had been dictated and the dictated notes were not available for filing yet. He was informed of pain during therapy and he had ordered additional pain medication ([MEDICATION NAME] 2 tablets) to be given prior to therapy. He stated that he was not informed of the swelling on the right leg, the difference of the leg length and the continued and increased pain especially during therapy. He added that if he had known it, he would reassess the resident, get an x-ray or get an orthopedic consult.

Based on record review and physician and staff interview, the facility failed to assess the underlying cause of continued and increased intensity of pain for 1 (Resident #188) of 1 sampled resident. The findings included: Resident #188 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #188 had intact cognition, had a fall prior to admission and had received a PRN (as needed) medication for pain. The assessment also indicated that Resident #188 had pain present which made it hard for her to sleep at night, limited her day to day activities and the pain intensity was " 9 " . The analog pain scale of 0-10 indicated " 0 " as having no pain and " 10 " as agonizing pain. The CAA (care area assessment) for pain dated 4/19/13 indicated " pain triggered related to pain during assessment period, she is at risk for discomfort from pain related to hip. Resident is assessed for pain by observing for facial expression such as grimacing, flinching with treatment/touch, verbal complaint of pain, moaning, groaning, etc (etcetera). Measures to relieve pain with PRN medications and scheduled medications per doctor, orders will be adhered to. She will have pain relieved during next review. Will proceed to care plan and referral as needed. " The care plan dated 4/24/13 for pain was reviewed. The problem was " pain/comfort needs as evidenced by complaint of pain and use of pain medications. " The goal was " pain will be controlled daily with medications through next review 7/19/13 " and the approaches included " assess pain PRN, encourage to verbalize feelings and medications as ordered. " Review of the physician's orders [REDACTED]. The PT (physical therapy) notes dated 4/8/13 were reviewed. The notes indicated that Resident #188 was evaluated and noted that the right leg was shorter than the left leg and the resident had some pain in the right hip with walking. The nurse's notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"4" and at 7:53 PM and was effective. On 5/8/13 at 1:12 PM, therapy staff #4 (PT)was interviewed. She acknowledged that she was the one who evaluated Resident #188 on admission. She indicated that the right leg was shorter about 2-3 inches than the left leg and thought it was not normal after surgery. She indicated that she did not inform nursing about it because the family indicated that the surgeon stated that it was expected after surgery. She also stated that pain was expected in the beginning of therapy and would decrease later on. The occupational therapy (OT) notes dated 4/9/13 indicated that Resident #188 stated that she was in a lot of pain. The PT notes dated 4/9/13 indicated that the resident stated " my hip hurt pretty bad last night what are we going to do? " The notes further indicated that Resident #188 was in a lot of pain and it was reported to the nurse and pain medication was administered prior to therapy. The MAR indicated [REDACTED]. The OT notes dated 4/10/13 and 4/12/13 indicated that Resident #188 stated that her leg was very sore. The PT notes dated 4/12/13 revealed that Resident #188 was experiencing pain in the right hip with movement and gait. The MAR indicated 4", on 4/11/13 at 4:02 PM and on 4/12/13 at 9:34 AM and was effective The PT notes dated 4/15/13 indicated that the resident was experiencing pain in the right hip with movement and gait, the resident seemed to hold her breath due to pain. This was reported to the nurse that hip did not seem to be progressing well. The MAR indicated [REDACTED]. The nurse who was informed by the therapist was not available for interview. The OT notes dated 4/16/13 revealed that Resident #188 stated " I am still hurting. " The PT notes dated 4/16/13 indicated that the resident stated that my leg is hurting especially in the knee. The notes further indicated that the pain was with movement and gait. The MAR indicated 5" and at 9:46 PM and was effective. The OT notes dated 4/17/13 revealed that Resident #188 stated " I am hurting so bad. " Resident had increased pain during movement which did not appear to be getting better, discussed with PTA (physical therapy assistant). The PTA asked the resident as to when her follow up appointment with the surgeon would be. The notes further indicated that the plan was to make the appointment. The PT notes dated 4/17/13 indicated that Resident #188 stated " I'm hurting bad. " The notes revealed that resident continued to have much pain, discussed with PT about starting e stim (electro stimulation) for pain. The MAR indicated [REDACTED]. The OT notes dated 4/18/13 revealed that the resident required frequent breaks due to increased pain. The PT notes indicated that the resident stated " my hip is hurting but I will be alright. " The PTA continued to express concern about the resident's pain. The MAR indicated 5". The notes further indicated that the resident was seen by the physician and he was informed of the pain during therapy. The physician had ordered additional [MEDICATION NAME] 2 tablets to be given prior to therapy. The physician was not informed of the swelling on the right leg and the leg length discrepancy, the right leg shorter that the left. The OT notes dated 4/19/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The notes further indicated that the resident had increased pain during movement which did not appear to be getting better. The PT notes revealed that the resident stated " I'm trying but it just hurts so bad. " The resident was in a lot of pain from hip to knee. Attempted supine there ex (therapeutic exercises) for hip mobility but resident could not tolerate. Resident even experienced discomfort when head of bed was lowered. Resident had been limited due to pain in hip and knee and she was unable to complete due to excruciating pain she was in and that we were concerned with the amount of pain limiting her movement and gait. On 5/8/13 at 3:05 PM, Nurse #1 was interviewed. She stated that she was aware that Resident #188 was in pain due to her surgery. The resident was on pain medication which was effective. She further stated that the physician had ordered to give [MEDICATION NAME] 2 tablets to be given prior to therapy and that seemed to be working. She was not informed that the resident was having a lot of pain during therapy especially during movement and gait. She indicated that if she had known, she would inform the physician about it. The MAR indicated [REDACTED]. The PT notes dated 4/21/13 indicated that Resident #188 stated " I would like my pain pill before we start. " The nurse was notified and pain medication was administered. The notes further indicated that resident was in a lot of pain from hip to knee with gait. Supine there ex (therapeutic exercise) for the right hip was attempted but resident could not tolerate. The resident had worked hard, still having much pain when returned to room and bed. The resident had made a comment that " maybe the pain medication would start working in a little meaning that she was in a lot of pain. " On 5/7/13 at 5:55 PM, Nurse #2 was interviewed. She stated that she was aware that Resident #188 was in pain and she was on pain medication which was effective. She stated that she was not informed that the resident was in much pain during therapy especially with movement and gait. She also stated that if she should have known it, she would assess the site for swelling and for any abnormalities that could possibly cause the pain and would inform the physician. The MAR indicated 8". The PT notes dated 4/22/13 revealed that the resident had worked hard, still having much pain. She pointed the pain across the groin and she was unable to flex her hip and knee. The MAR indicated [REDACTED]. The notes further indicated that the resident stated that her pain was never completely relieved. At 10:25 PM, 1 tablet of [MEDICATION NAME] was given due to complain of pain on the right hip rated at "8". The PT notes dated 4/23/13 revealed that the resident was assisted on right hip mobility but she could not tolerate it. She complained of pain in groin with movement. She continued to work hard but continued to have difficulty with movement of hip flex on about 25/30 degrees hip flex and with extreme pain. The MAR indicated [REDACTED]. The OT notes date 4/24/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The MAR indicated 8". The records from 4/18/13 -4/24/13 did not indicate that the physician was informed of the continued and increased intensity of pain especially during movement and gait, the resident's complaint that she could not move her leg and that the pain medication was not completely relieving the resident's pain. On 4/24/13, Resident #188 went to the orthopedic surgeon for her follow up appointment. The progress notes from the orthopedic surgeon dated 4/24/13 was reviewed. The notes revealed that on examination, the resident had pain on palpation of the thigh and also had increased discomfort with internal or external rotation of the hip. Weight bearing was not attempted. An x-ray of the hip was taken and demonstrated an oblique [MEDICAL CONDITION] femur at the mid portion of the femoral component. Resident #188 was transported to the hospital from the clinic on 4/24/13 for surgery. The hospital notes with the admission date of [DATE] indicated that Resident #188 had sustained a peri prosthetic fracture (fracture around joint replacement prosthetics/implants) of the right hip after hemi arthroplasty. The notes revealed that the resident had sustained the fracture while doing physical therapy. She was admitted from the office to the hospital for surgical repair of her peri prosthetic fracture. She underwent open reduction and internal fixation and implant revision of her right hip hemi arthroplasty. On 5/8/13 at 9:10 AM, therapy staff #1 (PTA)was interviewed. She acknowledged that she was assigned to work with Resident #188 during her stay at the facility. She admitted that the resident was having pain so bad during therapy but the resident would not admit having severe pain. She indicated that she could tell that the resident was hurting by not breathing well during therapy and she would say " I can't do it anymore. " She revealed that the resident's right leg was swollen since she was admitted . She also stated that the resident had an order for [REDACTED]. She also stated that in 2 weeks, it was not unusual for a resident to be experiencing pain and swelling and she did not think that something was wrong because the resident did not have any incidents that happened. She also stated that she was working with the resident on gait training and she knew that the resident was hurting by her breathing but the resident would say that " I have to do this so I can go back home. " On 5/8/13 at 9:15 AM, therapy staff #2 (OTA)was interviewed. She stated that she had worked with Resident #188 during her stay at the facility. She was working with the resident on transfers in and out of bed and dressing. She was aware that the resident's pain was worse than what she normally described. She was having hard time moving her right leg due to pain. She indicated that the PTA (physical therapist assistant) had started questioning about her pain and the orthopedic follow up appointment with the nurse. She also stated that the PT had called the family who indicated that the surgeon wanted to see her in 2 weeks but there was no appointment made yet. On 5/8/13 at 9:35 AM, therapy staff #3 (OT)was interviewed. She stated that pain was expected in about 2 weeks and the orthopedic appointment should be made with in 2 weeks after surgery. She stated that she was aware that the resident was having pain but the pain was relieved with the pain medications. She also added that the orthopedic follow up appointment was made on 4/19/13 and the earliest date the office had available was 4/24/13. On 5/8/13 at 10:35 AM, administrative staff #1 was interviewed. She stated that she was aware that the resident was having pain and the pain medication was effective. She was not aware that the pain was on going and was increasing during therapy. She expected that the therapy staff should inform nursing when the resident continuously experiencing pain during therapy. She also expected nursing to assess the resident for the underlying cause of pain and to inform the physician. On 5/8/13 at 1:12 PM, therapy staff # 4 (PT)was interviewed. She indicated that she had asked for a meeting with the family due to resident had plateau (long period of stability/progress ceases) due to a lot of pain, whether to push her or not. Review of the therapy staff #3 notes revealed that the meeting with the family occurred on 4/18/13. The notes indicated that the family was informed that the resident had decreased in mobility related to pain. The notes further indicated that the PTA had expressed concern over increased in right LE (lower extremity) pain and decreased tolerance for mobility with the use of the rolling walker. The family stated that she was aware of the increased in pain and was unsure of whether to push the resident or to let the resident listened to her body. The therapist discussed waiting for orthopedic appointment before pushing resident to participate at increased level. The notes indicated that the physician had ordered additional pain medication to possibly improve tolerance for treatment on 4/18/13. The notes further revealed that the orthopedic appointment was made for 4/24/13. On 5/8/13 at 2:10 PM, the physician was interviewed. He stated that he had seen the resident on 4/18/13. He was informed of pain during therapy and he had ordered additional pain medication to be given prior to therapy. He was not informed of the swelling on the right leg, the difference of the leg length and the continued and increased pain especially during therapy. He added that if he had known it, he would reassess the resident, get an x-ray or get an orthopedic consult.

Based on record review and staff interview, the facility failed to notify the responsible party (RP) of the change in the treatment and condition of the pressure ulcer for 1 (Resident #22) of 3 sampled residents with pressure ulcer. The findings included: Resident #22 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #22 had memory and decision making problems and had a stage II pressure ulcer. Review of the wound assessment form revealed that on 1/21/13, Resident #22 had developed a stage II pressure ulcer on the left heel. The ulcer was treated with [MEDICATION NAME] ([MEDICATION NAME] wound dressing) and kerlix. On 1/30/13, the wound assessment form indicated that the ulcer on the left heel had a white/grey non viable tissue and/or non adherent yellow slough, less than 25 % of wound bed covered. A new form of treatment was ordered to clean with seaclens and to apply hydrogel, cover with gauze and wrap with kerlix. Review of the nurse's notes and progress notes of the unit manager/supervisor revealed that the RP was not informed of the change in condition and the new treatment to the pressure ulcer on the left heel. The wound assessment form dated 2/20/13 revealed that the pressure ulcer on the left heel had a hard and black eschar, more than 50% and less than 75% of wound covered. A new form of treatment was ordered to apply [MEDICATION NAME] (non prescription topical wound spray) twice a day. Review of the nurse's notes and progress notes of unit manager/supervisor revealed that the RP was not informed of the change in condition and the new treatment to the pressure ulcer on the left heel. On 3/11/13, Resident #22 was seen by the wound doctor. The pressure ulcer on the left heel was assessed as unstageable due to necrosis (100%). A new form of treatment was ordered on [DATE] to apply silver hydrogel and calcium alginate once daily to the left heel. Review of the nurse's notes and progress notes of unit manager/supervisor revealed that the RP was not notified of the change in condition and the new treatment to the pressure ulcer on the left heel. On 3/18/13, there was a new order to apply Santyl and Dakins solution to the pressure ulcer on the left heel. The notes did not indicate that the RP was informed of the new treatment to the left heel. On 4/3/13 at 2:55 PM, Nurse #6 was interviewed. She stated that the RP should be notified when there was a new form of treatment. After reviewing the records, she stated that she did not see that the RP was informed of the change in condition and the new form of treatment to the left heel pressure ulcer. She acknowledged that she was the nurse who assessed the pressure ulcer on 1/30/13 but did not notify the RP. On 4/3/13 at 4:50 PM, Administrative staff #2 was interviewed. She agreed that Resident #22 was seen by the wound doctor on 3/11/13, 3/18/13 and 3/25/13 and was aware that the wound doctor had made changes to the treatment but she did not call the RP. She stated that the nurse should notify the RP when there was a change in condition of the pressure ulcer and when there was a change in treatment.

Based on record review and physician and staff interview, the facility failed to inform the physician of the difference in the length, the swelling and the continued and increased intensity of pain on the right leg for 1 (Resident #188) of 1 sampled resident. The findings included: Resident #188 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #188 had intact cognition, had a fall prior to admission and had received a PRN (as needed) medication for pain. The assessment also indicated that Resident #188 had pain present which made it hard for her to sleep at night, limited her day to day activities and the pain intensity was "9 " . The analog pain scale of 0-10 indicated "0" as having no pain and "10" as agonizing pain. The admission nursing assessment dated [DATE] did not indicate that Resident #188's right leg was shorter than the left leg. The assessment also indicated that the resident had [MEDICAL CONDITION] but did not indicate the location. Review of the physician's orders [REDACTED].#188 had an order for [REDACTED]. The PT (physical therapy) notes dated 4/8/13 were reviewed. The notes indicated that Resident #188 was evaluated and noted that the right leg was shorter than the left leg and the resident had some pain on the right hip with walking. On 5/8/13 at 1:12 PM, therapy staff #4 (PT) was interviewed. She acknowledged that she was the one who evaluated Resident #188 on admission. She indicated that the right leg was shorter about 2-3 inches than the left leg and thought it was not normal after surgery. She indicated that she did not inform nursing about it because the family indicated that the surgeon stated that it was expected after surgery. She also stated that pain was expected in the beginning of therapy and would decrease later on. The nurse's notes and the Medication Administration Record [REDACTED]" 4 " . The occupational therapy (OT) notes dated 4/9/13 indicated that Resident #188 stated that she was in a lot of pain. The PT notes dated 4/9/13 indicated that the resident stated " my hip hurt pretty bad last night what we are going to do? " The notes further indicated that Resident #188 was in a lot of pain and it was reported to the nurse and a pain medication was administered prior to therapy. The MAR for 4/9/13 revealed that the resident had received [MEDICATION NAME] at 1:32 PM and at 7:52 PM. The OT notes dated 4/10/13 and 4/12/13 indicated that Resident #188 stated that her leg was very sore. The PT notes dated 4/12/13 revealed that Resident #188 was experiencing pain in the right hip with movement and gait. The MAR for 4/10/13 revealed that the resident had received [MEDICATION NAME] for pain rated at " 4 " . The PT notes dated 4/15/13 indicated that the resident was experiencing pain in the right hip with movement and gait, and the resident seemed to hold her breath due to pain. This was reported to the nurse that hip did not seem to be progressing well. The nurse who was informed by the therapist was not available for interview. The MAR for 4/15/13 indicated that the resident had received [MEDICATION NAME] at 10:44 AM and at 9:33 PM. The OT notes dated 4/16/13 revealed that Resident #188 stated " I am still hurting. " The PT notes dated 4/16/13 indicated that the resident stated that my leg is hurting especially in the knee. The notes further indicated that the pain was with movement and gait. The MAR for 4/16/13 indicated that the resident had received [MEDICATION NAME] at 8:20 AM for pain rated at " 5 " . The OT notes dated 4/17/13 revealed that Resident #188 stated " I am hurting so bad. " Resident had increased pain during movement which did not appear to be getting better. The PT notes dated 4/17/13 indicated that Resident #188 stated " I'm hurting bad. " The notes revealed that the resident continued to have much pain. The MAR for 4/17/13 indicated that the resident had received the [MEDICATION NAME] at 12:45 PM and at 9:24 PM. The OT notes dated 4/18/13 revealed that the resident required frequent breaks due to increased pain. The PT notes indicated that the resident stated " my hip is hurting but I will be alright. " The PTA continued to express concern about the resident's pain. The therapy notes revealed that Resident #188 was seen by the physician on 4/18/13. The physician was informed of the pain during therapy and he ordered to give [MEDICATION NAME] 2 tablets prior to therapy. The records did not indicate that the physician was informed of the swelling on the right leg and the leg length difference, right leg shorter than the left leg. The MAR for 4/18/13 revealed that the resident had received [MEDICATION NAME] at 9:20 AM for hip pain rated at " 5 " . The OT notes dated 4/19/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The notes further indicated that the resident had increased pain during movement which did not appear to be getting better. The PT notes revealed that the resident stated " I'm trying but it just hurts so badly. " The resident was in a lot of pain from hip to knee. On 5/8/13 at 3:05 PM, Nurse #1 was interviewed. She stated that she was aware that Resident #188 was in pain due to her surgery. The resident was on pain medication which was effective. She further stated that the physician had ordered to give [MEDICATION NAME] 2 tablets to be given prior to therapy and that seemed to be working. She was not informed that the resident was having a lot of pain during therapy with movement and gait. She indicated that if she had known, she would inform the physician about it. The PT notes dated 4/21/13 indicated that Resident #188 stated " I would like my pain pill before we start. " The nurse was notified and pain medication was administered. The notes further indicated that resident was in a lot of pain from hip to knee with gait. On 5/7/13 at 5:55 PM, Nurse #2 was interviewed. She stated that she was aware that Resident #188 was in pain and she was on pain medication which was effective. She stated that she was not informed that the resident was in much pain during therapy. She also stated that if the resident had complained of continued pain with movement and gait, she would assess the site for swelling and for any increased in pain and would inform the physician. The nurse's notes revealed that the resident's pain was rated at " 8 " on 4/21/13 at 11:12 AM. The PT notes dated 4/22/13 revealed that the resident had worked hard, still having much pain. She pointed the pain across the groin and she was unable to flex her hip and knee. The MAR for 4/22/13 revealed that the resident had received 2 tablets of [MEDICATION NAME] at 8:46 AM. The notes further indicated that the resident stated that her pain was never completely relieved. At 10:25 PM, 1 tablet of pain medication was given due to complain of pain on the right hip rated at " 8 " . There was no indication in the records that the physician was informed of the pain not completely relieved after the pain medication was administered and the increased intensity of pain the resident was experiencing with movement and gait. The PT notes dated 4/23/13 revealed that the resident was assisted on right hip mobility but she could not tolerate it. She complained of pain in groin with movement. She continued to work hard but continued to have difficulty with movement of hip flex and with extreme pain. The MAR indicated [REDACTED]. The OT notes date 4/24/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The records from 4/18/13 to 4/24/13 did not indicate that the physician was informed of the increased intensity of pain during movement and gait, that the resident could not move her leg anymore and that the pain medication did not completely relieve the pain.. On 4/24/13, Resident #188 went to the orthopedic surgeon for her follow up appointment. The progress notes from the orthopedic surgeon dated 4/24/13 was reviewed. The notes indicated that an x-ray of the hip was taken and demonstrated an oblique [MEDICAL CONDITION] femur. Resident #188 was transported to the hospital from the clinic on 4/24/13 for surgery. The hospital notes with the admission date of [DATE] indicated that Resident #188 had sustained a peri prosthetic fracture (fracture around joint replacement prosthetics/implants) of the right hip. The notes revealed that the resident had sustained the fracture while doing physical therapy. She was admitted from the office to the hospital for surgical repair of her peri prosthetic fracture. She underwent open reduction and internal fixation and implant revision of her right hip hemi arthroplasty. On 5/8/13 at 9:10 AM, therapy staff #1 (PTA) was interviewed. She acknowledged that she was assigned to work with Resident #188 during her stay at the facility. She admitted that the resident was having pain so bad during therapy. She revealed that the resident's right leg was swollen since she was admitted . She also stated that her right leg was shorter than the left leg. She indicated that she had informed the nurse about her pain and a pain medication was administered. She also stated that in 2 weeks, it was not unusual for a resident to be experiencing pain and swelling and she did not think that something was wrong because the resident did not have any incidents that happened On 5/8/13 at 9:15 AM, therapy staff #2 (OTA)was interviewed. She stated that she had worked with Resident #188 during her stay at the facility. The resident was having hard time moving her right leg due to pain. She stated that nursing was aware of the resident's pain and pain medication was administered and was effective. She also stated that pain was not unusual for a resident with a fractured leg. On 5/8/13 at 9:35 AM, therapy staff #3 (OT)was interviewed. She stated that pain was expected in about 2 weeks and the orthopedic appointment should be made with in 2 weeks after surgery. She stated that she was aware that the resident was having pain but the pain was relieved with the pain medications. On 5/8/13 at 10:35 AM, administrative staff #1 was interviewed. She stated that she was aware that the resident was having pain and the pain medication was effective. She was not aware that the pain was on going and was increasing during therapy. She also was not aware that the right leg was shorter than the left leg and was swollen. She expected that the therapy staff should communicate with nursing when the resident continuously experiencing pain during therapy and any abnormality so nursing could inform the physician. On 5/8/13 at 2:10 PM, the physician was interviewed. He stated that he had seen the resident once and that was on 4/18/13. The notes for that visit had been dictated and the dictated notes were not available for filing yet. He was informed of pain during therapy and he had ordered additional pain medication ([MEDICATION NAME] 2 tablets) to be given prior to therapy. He stated that he was not informed of the swelling on the right leg, the difference of the leg length and the continued and increased pain especially during therapy. He added that if he had known it, he would reassess the resident, get an x-ray or get an orthopedic consult.

Based on record review, observation and staff interview, the facility failed to ensure that fluid restriction was followed as ordered and failed to develop a dietary and nursing plan for managing the fluid restriction for 1 (Resident #118) of 1 sampled resident on [MEDICAL TREATMENT]. The finding included: Resident #118 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #118 had no memory and decision making problem and was on [MEDICAL TREATMENT]. On 11/30/12, there was a doctor's order for " fluid restriction 1000 ml (milliliter) daily. " The care plan dated 2/28/13 for Resident #118 was reviewed. One of the care plan problems was " [MEDICAL TREATMENT] needs " and the goal was " will have no complications related to bleeding/infection at the shunt/[MEDICAL TREATMENT] site daily through next review. " The approaches included " adhere to fluid restriction as ordered. " The care plan did not specify how much fluid dietary and nursing would provide in 24 hours. The fluid intake documentation for the last 7 days was reviewed. The fluid documentation included breakfast, lunch, supper and bedtime snacks. The daily fluid intake on 4/2/13 was 1320 ml, 4/1/13 was 1440 ml, 3/31/13 was 1200 ml, 3/30/13 was 1560 ml, 3/29/13 was 1080 ml, 3/28/13 was 1080 ml and 3/27/13 was 1200 ml. The daily fluid intake did not include the fluid given during medication pass and the fluid provided at bedside. On 4/2/13 at 9:52 AM, Resident #118 was observed. There was a styro foam cup (437 ml) full of water at bedside. On 4/3/13 at 10:35 AM, Resident #118 was observed. The lunch tray was served early because he was scheduled for [MEDICAL TREATMENT]. The dietary card indicated 1000 ml fluid restriction but did not specify how much fluid to offer for breakfast, lunch and supper. The tray contained 1 glass of tea (240 ml) and 1 can of sprite (220 ml). There was also a styro foam cup (437 ml) full of water at bedside. Unsweetened tea and diet sprite were listed on the diet card for lunch. On 4/4/13 at 8:30 AM, Resident #118 was observed during breakfast. The breakfast tray contained apple juice (118 ml) and a whole milk (237 ml). Apple juice and whole milk were listed on the diet card for breakfast. On 4/3/13 at 4:50 PM, Nurse #7 was interviewed. She stated that she did not know how much fluid each shift has to be provided to Resident #118. She stated that she would ask the director of nursing. On 4/3/13 at 4:51 PM, Administrative staff # 2 was interviewed. She stated that nobody had been monitoring the fluid intake to make sure that the resident was provided 1000 ml in 24 hours as ordered. On 4/3/13 at 4:59 PM, NA #1 (nursing assistant assigned to Resident #118) was interviewed. She stated that she provided Resident #118 with 360 ml of water on her shift at bedside in addition to the fluids that were provided by the kitchen. On 4/3/13 at 5:15 PM, Nurse #7 indicated that the kitchen should provide 360 ml of fluids for breakfast, 240 ml for lunch and supper and 160 ml for the nurses to use during the medication pass. These provided 1000 ml of fluids in 24 hours. She further stated that Resident #118 should not have water at bedside. On 4/4/13 at 3:05 PM, administrative staff #3 was interviewed. She stated that Resident #118 should received 840 ml of fluids from the kitchen, 360 ml for breakfast and 240 ml for lunch and supper. She further stated that nurses should provide 160 ml for medication pass and Resident #118 should not have water at bedside. She also indicated that she was made aware today (4/4/13) that Resident #118 was getting more than 1000 ml of fluids in 24 hours. The doctor was notified and the diet card was corrected to reflect the 360 ml for breakfast and 240 ml for lunch and supper.

Based on record review and physician and staff interview, the facility failed to assess the underlying cause of continued and increased intensity of pain for 1 (Resident #188) of 1 sampled resident. The findings included: Resident #188 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #188 had intact cognition, had a fall prior to admission and had received a PRN (as needed) medication for pain. The assessment also indicated that Resident #188 had pain present which made it hard for her to sleep at night, limited her day to day activities and the pain intensity was " 9 " . The analog pain scale of 0-10 indicated " 0 " as having no pain and " 10 " as agonizing pain. The CAA (care area assessment) for pain dated 4/19/13 indicated " pain triggered related to pain during assessment period, she is at risk for discomfort from pain related to hip. Resident is assessed for pain by observing for facial expression such as grimacing, flinching with treatment/touch, verbal complaint of pain, moaning, groaning, etc (etcetera). Measures to relieve pain with PRN medications and scheduled medications per doctor, orders will be adhered to. She will have pain relieved during next review. Will proceed to care plan and referral as needed. " The care plan dated 4/24/13 for pain was reviewed. The problem was " pain/comfort needs as evidenced by complaint of pain and use of pain medications. " The goal was " pain will be controlled daily with medications through next review 7/19/13 " and the approaches included " assess pain PRN, encourage to verbalize feelings and medications as ordered. " Review of the physician's orders [REDACTED].#188 was on [MEDICATION NAME] (pain medication) 5/325 mgs (milligram) 1 tablet every 4 hours as needed for pain. The PT (physical therapy) notes dated 4/8/13 were reviewed. The notes indicated that Resident #188 was evaluated and noted that the right leg was shorter than the left leg and the resident had some pain in the right hip with walking. The nurse's notes and the Medication Administration Record [REDACTED]"4" and at 7:53 PM and was effective. On 5/8/13 at 1:12 PM, therapy staff #4 (PT)was interviewed. She acknowledged that she was the one who evaluated Resident #188 on admission. She indicated that the right leg was shorter about 2-3 inches than the left leg and thought it was not normal after surgery. She indicated that she did not inform nursing about it because the family indicated that the surgeon stated that it was expected after surgery. She also stated that pain was expected in the beginning of therapy and would decrease later on. The occupational therapy (OT) notes dated 4/9/13 indicated that Resident #188 stated that she was in a lot of pain. The PT notes dated 4/9/13 indicated that the resident stated " my hip hurt pretty bad last night what are we going to do? " The notes further indicated that Resident #188 was in a lot of pain and it was reported to the nurse and pain medication was administered prior to therapy. The MAR indicated [REDACTED]. The OT notes dated 4/10/13 and 4/12/13 indicated that Resident #188 stated that her leg was very sore. The PT notes dated 4/12/13 revealed that Resident #188 was experiencing pain in the right hip with movement and gait. The MAR indicated [REDACTED]" 4", on 4/11/13 at 4:02 PM and on 4/12/13 at 9:34 AM and was effective The PT notes dated 4/15/13 indicated that the resident was experiencing pain in the right hip with movement and gait, the resident seemed to hold her breath due to pain. This was reported to the nurse that hip did not seem to be progressing well. The MAR indicated [REDACTED]. The nurse who was informed by the therapist was not available for interview. The OT notes dated 4/16/13 revealed that Resident #188 stated " I am still hurting. " The PT notes dated 4/16/13 indicated that the resident stated that my leg is hurting especially in the knee. The notes further indicated that the pain was with movement and gait. The MAR indicated [REDACTED]. The OT notes dated 4/17/13 revealed that Resident #188 stated " I am hurting so bad. " Resident had increased pain during movement which did not appear to be getting better, discussed with PTA (physical therapy assistant). The PTA asked the resident as to when her follow up appointment with the surgeon would be. The notes further indicated that the plan was to make the appointment. The PT notes dated 4/17/13 indicated that Resident #188 stated " I'm hurting bad. " The notes revealed that resident continued to have much pain, discussed with PT about starting e stim (electro stimulation) for pain. The MAR indicated [REDACTED]. The OT notes dated 4/18/13 revealed that the resident required frequent breaks due to increased pain. The PT notes indicated that the resident stated " my hip is hurting but I will be alright. " The PTA continued to express concern about the resident's pain. The MAR indicated [REDACTED]. The notes further indicated that the resident was seen by the physician and he was informed of the pain during therapy. The physician had ordered additional [MEDICATION NAME] 2 tablets to be given prior to therapy. The physician was not informed of the swelling on the right leg and the leg length discrepancy, the right leg shorter that the left. The OT notes dated 4/19/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The notes further indicated that the resident had increased pain during movement which did not appear to be getting better. The PT notes revealed that the resident stated " I'm trying but it just hurts so bad. " The resident was in a lot of pain from hip to knee. Attempted supine there ex (therapeutic exercises) for hip mobility but resident could not tolerate. Resident even experienced discomfort when head of bed was lowered. Resident had been limited due to pain in hip and knee and she was unable to complete due to excruciating pain she was in and that we were concerned with the amount of pain limiting her movement and gait. On 5/8/13 at 3:05 PM, Nurse #1 was interviewed. She stated that she was aware that Resident #188 was in pain due to her surgery. The resident was on pain medication which was effective. She further stated that the physician had ordered to give [MEDICATION NAME] 2 tablets to be given prior to therapy and that seemed to be working. She was not informed that the resident was having a lot of pain during therapy especially during movement and gait. She indicated that if she had known, she would inform the physician about it. The MAR indicated [REDACTED]. The PT notes dated 4/21/13 indicated that Resident #188 stated " I would like my pain pill before we start. " The nurse was notified and pain medication was administered. The notes further indicated that resident was in a lot of pain from hip to knee with gait. Supine there ex (therapeutic exercise) for the right hip was attempted but resident could not tolerate. The resident had worked hard, still having much pain when returned to room and bed. The resident had made a comment that " maybe the pain medication would start working in a little meaning that she was in a lot of pain. " On 5/7/13 at 5:55 PM, Nurse #2 was interviewed. She stated that she was aware that Resident #188 was in pain and she was on pain medication which was effective. She stated that she was not informed that the resident was in much pain during therapy especially with movement and gait. She also stated that if she should have known it, she would assess the site for swelling and for any abnormalities that could possibly cause the pain and would inform the physician. The MAR indicated [REDACTED]. The PT notes dated 4/22/13 revealed that the resident had worked hard, still having much pain. She pointed the pain across the groin and she was unable to flex her hip and knee. The MAR indicated [REDACTED]. The notes further indicated that the resident stated that her pain was never completely relieved. At 10:25 PM, 1 tablet of [MEDICATION NAME] was given due to complain of pain on the right hip rated at "8". The PT notes dated 4/23/13 revealed that the resident was assisted on right hip mobility but she could not tolerate it. She complained of pain in groin with movement. She continued to work hard but continued to have difficulty with movement of hip flex on about 25/30 degrees hip flex and with extreme pain. The MAR indicated [REDACTED]. The OT notes date 4/24/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The MAR indicated [REDACTED]". The records from 4/18/13 -4/24/13 did not indicate that the physician was informed of the continued and increased intensity of pain especially during movement and gait, the resident's complaint that she could not move her leg and that the pain medication was not completely relieving the resident's pain. On 4/24/13, Resident #188 went to the orthopedic surgeon for her follow up appointment. The progress notes from the orthopedic surgeon dated 4/24/13 was reviewed. The notes revealed that on examination, the resident had pain on palpation of the thigh and also had increased discomfort with internal or external rotation of the hip. Weight bearing was not attempted. An x-ray of the hip was taken and demonstrated an oblique [MEDICAL CONDITION] femur at the mid portion of the femoral component. Resident #188 was transported to the hospital from the clinic on 4/24/13 for surgery. The hospital notes with the admission date of [DATE] indicated that Resident #188 had sustained a peri prosthetic fracture (fracture around joint replacement prosthetics/implants) of the right hip after hemi arthroplasty. The notes revealed that the resident had sustained the fracture while doing physical therapy. She was admitted from the office to the hospital for surgical repair of her peri prosthetic fracture. She underwent open reduction and internal fixation and implant revision of her right hip hemi arthroplasty. On 5/8/13 at 9:10 AM, therapy staff #1 (PTA)was interviewed. She acknowledged that she was assigned to work with Resident #188 during her stay at the facility. She admitted that the resident was having pain so bad during therapy but the resident would not admit having severe pain. She indicated that she could tell that the resident was hurting by not breathing well during therapy and she would say " I can't do it anymore. " She revealed that the resident's right leg was swollen since she was admitted . She also stated that the resident had an order for [REDACTED]. She also stated that in 2 weeks, it was not unusual for a resident to be experiencing pain and swelling and she did not think that something was wrong because the resident did not have any incidents that happened. She also stated that she was working with the resident on gait training and she knew that the resident was hurting by her breathing but the resident would say that " I have to do this so I can go back home. " On 5/8/13 at 9:15 AM, therapy staff #2 (OTA)was interviewed. She stated that she had worked with Resident #188 during her stay at the facility. She was working with the resident on transfers in and out of bed and dressing. She was aware that the resident's pain was worse than what she normally described. She was having hard time moving her right leg due to pain. She indicated that the PTA (physical therapist assistant) had started questioning about her pain and the orthopedic follow up appointment with the nurse. She also stated that the PT had called the family who indicated that the surgeon wanted to see her in 2 weeks but there was no appointment made yet. On 5/8/13 at 9:35 AM, therapy staff #3 (OT)was interviewed. She stated that pain was expected in about 2 weeks and the orthopedic appointment should be made with in 2 weeks after surgery. She stated that she was aware that the resident was having pain but the pain was relieved with the pain medications. She also added that the orthopedic follow up appointment was made on 4/19/13 and the earliest date the office had available was 4/24/13. On 5/8/13 at 10:35 AM, administrative staff #1 was interviewed. She stated that she was aware that the resident was having pain and the pain medication was effective. She was not aware that the pain was on going and was increasing during therapy. She expected that the therapy staff should inform nursing when the resident continuously experiencing pain during therapy. She also expected nursing to assess the resident for the underlying cause of pain and to inform the physician. On 5/8/13 at 1:12 PM, therapy staff # 4 (PT)was interviewed. She indicated that she had asked for a meeting with the family due to resident had plateau (long period of stability/progress ceases) due to a lot of pain, whether to push her or not. Review of the therapy staff #3 notes revealed that the meeting with the family occurred on 4/18/13. The notes indicated that the family was informed that the resident had decreased in mobility related to pain. The notes further indicated that the PTA had expressed concern over increased in right LE (lower extremity) pain and decreased tolerance for mobility with the use of the rolling walker. The family stated that she was aware of the increased in pain and was unsure of whether to push the resident or to let the resident listened to her body. The therapist discussed waiting for orthopedic appointment before pushing resident to participate at increased level. The notes indicated that the physician had ordered additional pain medication to possibly improve tolerance for treatment on 4/18/13. The notes further revealed that the orthopedic appointment was made for 4/24/13. On 5/8/13 at 2:10 PM, the physician was interviewed. He stated that he had seen the resident on 4/18/13. He was informed of pain during therapy and he had ordered additional pain medication to be given prior to therapy. He was not informed of the swelling on the right leg, the difference of the leg length and the continued and increased pain especially during therapy. He added that if he had known it, he would reassess the resident, get an x-ray or get an orthopedic consult.

Based on resident, staff, physician and pharmacy consultant interview and record review; the facility failed to notify the physician and obtain direction when medications were not available for 3 of 3 residents sampled for availability of medications (Resident #3, #4 and #5) 1. Resident #3 was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was not due prior to her discharge and was not completed. Review of the Hospital Discharge Medication Reconciliation dated 1/17/13 at 11:38 PM revealed that while in hospital the resident had an order for [REDACTED]. a. [MEDICATION NAME] - [MEDICATION NAME] 10-500 mg (milligrams) 1 tablet every 4 hours as needed. There was no date or time noted under the column " Last Dose Taken. " The reconciliation indicated that this medication was to be discontinued at discharge. b. [MEDICATION NAME] - [MEDICATION NAME] 5 - 325 mg 2 tablets every 4 hours as needed. Under the column " Last Dose Taken " it read 1/17/13, 10:02 PM. The reconciliation indicated that this medication was to be continued after discharge from the hospital. There was also a hand written addition that changed the dosage to read 1 - 2 tablets every 4 - 6 hours as needed. The FL2 Level of Care Screening Tool dated 1/18/13 indicated Resident #3 was cognitively intact. Review of the physician's order [REDACTED]. The Admission Pain Assessment 1/18/13 revealed the resident had no pain at that time. No other information was documented. On 1/18/13 the first entry in the nursing notes at 10:43 PM revealed " Resident complained of pain to right knee surgical site. No further information regarding the pain was documented. Review of the electronic medical record and Nursing Notes for 1/18/13 revealed no admission note, no admission assessment or assessment of the Resident #3 ' s pain noted in the above Nursing Note and no documentation of pain management interventions, including pain medications. Interview with Nurse # 1 on 2/13/13 at 2:42 PM revealed that Resident #3 arrived at 2:30 PM near the end of her shift (3 PM) on 1/18/13. She indicated that she stayed to input the medication orders and to clarify the [MEDICATION NAME] - Acetominophen 5 - 325 mg 1 - 2 tablets as needed for pain medication order. Nurse #1 added that she needed to clarify the pain medication order to be for either just 1 tablet or for 2 tablets. She added that medications ordered from the pharmacy in the evening before 6 PM usually arrived on third shift around 11 PM. In interview with Nurse #2 on 2/13/13 at 5:15 PM she recalled that Resident #3 had a lot of complaints and was very concerned that her pain medications may not arrive in the facility that evening. She added that she did everything she could to reassure Resident #3 her medications would arrive. When asked if she offered the resident pain medication Nurse #2 said that she was sure she would have (there was no documentation regarding pain assessment or pain management intervention including medication on 1/18/13) but that Resident #3 wanted 2 tablets like she had in the hospital " but I told her we don ' t do that " . When asked why she did not contact the physician to discuss Resident #3 ' s pain signs/symptoms and request for 2 tablets, Nurse #2 said that this was the responsibility of the first shift nurse. Interview with the pharmacy consultant on 2/14/13 at 9:30 AM revealed that if medications were not ordered from pharmacy by 5 PM they would not be delivered that night and so would arrive the following day around 11 PM. He said that according to pharmacy records the pharmacy received the order for Resident #3 ' s medications on 1/18/13 at 4:03 PM and her medications including the [MEDICATION NAME] - [MEDICATION NAME] 5 - 325 mg were delivered to the facility at 11:15 PM. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that if Resident #3 was asking for 2 tablets of pain medication instead of 1, the physician should have been notified. She added that the pain assessment should have been communicated with the physician so appropriate interventions could be determined. The DON indicated that she expected pain medication to be given, when needed, and that not giving it because the resident ' s medications had not arrived from pharmacy was not acceptable as there were back-up sources and options. During telephone interview with Resident #3 on 2/14/13 at 2:45 PM she said that she repeatedly asked for pain medication on 1/18/13 and that she thought the facility should have been more prepared and had the medication available to her. Resident #3 indicated that she was " in so much pain " that day. She did not recall being asked to rate her pain on a scale of 0 - 10 but said that " I told them I was really hurting " . Interview with the physician on 2/14/13 at 3 PM revealed he did not specifically recall if he had gotten any calls regarding Resident #3. He also indicated that if he had been informed of Resident #3 ' s concerns regarding pain management he would have expected the nurse to have completed a pain assessment on the resident with information regarding the characteristics and intensity of the pain so appropriate interventions could have been implemented. 2. Resident #4 was admitted [DATE] at 4:15 PM with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] revealed Resident #4 was cognitively intact. Review of the physician's order [REDACTED]. [MEDICATION NAME] 12.5 mg (milligrams) ordered for hypertension daily, [MEDICATION NAME] 125 mcg (micrograms) daily ([MEDICATION NAME] is used to treat [MEDICAL CONDITION]), [MEDICATION NAME] (antibiotic) 875 mg twice daily for 7 days, ordered [MEDICAL CONDITION], [MEDICATION NAME] 4 gtts (drops) otic (ear) solution three times a day for otttis media (ear infection), Lactobacillis 500 mg twice daily for 7 days, ordered [MEDICAL CONDITION] (Lactobacillis is used for general digestive problems such as diarrhea caused by antibiotic therapy) Mirlax Powder 17 g (grams) daily ordered for constipation, [MEDICATION NAME] Coated 40 mg daily ([MEDICATION NAME] is used to treat heartburn) Review of the electronic medical record daily summary sheet for 1/22/13 revealed the following medications were not given as ordered on the morning of 1/22/13: [MEDICATION NAME], lactobacillis, mirilax powder and [MEDICATION NAME]. Review of the electronic medical record variance report associated with these missed medication doses revealed that in each case the reason the medications were missed was documented as " medication on order from pharmacy, pharmacy notified " . There was no documentation indicating that the physician had been notified. Telephone Interview with Nurse #3 on 2/28/13 at 2:45 PM revealed that Resident #4 ' s medications were not available on the morning of 1/22/13. She stated because they had not arrived the night before she faxed the hospital discharge medications list to pharmacy that morning, and expected they would arrive around 11 PM that night. Nurse #3 said she did not think about notifying the physician that the medications were not given as ordered. Review of the electronic medical record daily summary sheet for 1/23/13 and 1/24/13 revealed the following medication was not given as ordered on the morning of 1/23/13 and 1/24/13: lactobacillis. Review of the electronic medical record variance report associated with this missed medication revealed that in both cases the reason the medication was missed was documented as " medication on order from pharmacy, pharmacy notified " . Interview with the Pharmacy Consultant on 2/14/13 at 9:30 AM revealed that medications ordered by 5 PM were usually delivered that same day by 11 PM. He added that if medications were ordered from pharmacy after that cut off time they would not be delivered to the facility until 11 PM the next day. The pharmacist also indicated that for most medications missing one dose was acceptable, so he did not think it was necessary for nursing staff to take any action to notify the physician or to obtain the medications from the back up pharmacy. Interview with Resident #4 on 2/14/13 at 2:30 PM revealed that she recalled that she did not get her medications, including her antibiotic, as ordered on the morning of 1/22/13 as they had not yet arrived in the facility. She indicated that she thought the medications should have been available that morning. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that Nursing staff were expected to inform the physician if medications were not being given because they were not available in the facility. She also said that for some non essential medications it would be acceptable to wait until they arrived from pharmacy. Interview with the physician on 2/14/13 at 3 PM revealed he expected to be notified when medications were not being given because they were not available and that alternatives such as the back-up emergency kit and back-up pharmacy needed to be utilized, or an order to hold the medications until arrival from pharmacy could be written if appropriate. 3. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired. Review of the electronic medical record daily summary sheet for 1/9/13 - 1/12/13 revealed the [MEDICATION NAME] Patch was not given as ordered 1/9/13 through 1/12/13. Review of the electronic medical record variance report associated with these missed medication doses revealed that the reason the medication was missed was documented on each occasion as " medication on order from pharmacy, pharmacy notified " . Review of the Grievance Report dated 1/12/13 revealed, in part, " This is the 3rd time that (Resident #5) has run out of her [MEDICATION NAME] Patch. She ran out this time on 1/8/2013. Family notes that her mental status has changed and that is what prompted them to inquire about patch. Please note (name of nurse) promptly contacted pharmacy and it will be on tonight ' s tote " . Under action taken a hand written note indicated the [MEDICATION NAME] Patch arrived on 1/12/13 and was applied at 8:20 AM. It also indicated that staff were inserviced on ordering of medications and contacting appropriate staff members. Telephone Interview with Nurse #4 on 2/28/13 at 2:20 PM revealed that she worked with Resident #4 on the morning of 1/9/13 and 1/10/13, and that on both days the [MEDICATION NAME] Patch was not given because it had not arrived from pharmacy. She stated that she did not contact pharmacy to reorder the medication on either 1/9/13 or 1/10/13, since she noticed the reorder sticker was missing and she therefore assumed that the medication had already been reordered. Nurse #4 said she did not notify the physician that this medication had not been given and that she typically had not been notifying the physician when other medications were not available, and therefore not given. She added that she did not observe any change in the resident. Telephone Interview with Nurse #5 on 2/28/13 at 2 PM revealed that she worked with Resident #4 on the morning of 1/11/13, and that the [MEDICATION NAME] Patch was not given that day because it had not arrived from pharmacy. She said that on 1/11/13 she was aware that the [MEDICATION NAME] had been missed for the previous two days as well. Nurse #5 said another Nurse (Nurse #6) contacted pharmacy for her, to reorder the medication. Nurse #5 said that she did not notify the physician that the [MEDICATION NAME] had not been given for 3 days. She also said that she did not notice any mental status changes in the resident. Interview with the Pharmacy Consultant on 2/14/13 at 9:30 AM revealed that medications ordered by 5 PM were usually delivered that same day by 11 PM. He added that if medications were ordered from pharmacy after that cut off time they would not be delivered to the facility until 11 PM the next day. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that Nursing staff should have contacted the physician when the [MEDICATION NAME] Patch for Resident #5 was not available. Interview with the physician on 2/14/13 at 3 PM revealed that he would have expected to be informed when the [MEDICATION NAME] was not available from pharmacy. He did not recall if he had been contacted. He said however that he believed he was not contacted, as he would have ensured action was taken, such as ordering the medication from the back-up pharmacy if he had been aware.

Based on record review and staff interview, the facility failed to notify the responsible party (RP) of the change in the treatment and condition of the pressure ulcer for 1 (Resident #22) of 3 sampled residents with pressure ulcer. The findings included: Resident #22 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #22 had memory and decision making problems and had a stage II pressure ulcer. Review of the wound assessment form revealed that on 1/21/13, Resident #22 had developed a stage II pressure ulcer on the left heel. The ulcer was treated with [MEDICATION NAME] ([MEDICATION NAME] wound dressing) and kerlix. On 1/30/13, the wound assessment form indicated that the ulcer on the left heel had a white/grey non viable tissue and/or non adherent yellow slough, less than 25 % of wound bed covered. A new form of treatment was ordered to clean with seaclens and to apply hydrogel, cover with gauze and wrap with kerlix. Review of the nurse's notes and progress notes of the unit manager/supervisor revealed that the RP was not informed of the change in condition and the new treatment to the pressure ulcer on the left heel. The wound assessment form dated 2/20/13 revealed that the pressure ulcer on the left heel had a hard and black eschar, more than 50% and less than 75% of wound covered. A new form of treatment was ordered to apply [MEDICATION NAME] (non prescription topical wound spray) twice a day. Review of the nurse's notes and progress notes of unit manager/supervisor revealed that the RP was not informed of the change in condition and the new treatment to the pressure ulcer on the left heel. On 3/11/13, Resident #22 was seen by the wound doctor. The pressure ulcer on the left heel was assessed as unstageable due to necrosis (100%). A new form of treatment was ordered on [DATE] to apply silver hydrogel and calcium alginate once daily to the left heel. Review of the nurse's notes and progress notes of unit manager/supervisor revealed that the RP was not notified of the change in condition and the new treatment to the pressure ulcer on the left heel. On 3/18/13, there was a new order to apply Santyl and Dakins solution to the pressure ulcer on the left heel. The notes did not indicate that the RP was informed of the new treatment to the left heel. On 4/3/13 at 2:55 PM, Nurse #6 was interviewed. She stated that the RP should be notified when there was a new form of treatment. After reviewing the records, she stated that she did not see that the RP was informed of the change in condition and the new form of treatment to the left heel pressure ulcer. She acknowledged that she was the nurse who assessed the pressure ulcer on 1/30/13 but did not notify the RP. On 4/3/13 at 4:50 PM, Administrative staff #2 was interviewed. She agreed that Resident #22 was seen by the wound doctor on 3/11/13, 3/18/13 and 3/25/13 and was aware that the wound doctor had made changes to the treatment but she did not call the RP. She stated that the nurse should notify the RP when there was a change in condition of the pressure ulcer and when there was a change in treatment.

Based on record review and physician and staff interview, the facility failed to inform the physician of the difference in the length, the swelling and the continued and increased intensity of pain on the right leg for 1 (Resident #188) of 1 sampled resident. The findings included: Resident #188 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #188 had intact cognition, had a fall prior to admission and had received a PRN (as needed) medication for pain. The assessment also indicated that Resident #188 had pain present which made it hard for her to sleep at night, limited her day to day activities and the pain intensity was "9 " . The analog pain scale of 0-10 indicated "0" as having no pain and "10" as agonizing pain. The admission nursing assessment dated [DATE] did not indicate that Resident #188's right leg was shorter than the left leg. The assessment also indicated that the resident had [MEDICAL CONDITION] but did not indicate the location. Review of the physician's orders [REDACTED].#188 had an order for [REDACTED]. The PT (physical therapy) notes dated 4/8/13 were reviewed. The notes indicated that Resident #188 was evaluated and noted that the right leg was shorter than the left leg and the resident had some pain on the right hip with walking. On 5/8/13 at 1:12 PM, therapy staff #4 (PT) was interviewed. She acknowledged that she was the one who evaluated Resident #188 on admission. She indicated that the right leg was shorter about 2-3 inches than the left leg and thought it was not normal after surgery. She indicated that she did not inform nursing about it because the family indicated that the surgeon stated that it was expected after surgery. She also stated that pain was expected in the beginning of therapy and would decrease later on. The nurse's notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" 4 " . The occupational therapy (OT) notes dated 4/9/13 indicated that Resident #188 stated that she was in a lot of pain. The PT notes dated 4/9/13 indicated that the resident stated " my hip hurt pretty bad last night what we are going to do? " The notes further indicated that Resident #188 was in a lot of pain and it was reported to the nurse and a pain medication was administered prior to therapy. The MAR for 4/9/13 revealed that the resident had received [MEDICATION NAME] at 1:32 PM and at 7:52 PM. The OT notes dated 4/10/13 and 4/12/13 indicated that Resident #188 stated that her leg was very sore. The PT notes dated 4/12/13 revealed that Resident #188 was experiencing pain in the right hip with movement and gait. The MAR for 4/10/13 revealed that the resident had received [MEDICATION NAME] for pain rated at " 4 " . The PT notes dated 4/15/13 indicated that the resident was experiencing pain in the right hip with movement and gait, and the resident seemed to hold her breath due to pain. This was reported to the nurse that hip did not seem to be progressing well. The nurse who was informed by the therapist was not available for interview. The MAR for 4/15/13 indicated that the resident had received [MEDICATION NAME] at 10:44 AM and at 9:33 PM. The OT notes dated 4/16/13 revealed that Resident #188 stated " I am still hurting. " The PT notes dated 4/16/13 indicated that the resident stated that my leg is hurting especially in the knee. The notes further indicated that the pain was with movement and gait. The MAR for 4/16/13 indicated that the resident had received [MEDICATION NAME] at 8:20 AM for pain rated at " 5 " . The OT notes dated 4/17/13 revealed that Resident #188 stated " I am hurting so bad. " Resident had increased pain during movement which did not appear to be getting better. The PT notes dated 4/17/13 indicated that Resident #188 stated " I'm hurting bad. " The notes revealed that the resident continued to have much pain. The MAR for 4/17/13 indicated that the resident had received the [MEDICATION NAME] at 12:45 PM and at 9:24 PM. The OT notes dated 4/18/13 revealed that the resident required frequent breaks due to increased pain. The PT notes indicated that the resident stated " my hip is hurting but I will be alright. " The PTA continued to express concern about the resident's pain. The therapy notes revealed that Resident #188 was seen by the physician on 4/18/13. The physician was informed of the pain during therapy and he ordered to give [MEDICATION NAME] 2 tablets prior to therapy. The records did not indicate that the physician was informed of the swelling on the right leg and the leg length difference, right leg shorter than the left leg. The MAR for 4/18/13 revealed that the resident had received [MEDICATION NAME] at 9:20 AM for hip pain rated at " 5 " . The OT notes dated 4/19/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The notes further indicated that the resident had increased pain during movement which did not appear to be getting better. The PT notes revealed that the resident stated " I'm trying but it just hurts so badly. " The resident was in a lot of pain from hip to knee. On 5/8/13 at 3:05 PM, Nurse #1 was interviewed. She stated that she was aware that Resident #188 was in pain due to her surgery. The resident was on pain medication which was effective. She further stated that the physician had ordered to give [MEDICATION NAME] 2 tablets to be given prior to therapy and that seemed to be working. She was not informed that the resident was having a lot of pain during therapy with movement and gait. She indicated that if she had known, she would inform the physician about it. The PT notes dated 4/21/13 indicated that Resident #188 stated " I would like my pain pill before we start. " The nurse was notified and pain medication was administered. The notes further indicated that resident was in a lot of pain from hip to knee with gait. On 5/7/13 at 5:55 PM, Nurse #2 was interviewed. She stated that she was aware that Resident #188 was in pain and she was on pain medication which was effective. She stated that she was not informed that the resident was in much pain during therapy. She also stated that if the resident had complained of continued pain with movement and gait, she would assess the site for swelling and for any increased in pain and would inform the physician. The nurse's notes revealed that the resident's pain was rated at " 8 " on 4/21/13 at 11:12 AM. The PT notes dated 4/22/13 revealed that the resident had worked hard, still having much pain. She pointed the pain across the groin and she was unable to flex her hip and knee. The MAR for 4/22/13 revealed that the resident had received 2 tablets of [MEDICATION NAME] at 8:46 AM. The notes further indicated that the resident stated that her pain was never completely relieved. At 10:25 PM, 1 tablet of pain medication was given due to complain of pain on the right hip rated at " 8 " . There was no indication in the records that the physician was informed of the pain not completely relieved after the pain medication was administered and the increased intensity of pain the resident was experiencing with movement and gait. The PT notes dated 4/23/13 revealed that the resident was assisted on right hip mobility but she could not tolerate it. She complained of pain in groin with movement. She continued to work hard but continued to have difficulty with movement of hip flex and with extreme pain. The MAR indicated [REDACTED]. The OT notes date 4/24/13 revealed that Resident #188 stated " my leg hurts so bad, I can not move it. " The records from 4/18/13 to 4/24/13 did not indicate that the physician was informed of the increased intensity of pain during movement and gait, that the resident could not move her leg anymore and that the pain medication did not completely relieve the pain.. On 4/24/13, Resident #188 went to the orthopedic surgeon for her follow up appointment. The progress notes from the orthopedic surgeon dated 4/24/13 was reviewed. The notes indicated that an x-ray of the hip was taken and demonstrated an oblique [MEDICAL CONDITION] femur. Resident #188 was transported to the hospital from the clinic on 4/24/13 for surgery. The hospital notes with the admission date of [DATE] indicated that Resident #188 had sustained a peri prosthetic fracture (fracture around joint replacement prosthetics/implants) of the right hip. The notes revealed that the resident had sustained the fracture while doing physical therapy. She was admitted from the office to the hospital for surgical repair of her peri prosthetic fracture. She underwent open reduction and internal fixation and implant revision of her right hip hemi arthroplasty. On 5/8/13 at 9:10 AM, therapy staff #1 (PTA) was interviewed. She acknowledged that she was assigned to work with Resident #188 during her stay at the facility. She admitted that the resident was having pain so bad during therapy. She revealed that the resident's right leg was swollen since she was admitted . She also stated that her right leg was shorter than the left leg. She indicated that she had informed the nurse about her pain and a pain medication was administered. She also stated that in 2 weeks, it was not unusual for a resident to be experiencing pain and swelling and she did not think that something was wrong because the resident did not have any incidents that happened On 5/8/13 at 9:15 AM, therapy staff #2 (OTA)was interviewed. She stated that she had worked with Resident #188 during her stay at the facility. The resident was having hard time moving her right leg due to pain. She stated that nursing was aware of the resident's pain and pain medication was administered and was effective. She also stated that pain was not unusual for a resident with a fractured leg. On 5/8/13 at 9:35 AM, therapy staff #3 (OT)was interviewed. She stated that pain was expected in about 2 weeks and the orthopedic appointment should be made with in 2 weeks after surgery. She stated that she was aware that the resident was having pain but the pain was relieved with the pain medications. On 5/8/13 at 10:35 AM, administrative staff #1 was interviewed. She stated that she was aware that the resident was having pain and the pain medication was effective. She was not aware that the pain was on going and was increasing during therapy. She also was not aware that the right leg was shorter than the left leg and was swollen. She expected that the therapy staff should communicate with nursing when the resident continuously experiencing pain during therapy and any abnormality so nursing could inform the physician. On 5/8/13 at 2:10 PM, the physician was interviewed. He stated that he had seen the resident once and that was on 4/18/13. The notes for that visit had been dictated and the dictated notes were not available for filing yet. He was informed of pain during therapy and he had ordered additional pain medication ([MEDICATION NAME] 2 tablets) to be given prior to therapy. He stated that he was not informed of the swelling on the right leg, the difference of the leg length and the continued and increased pain especially during therapy. He added that if he had known it, he would reassess the resident, get an x-ray or get an orthopedic consult.

Based on resident, staff , physician and pharmacy consultant interview, record review and the facility failed to complete a nursing admission assessment for 1 of 3 residents sampled for nursing admission assessment completion (Resident #3), failed to assess pain and to provide pain management interventions for 1 of 3 residents sampled for pain management (Resident #3) and failed to assess or document pain characteristics pre and post pain management intervention for 2 of 3 residents sampled for pain management (Resident #3 and Resident #4). Findings included: 1a. Resident #3 was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was not due prior to her discharge and was not completed. The FL2 Level of Care Screening Tool dated 1/18/13 indicated Resident #3 was cognitively intact. The Admission Pain Assessment 1/18/13 at 2:30 PM revealed the resident had no pain at that time. No other information was documented. On 1/18/13 the first entry in the nursing notes at 10:43 PM revealed " Resident complained of pain to right knee surgical site. No further information regarding the pain was documented. Review of the electronic medical record and Nursing Notes for 1/18/13 revealed no admission note, no admission assessment or assessment of the Resident #3 ' s pain noted in the above Nursing Note and no documentation of pain management interventions, including pain medications. Further review of the medical record from 1/19/13 until the residents discharge on 1/21/13 revealed that an admission assessment was not documented. Interview with Nurse # 1 on 2/13/13 at 2:42 PM revealed that Resident #3 arrived at 2:30 PM near the end of her shift (3 PM) on 1/18/13. She indicated that because the Resident had come so close to the end of the shift it was the responsibility of the oncoming nurse to complete the admission assessment. In interview with Nurse #2 on 2/13/13 at 5:15 PM she stated that because the resident arrived on first shift it was the responsibility of the first shift nurse to complete the admission assessment. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that it was the responsibility of the second shift nurse (Nurse #2) to complete the nursing admission assessment. She said it was her expectation that the Nursing Admission Assessment, including a thorough pain assessment could have been completed before the end of second shift (11 PM). She added that if a nursing admission assessment was not completed by the nurse who was responsible for it this information should have been passed on for the following day. 1b. The facility policy on Pain Management was from Lippincott ' s Nursing Procedures 4th Edition, 2004, pages 533 - 536. and read, in part, " To assess pain properly, you ' ll need to consider the patient ' s description and your observations of the patient ' s physical and behavioral responses. Start by asking the following series of questions (bearing in mind that the patient ' s responses will be shaped by his prior experiences, self-image, and beliefs about his condition): - Where is the pain located? How long does it last? How often does it occur? - Can you describe the pain? - What brings the pain on? - What relieves the pain or makes it worse? Ask the patient to rank his pain on a scale of 0 - 10, with 10 denoting the worst pain. This helps the patient verbally evaluate pain therapies. Observe the patient ' s behavioral and physiologic responses to pain. Physiologic responses may be sympathetic or parasympathetic. " Resident #3 was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was not due prior to her discharge and was not completed. Review of the Hospital Discharge Summary dated 1/18/13 revealed, in part, that Resident #3 had medial calf tenderness and because of this a Doppler study (a test to evaluate blood flow) had been done. The results of this were still pending at the time of discharge. The FL2 Level of Care Screening Tool dated 1/18/13 indicated Resident #3 was cognitively intact. Review of the Hospital Discharge Medication Reconciliation dated 1/17/13 at 11:38 PM revealed that while in hospital the resident had an order for [REDACTED]. a. [MEDICATION NAME] - [MEDICATION NAME] 10-500 mg (milligrams) 1 tablet every 4 hours as needed. There was no date or time noted under the column " Last Dose Taken. " The reconciliation indicated that this medication was to be discontinued at discharge. b. [MEDICATION NAME] - [MEDICATION NAME] 5 - 325 mg 2 tablets every 4 hours as needed. Under the column " Last Dose Taken " it read 1/17/13, 10:02 PM. The reconciliation indicated that this medication was to be continued after discharge from the hospital. There was also a hand written addition that changed the dosage to read 1 - 2 tablets every 4 - 6 hours as needed. The Admission Pain Assessment 1/18/13 at 2:30 PM revealed the resident had no pain at that time. No other information was documented. Review of the Interim Care Plan dated 1/18/13 revealed a Care Plan focus area for " Pain/Comfort Needs " . The interventions listed included: pain assessment to be completed on admitting shift, [MEDICATION NAME] - [MEDICATION NAME] 5/325 mg 1 tablet every 4 hours as needed for pain and [MEDICATION NAME] (a Brand name for [MEDICATION NAME] - [MEDICATION NAME]) 5/325 mg 1 tablet every 4 hours as needed for pain. Review of the physician's order [REDACTED]. Review of the physician's order [REDACTED]. On 1/18/13 the first entry in the nursing notes at 10:43 PM revealed " Resident complained of pain to right knee surgical site. Area red and warm to touch. Requested to go to hospital for evaluation and requested family take her to hospital. (Name of Doctor) gave order to send to ER (emergency room ) for evaluation. Family arrived at facility to take to (name of hospital) " . Further review of the electronic medical record and Nursing Notes for 1/18/13 revealed no admission note, no admission assessment or assessment of the Resident #3 ' s pain noted in the above Nursing Note and no documentation of pain management interventions, including pain medications. The Emergency Department Physician Record dated 1/18/13 with the " time seen " documented at 11:31 PM revealed that Resident #3 had right knee pain with an onset of the afternoon of 1/18/13. No vital signs were documented but her cardiovascular status was " normal " . Her right knee was noted to be swollen with limited range of motion and [DIAGNOSES REDACTED] (redness of the skin). There was no documentation in the section regarding pain severity and no indication of any treatment given. The [DIAGNOSES REDACTED].? (query) [MEDICAL CONDITION] (([MEDICAL CONDITION]) painful leg (leg was crossed out) knee " . Under the heading reevaluation " improved " was circled and under the heading for discharge condition " good " was circled. The 1/19/13, 4:18 AM Nursing Note revealed, in part, " Resident reports that per hospital that her pain was just not controlled and that they gave her some of their medication " . " Called and spoke with (Name of hospital staff member) at (Name of Hospital) who reported that resident had dx (diagnosis) of [MEDICAL CONDITION] ([MEDICAL CONDITION] and leg pain, received [MEDICATION NAME] 2 mg (a narcotic pain medication) for pain while at hospital " . Interview with Nurse # 1 on 2/13/13 at 2:42 PM revealed that Resident #3 arrived at 2:30 PM near the end of her shift (3 PM) on 1/18/13. She indicated that because the Resident had come so close to the end of the shift it was the responsibility of the oncoming nurse to complete the admission assessment. She acknowledged that she did stay to input the medication orders and to clarify the as needed pain medication order. Nurse #1 noted that the Hospital Discharge Summary indicated 1 - 2 tablets of [MEDICATION NAME] - [MEDICATION NAME] 5 - 325 mg could be given to Resident #3 as needed for pain every 4 - 6 hours. She stated that per facility policy, the order needed to be clarified to be specifically for 1 tablet, or for 2 tablets, and that an order for [REDACTED]. Nurse #1 also said that medications ordered from the pharmacy in the evening before 6 PM usually arrived on third shift around 11 PM. In interview with Nurse #2 on 2/13/13 at 5:15 PM she recalled that Resident #3 had a lot of complaints and was very concerned that her pain medications may not arrive in the facility that evening. When asked if she offered the resident pain medication she Nurse #2 said that she was sure she would have but that Resident #3 wanted 2 tablets like she had in the hospital " but I told her we don ' t do that " . When asked to clarify this statement Nurse #2 stated that the order from the hospital was for 1 - 2 tablets of pain medication as needed every 4 - 6 hours but that the first shift nurse needed to have the order clarified (1 tablet only or 2 tablets only) as Nurse #1 was responsible for the admission and admission assessment. During this interview, when asked why she did not contact the physician to discuss Resident #3 ' s pain signs/symptoms and request for 2 tablets, Nurse #2 reiterated that this was the responsibility of the first shift nurse. Nurse #2 also indicated that she was aware that [MEDICATION NAME] - [MEDICATION NAME] 5 - 325 was available in the emergency back-up kit within the facility but said that Resident #3 did not want the pain medication and just wanted to go back to the hospital because she did not want to be admitted to the facility. Telephone interview with Resident #3 ' s Family Member #1 on 2/13/13 at 6:30 PM she said that Resident #3 was admitted around 3 PM and by 4 PM she was hurting and asked for pain medication. She stated that after she (Family Member #1) left she received a call from Resident #3 who said she was really hurting and still hadn ' t received any pain medications. Family Member #1 then said that she called Nurse #2 and Nurse #2 said she just gave Resident #1 something for pain around 9 PM that was borrowed from another resident. Family Member #1 said she asked when Resident #3 ' s medications would arrive and Nurse #2 said 11 PM. Family Member #1 stated that she then asked what would happen if the medication did not arrive and Nurse #2 said she will have to wait until the morning. Family Member #1 added that Nurse #2 called her back later and told her she had gone back to assess Resident #2 ' s knee and it was sore with red streeks running up her leg possibly related to a blood clot. She also said that Nurse #2 said Emergency Medical Services could be called to take Resident #3 to the hospital but that Resident #3 wanted family to take her. Family Member #1 said Resident #3 was crying and really hurting when she went with her to the hospital. (Review of the [MEDICATION NAME] - Acetominophen Narcotic Count Sheets and corresponding Medication Administration Records for 1/18/13 revealed no borrowed medications and the Count Sheet for the [MEDICATION NAME] - Acetominophen in the emergency kit revealed it was not used. Resident #3's MAR indicated [REDACTED]. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that it was her expectation that the Nursing Admission Assessment, including a thorough pain assessment could have been completed before Resident #3 left for theER on [DATE] (approximately 10:43 PM). She also said that if Resident #3 was asking for 2 tablets of pain medication instead of 1 the physician should have been notified and provided with information regarding Resident #3 ' s pain assessment, so appropriate interventions could be determined. The DON indicated that she expected pain medication to be given, when needed, and that not giving it because the resident ' s medications had not arrived from pharmacy was not acceptable as there were back-up sources and options. During telephone interview with Resident #3 on 2/14/13 at 2:45 PM she said that she repeatedly asked for pain medication on 1/18/13 and that she thought the facility should have been more prepared and had the medication available to her. Resident #3 indicated that she was " in so much pain " that day. She did not recall being asked to rate her pain on a scale of 0 - 10 but said that " I told them I was really hurting " . Resident #3 also said that Nurse #2 finally gave her something for pain that she said was borrowed from another resident but it was too late and she needed to go to the hospital. (Review of the [MEDICATION NAME] - Acetominophen Narcotic Count Sheets and corresponding Medication Administration Records for 1/18/13 revealed no borrowed medications and the Count Sheet for the [MEDICATION NAME] - Acetominophen in the emergency kit revealed it was not used. Resident #3's MAR indicated [REDACTED]. Interview with the physician on 2/14/13 at 3 PM revealed he did not specifically recall if he had gotten any calls regarding Resident #3. He also indicated that if he had been informed of Resident #3 ' s concerns regarding pain management he would have expected the nurse to have completed a pain assessment on the resident with information regarding the characteristics and intensity of the pain so appropriate interventions could have been implemented. The physician also confirmed that an order for [REDACTED]. Telephone interview with Nurse #2 on 2/28/13 at 3:30 PM revealed that Resident #3 seemed fine while her family was visiting on the evening of 1/18/13 but after they left she talked about not wanting to be there and said her family could take care of her at home. Nurse #2 stated the resident indicated her pain was mild but also said the resident was worried about a blood clot. Nurse #2 said that she assessed the residents leg and found no signs of a [MEDICAL CONDITION] (blood clot) but said the resident ' s knee was a little red. She stated that she offered Resident #2 Tylenol as there are standing orders for Tylenol but did not give the [MEDICATION NAME] - [MEDICATION NAME] because the order had not been clarified by Nurse #1 yet. Nurse #2 also said that Resident #3 did not show any non-verbal signs of pain only verbal signs. She said that she assessed Resident #2 ' s pain on a 0 - 10 scale but could not remember the result and did not document it. Nurse #2 said she did not give Resident #3 pain medication borrowed from another resident and did not recall receiving a call from Family Member #1. She stated Resident #3 had already called Family Member #1 to take her to the hospital before she (Nurse #2) was able to call her and let her know Resident #3 wanted to go to the hospital. 1c. Resident #3 was admitted on [DATE] at 2:30 PM with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) was not due prior to her discharge and was not completed. The FL2 Level of Care Screening Tool dated 1/18/13 indicated Resident #3 was cognitively intact. The Admission Pain Assessment 1/18/13 at 2:30 PM revealed the resident had no pain at that time. No other information was documented. Review of the physician's order [REDACTED]. Review of the physician's order [REDACTED]. On 1/18/13 the first entry in the nursing notes at 10:43 PM revealed " Resident complained of pain to right knee surgical site. Area red and warm to touch. Requested to go to hospital for evaluation and requested family take her to hospital. (Name of Doctor) gave order to send to ER (emergency room ) for evaluation. Family arrived at facility to take to (name of hospital) " . Further review of the electronic medical record and Nursing Notes for 1/18/13 revealed no admission note, no admission assessment or assessment of the Resident #3 ' s pain noted in the above Nursing Note and no documentation of pain management interventions, including pain medications. Review of the Nursing Notes, Pain Assessment Notes and Narcotic Count Sheet for 1/19/13 through 1/21/13 revealed: 1/19/13, 4:18 AM Nursing Note: " Resident reports that per hospital that her pain was just not controlled and that they gave her some of their medication " . " Called and spoke with (Name of hospital staff member) at (Name of Hospital) who reported that resident had dx (diagnosis) of [MEDICAL CONDITION] ([MEDICAL CONDITION] and leg pain, received [MEDICATION NAME] 2 mg (a narcotic pain medication) for pain while at hospital " . 1/19/13 4:30 AM Pain Assessment - " resident C/O (complains) some pain but received pain med (medication) at (name of hospital) while in the ER (emergency room ) " . No further information regarding the pain was documented. 1/19/13, 5:44 AM Nursing Note: administration of pain medication as ordered was documented as given for right leg and knee pain. No other information regarding the pain was documented. 1/19/13, 8:45 AM (per Narcotic Count Sheet) - I tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/19/13, 10:32 AM Nursing Note: " No pain at present, PRN (as needed) pain med (medication) given this shift " . 1/19/13, 12:42 PM (per Narcotic Count Sheet) - I tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/19/13, 4:42 PM (per Narcotic Count Sheet) - 2 tablets of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. (Note: although the physician's order [REDACTED]. 1/19/13, 4:53 PM Nursing Note: administration of pain medication as ordered was documented as given. No other information regarding the pain was documented. 1/20/13, 1:20 AM (per Narcotic Count Sheet) - 2 tablets of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/20/13 1:42 AM: administration of pain medication as ordered was documented as given for right knee and leg pain. No other information regarding the pain was documented. 1/20/13, 2:44 AM Nursing Note: " Gave her pain medication at 0120 (1:20 AM) for right lower leg pain. Has [MEDICAL CONDITION] to her right lower leg. Skin tight and red " . 1/20/13, 4:58 AM Nursing Note: administration of pain medication as ordered was documented. The note also read that the resident had no other complaints " at this time " . 1/20/12, 5:45 AM (per Narcotic Count Sheet) - 2 tablets of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/20/13, 10:40 AM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/20/13, 1:18 PM Pain Assessment: the assessment indicated " yes " for pain. No further information regarding the pain was documented. 1/20/13 4:03 PM Nursing Note: administration of pain medication as ordered was documented as given for complaints of pain. The note also read that effectiveness would be monitored. No other information regarding the pain was documented. 1/20/13, 5 PM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/20/13, 8:55 PM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/20/13, 10 PM Pain Assessment: the assessment indicated " yes " for pain. No further information regarding the pain was documented. 1/21/13, 3:20 AM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/21/13, 3:20 AM Nursing Note: administration of pain medication as ordered was documented as given for complaints of pain. No other information regarding the pain was documented. 1/21/13, 8:05 AM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/21/13, 8:09 AM Nursing Note: administration of pain medication as ordered was documented the note also read " C/O (complains) pain with PRN (as needed) medication given. Pain 8 on scale of 1/10. Will monitor for effectivemness. 1/21/13, 12:20 PM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. 1/21/13, 2 PM Pain Assessment: the assessment indicated " yes " for pain. No further information regarding the pain was documented. 1/21/13, 2:42 PM Nursing Note: " C/O pain with medication given. No acute distress or discomfort noted " . 1/21/13, 5:15 PM (per Narcotic Count Sheet) - 1 tablet of [MEDICATION NAME] - [MEDICATION NAME] 5-325 mg given. According to the medical record Resident #3 was discharged against medical advice on 1/21/13 at 6:35 PM. Interview with Nurse # 1 on 2/13/13 at 2:42 PM revealed that when doing a pain assessment she would use a 0 - 10 scale to assess pain intensity or a faces scale to assess non-verbal indications of pain with cognitively impaired residents. She indicated that documentation of pain characteristics, including pain intensity is sometimes missed with the electronic system. Nurse #1 noted that with the paper system of charting it was easier to document pain assessment. She said with the paper system as there was a specific place to document pain characteristics and intensity and that effectiveness of pain medications could be documented on the back of the Medication Administration Record. In interview with Nurse #2 on 2/13/13 at 5:15 PM she recalled that Resident #3 was concerned about her pain medication as soon as she came in the door. When asked if she assessed the reesident ' s pain and offered the resident pain medication, Nurse #2 said that she was sure she would have and that she would have documented this (there was no documentation regarding pain assessment or pain management intervention including medication on 1/18/13). Nurse #2 stated when doing a pain assessment she used a 0 - 10 to assess pain intensity. When asked why she did not contact the physician to discuss Resident #3 ' s pain signs/symptoms and request for 2 tablets, Nurse #2 reiterated that this was the responsibility of the first shift nurse. Interview with the Staff Development Coordinator on 2/13/13 at 5:30 PM revealed that nurses were expected to use the alerts tab in the electronic medical record to find out when the last dose of as needed pain medication was given. She also stated that nurses should be documenting a more detailed pain assessment in their notes and should be reevaluating the effectiveness of pain medication. She acknowledged that this was not being done on a consistent basis. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that it was her expectation that the Nursing Admission Assessment, including a thorough pain assessment could have been completed before Resident #3 left for theER on [DATE] (approximately 10:43 PM). She also said that if Resident #3 was asking for 2 tablets of pain medication instead of 1 the physician should have been notified and provided with information regarding Resident #3 ' s pain assessment, so appropriate interventions could be determined. During telephone interview with Resident #3 on 2/14/13 at 2:45 PM she indicated that she was " in so much pain " the day she was admitted (1/18/13). She did not recall being asked to rate her pain on a scale of 0 - 10 but said that " I told them I was really hurting " . Resident #3 also said that because she is used to taking pain medications for migraines she needs a higher dose (two tablets instead of one). She added that while at the facility, on most occasions, more than 4 hours had elapsed since her last dose of pain medication so she was always getting it late. Resident #3 felt that nursing staff should have known that she needed her pain medications every 4 hours and they should have brought her pain medication every 4 hours without her having to ask for it. Interview with the physician on 2/14/13 at 3 PM revealed he did not specifically recall if he had gotten any calls regarding Resident #3. He also indicated that if he had been informed of Resident #3 ' s concerns regarding pain management he would have expected the nurse to have completed a pain assessment on the resident with information regarding the characteristics and intensity of the pain so appropriate interventions could have been implemented. The physician also confirmed that an order for [REDACTED]. 2. Resident #4 was admitted [DATE] at 4:15 PM with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] revealed Resident #4 was cognitively intact. The MDS indicated she had pain rarely, that it was moderate intensity and 7 on a scale of 0 (no pain) - 10 (worst pain) at its worst. Review of the Physician order [REDACTED]. Review of the Nursing Notes and the Medication Administration Record [REDACTED] On 1/22/13 Resident #4 received 2 doses of [MEDICATION NAME]-acetominophen (Loracet) according to the MAR. The 4:27 AM Nursing note indicated this medication was " given per prn (as needed) order and resident request " ; no further information regarding the pain was documented. The 4:30 AM nursing note read, in part, " Resident questioned why she hasn ' t received her pain medication that was due. Explained to resident that pain medication was not scheduled and she had not c/o (complained) pain or asked for any pain medication this shift " . The 11:29 PM Nursing Note indicated Loracet was given per prn order and patient request; no further information regarding the pain was documented. On 1/24/13 Resident #4 received 2 doses of Loracet according to the MAR. The 12:05 AM Nursing Note indicated Loracet was " given per prn order and resident request " ; no other information regarding the pain was documented. The 2:12 PM Nursing Note indicated " prn pain med (medication) was given " , no other information regarding the pain was documented. The 6:11 PM Nursing Note indicated " no c/o of pain at this time. No acute distress noted " . On 1/25/13 Resident #4 received 2 doses of Loracet according to the MAR. The 12:30 AM Nursing Note indicated Loracet was given due to resident complaints of pain to the right leg and that the pain was 9 out of 10. The note also indicated the medication was tolerated well. On 1/26/13 Resident #4 received 1 dose of Loracet according to the MAR. The 1:51 PM note indicated " prn pain med given " and the 11:53 PM note indicated " no c/o pain at this time " . On 1/27/13 Resident #4 received 2 doses of Loracet according to the MAR. The 1:43 AM Nursing Note indicated the resident requested a pain pill earlier in the shift and it was given per prn order and resident request with no further signs or symptoms of pain. On 1/28/13 Resident #4 received 2 doses of Loracet according to the MAR. The 8:24 AM Nursing Note indicated " prn pain med given, will continue to monitor effectiveness " . The 9:48 AM Nursing Note indicated " c/o back pain, prn pain med given will monitor for effectiveness " . On 1/29/13 Resident #4 received 1 dose of Loracet according to the MAR. The 5:41 PM Nursing Note indicated " complained of pain with prn medication given " ; no further information regarding the pain was documented. The 8:04 PM Nursing Note indicated " c/o pain of 9 on 1/10 pain scale. Will monitor for effectiveness " . On 1/30/13 Resident #4 received 1 dose of Loracet according to the MAR. The 7:58 PM Nursing Note indicated " c/o back/leg pain, prn pain med given, will monitor for effectiveness " . On 1/30/13 Resident #4 received 1 dose of Loracet according to the MAR. The 11:04 AM Nursing Note indicated " pain med ' s requested for back/leg " . The 2:19 PM Nursing Note indicated " no c/o pain " . Review of the Nursing Notes and MAR from 2/1/13 - 2/14/13 revealed no further documentation regarding complaints of pain and no further Loracet or other pain medication administered. The 2/14/13 2:29 PM Nursing Note indicated " no c/o pain or discomfort at this time " . Interview with Nurse # 1 on 2/13/13 at 2:42 PM revealed that when doing a pain assessment she would use a 0 - 10 scale to assess pain intensity or a faces scale to assess non-verbal indications of pain with cognitively impaired residents. She indicated that documentation of pain characteristics, including pain intensity is sometimes missed with the electronic system. Nurse #1 noted that with the paper system of charting it was easier to document pain assessment. She said with the paper system as there was a specific place to document pain characteristics and intensity and that effectiveness of pain medications could be documented on the back of the Medication Administration Record. Interview with the Staff Development Coordinator on 2/13/13 at 5:30 PM revealed that nurses were expected to use the alerts tab in the electronic medical record to find out when the last dose of as needed pain medication was given. She also stated that nurses should be documenting a more detailed pain assessment in their notes and should be reevaluating the effectiveness of pain medication. She acknowledged that this was not being done on a consistent basis. Interview with Resident #4 on 2/14/13 at 2:30 PM revealed that pain medications were given if she asked for them. She did not recall being asked specific questions regarding pain, like how intense her pain had been on a scale of 0 - 10. She also stated she had a sore throat for a few days and she did not think the medication she was taking for it was effective. Resident #4 said that she had told the nurses that it wasn ' t working but she didn ' t think anything was being done about it. She then said she was told the doctor would be in to see her today. An interview with the Director of Nursing (DON) on 2/14/13 at 11:30 AM revealed that it was her expectation that pain assessment was done on admission and prior to pain management interventions. She added that effectiveness of pain management interventions was to be assessed and documented. The DON also indicated that she expected that concerns regarding pain management would be communicated to the physician, with a thorough pain assessment, so appropriate pain management interventions could be identified. Interview with the physician on 2/14/13 at 3 PM revealed he expected to be notified when pain management interventions were needed or ineffective. He also indicated that he expected that a pain assessment, including characteristics of the pain and exacerbating or relieving factors was completed and communicated to him to aid in determining effective pain management interventions.

Based on record review, observation and staff interview, the facility failed to ensure that fluid restriction was followed as ordered and failed to develop a dietary and nursing plan for managing the fluid restriction for 1 (Resident #118) of 1 sampled resident on [MEDICAL TREATMENT]. The finding included: Resident #118 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #118 had no memory and decision making problem and was on [MEDICAL TREATMENT]. On 11/30/12, there was a doctor's order for " fluid restriction 1000 ml (milliliter) daily. " The care plan dated 2/28/13 for Resident #118 was reviewed. One of the care plan problems was " [MEDICAL TREATMENT] needs " and the goal was " will have no complications related to bleeding/infection at the shunt/[MEDICAL TREATMENT] site daily through next review. " The approaches included " adhere to fluid restriction as ordered. " The care plan did not specify how much fluid dietary and nursing would provide in 24 hours. The fluid intake documentation for the last 7 days was reviewed. The fluid documentation included breakfast, lunch, supper and bedtime snacks. The daily fluid intake on 4/2/13 was 1320 ml, 4/1/13 was 1440 ml, 3/31/13 was 1200 ml, 3/30/13 was 1560 ml, 3/29/13 was 1080 ml, 3/28/13 was 1080 ml and 3/27/13 was 1200 ml. The daily fluid intake did not include the fluid given during medication pass and the fluid provided at bedside. On 4/2/13 at 9:52 AM, Resident #118 was observed. There was a styro foam cup (437 ml) full of water at bedside. On 4/3/13 at 10:35 AM, Resident #118 was observed. The lunch tray was served early because he was scheduled for [MEDICAL TREATMENT]. The dietary card indicated 1000 ml fluid restriction but did not specify how much fluid to offer for breakfast, lunch and supper. The tray contained 1 glass of tea (240 ml) and 1 can of sprite (220 ml). There was also a styro foam cup (437 ml) full of water at bedside. Unsweetened tea and diet sprite were listed on the diet card for lunch. On 4/4/13 at 8:30 AM, Resident #118 was observed during breakfast. The breakfast tray contained apple juice (118 ml) and a whole milk (237 ml). Apple juice and whole milk were listed on the diet card for breakfast. On 4/3/13 at 4:50 PM, Nurse #7 was interviewed. She stated that she did not know how much fluid each shift has to be provided to Resident #118. She stated that she would ask the director of nursing. On 4/3/13 at 4:51 PM, Administrative staff # 2 was interviewed. She stated that nobody had been monitoring the fluid intake to make sure that the resident was provided 1000 ml in 24 hours as ordered. On 4/3/13 at 4:59 PM, NA #1 (nursing assistant assigned to Resident #118) was interviewed. She stated that she provided Resident #118 with 360 ml of water on her shift at bedside in addition to the fluids that were provided by the kitchen. On 4/3/13 at 5:15 PM, Nurse #7 indicated that the kitchen should provide 360 ml of fluids for breakfast, 240 ml for lunch and supper and 160 ml for the nurses to use during the medication pass. These provided 1000 ml of fluids in 24 hours. She further stated that Resident #118 should not have water at bedside. On 4/4/13 at 3:05 PM, administrative staff #3 was interviewed. She stated that Resident #118 should received 840 ml of fluids from the kitchen, 360 ml for breakfast and 240 ml for lunch and supper. She further stated that nurses should provide 160 ml for medication pass and Resident #118 should not have water at bedside. She also indicated that she was made aware today (4/4/13) that Resident #118 was getting more than 1000 ml of fluids in 24 hours. The doctor was notified and the diet card was corrected to reflect the 360 ml for breakfast and 240 ml for lunch and supper.