Every finding on record at Riverwoods at Exeter

Based on interview, and record review, the facility failed to implement water management control measures, potentially exposing a census of 3 residents to waterborne pathogens. Findings include:Review on 3/18/26 of the facility Water Management Plan for Legionella Control, reviewed on 9/26/25, revealed .Protocol for Flushing Unoccupied Resident Rooms and Daily Use Outlets: Maximum number of days a resident room is allowed to be vacant without action: 3 days. Protocols for resident rooms recently vacated: Open every fixture in room on maximum hot setting for 1 minute. Open every fixture in room on maximum cold setting for 1 minute. Flush toilet times 1. Clean and disinfect faucets, showerheads, and jets. Document activity. Protocol for resident rooms vacant for more than 5 days: Open every fixture in room on maximum hot setting for 2 minute. Open every fixture in room on maximum cold setting for 2 minute. Flush toilet times 2. Clean and disinfect faucets, showerheads, and jets. Document activity. Protocol for the resident rooms vacant for more than 3 days. Open water pipe and flush for 2 minutes (if outside temperature is above 68 [degrees] F [Fahrenheit] .Potable Water System Routine Monitoring Plan Test water temperature in each hot water tank, acceptable range 120F -140F, frequency .biweekly .Test water temperature in one hot water outlet per building in use, Acceptable range 113F-120F, frequency .biweekly .Test Chlorine residual level in 1 shower for each building in use, acceptable range Greater than 0.2 mg[milligrams]/[per]L[Liter] Frequency .biweekly .Test pH [power of hydrogen] level in 1 shower for each building in use, acceptable range 7.2-7.8 .Frequency .biweekly .Review on 3/18/26 of the Healthcare Domestic Hot Water Temperature Checks Log for February 2026 and March 2026 revealed the following:2/2/26 the skilled dining room hot water outlet temperature 110 ;2/10/26 the skilled dining room hot water outlet temperature 108 ;2/16/26 the skilled unit mop closet hot water outlet temperature 108 ;2/23/26 the skilled kitchen hot water outlet temperature 108 ;3/2/26 the skilled unit mop closet hot water outlet temperature 108 ;3/9/26 the skilled unit mop sink hot water outlet temperature 108 ;3/16/26 the skilled unit island sink hot water outlet temperature 106 .Interview on 3/18/26 at approximately 9:00 a.m. with Staff A (Maintenance Supervisor) revealed the facility could not provide documentation of the flush logs for vacant rooms, biweekly hot water tank temperature logs, biweekly shower chlorine residual logs, and biweekly shower pH level logs as required by the facility water management plan. Staff A confirmed the above hot water outlet temperatures were below the allowable levels defined in the water management plan and stated that no corrective action had been taken for the out of range temperatures.

Based on observation and interview, it was determined that the facility failed to ensure that equipment used to prepare food was properly cleaned in the main kitchen. Findings include: Observation on 3/5/25 at approximately 8:20 a.m. in the kitchen revealed a mixer that had dried white and grey particle splatters throughout the machine. Interview on 3/5/25 at approximately 8:45 a.m. with Staff D (Kitchen Manager) confirmed that there were dried white and grey food particles throughout the mixer. He/she was unaware when it was last used. Interview on 3/5/25 at approximately 8:45 a.m. with Staff A (Dietary Aide) revealed the mixer was not used that morning. Interview on 3/5/25 at approximately 11:45 a.m. with Staff B (Director of Culinary Operations) revealed that mixer was used the night before to make mashed potatoes. Review on 3/6/25 of the facility policy titled, HACCP-Based Standard Operating Procedures, 5C: Cleaning & Sanitizing Food Contact Surfaces revealed: Cleaning is defined as physically removing visible food or soil from surfaces with the aid of a detergent, water, and some muscle power. If State or local requirements are used, wash, rinse, and sanitize food contact surfaces of sinks, tables, equipment, utensils, thermometers, carts, and equipment: before each use, between uses when preparing different types of raw animal foods, such as eggs, fish, meat, and poultry, and anytime contamination occurs or is suspected .

Based on record review, it was determined that the facility failed to submit complete and accurate data for Payroll Based Journal for Fiscal Year Quarter 4 (July 1, 2024 - September 30, 2024). Findings include: Review on 3/5/25 of the Payroll Based Journal (PBJ) Staffing Data [NAME] Report for Fiscal Year 2024, Quarter 4, revealed that the facility failed to report Registered Nurse hours for 8 consecutive hours in a 24 hour period on the following dates: 7/20/24, 8/17/24, 9/22/24, 9/28/24, and 9/29/24. The facility also failed to report 24 hour a day licensed nursing coverage for the following dates: 7/7/24, 7/14/24, 7/20/24, 8/3/24, 8/18/24, 8/25/24, 9/8/24, and 9/28/24. Review on 3/6/25 of the facility's time punches revealed that there was licensed RN nursing coverage for more than 8 consecutive hours in a 24 hour period for 7/20/24, 8/17/24, 9/22/24, 9/28/24, and 9/29/24. Further review of the facility's time punches revealed that there was 24 hour a day licensed nursing coverage on 7/7/24, 7/14/24, 7/20/24, 8/3/24, 8/18/24, 8/25/24, 9/8/24, and 9/28/24. Review on 3/6/25 of Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, effective date June 2022, revealed: .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline .

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards. Findings include: Observation on 3/27/24 at 9:00 a.m. of the kitchen's walk-in refrigerator with Staff B (Culinary Manager) and Staff C (Assistant Dietary Manager) revealed the following: A facility container labeled marinara sauce with an open date of 3/18/24 without a use-by date Vegetable pot pie with an open date of 3/19/24 without a use-by date A clear plastic facility container with onions that were soft and sitting in water with a date of 3/16/24 without a use-by date One package of sauerkraut with an open date of 2/19/24 without a use-by date One large plastic container of poppyseed dressing with a manufacturer's use by date of 2/1/23 One large plastic facility container, with the lid open, with cooked pasta and the pasta was hard around the edges and dried with no dates Three sheet pans with potato pancakes uncovered and exposed to the air with no dates Five 8 ounce cartons of milk with a manufacturer's expiration date on the cartons dated 3/22/24 One clear facility container with thick yellow liquid with no identifier and no dates 11 quarts of milk with a manufacturer's expiration date of 3/24/24 Three sheet pans with cut up mushrooms uncovered and exposed to the air with no dates One large eggplant with a large area that was soft and leaking fluid. Interview on 3/27/24 at 9:15 a.m. with Staff B confirmed the above findings and stated that all items should be covered, dated when opened, and should be discarded within 5 days of the open date. Interview on 3/27/24 at 9:20 a.m. with Staff C confirmed the above findings in the walk-in refrigerator. Review on 3/27/24 of the facility's policy titled Dining Service Food Storage (policy not dated) revealed: .Proper storage of food assures that there will be minimal contamination of the food from any sources and that the natural growth of microorganisms in food will not result in food-borne illness. Therefore, measures to prevent the contamination of food must consider the environment in which food is stored and the potential for contamination under these conditions .Food Storage #1 B. Sanitation in storage area: .G. Routinely inspect the area for cleanliness. H. Check for bulging or broken containers, spilled, spoiled, or infected food. Remove immediately, and thoroughly clean the area to prevent contamination to other food .#7 All items should be sealed and labeled Review on 4/5/24 of the 2022 Food Code U.S. Food and Drug Administration, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2022, revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .

Based on interview and record review, it was determined that the facility failed to ensure that the irregularities identified by the pharmacist during the monthly review were documented in the residents medical record for 3 out of 5 residents reviewed for unnecessary medications (Resident Identifiers are #4, #6, and #9). Findings include: Resident #9: Review on 2/24/23 of Resident #9's medical record revealed a progress note dated 12/27/22 documenting that a medication regimen review was performed with one new irregularity found. Further review revealed no pharmacy consultation report to identify the irregularities from 12/27/22. Interview on 2/23/23 at approximately 2:00 p.m. with Staff A (Interim Director of Nursing) revealed the facility did not have the December 2022 pharmacy consultation report and could not identify what irregularity were being referred to the 12/27/22 visit. 28881 Resident #6 Review on 2/24/23 of Resident #6's medical record revealed a monthly drug regimen review from the pharmacy had irregularities noted on 11/26/22. Further review of Resident #6's medical record revealed no pharmacy consultation report to identify the irregularities from November 2022. Interview on 2/24/23 at approximately 1:00 p.m. with Staff A (Interim Director of Nursing) confirmed that the pharmacy consultation was not reviewed and signed by the provider. Resident # 4 Review on 2/23/23 of Resident #4's progress notes revealed the following monthly drug regimen reviews from the pharmacy had irregularities noted: 2/9/23, 1/26/23 and 12/27/22. Further review of Resident #4's medical record revealed no pharmacy consultation report to identify the irregularities from December 2022 or January 2023. Interview on 2/23/23 at approximately 1:30 p.m. with Staff A (Interim Director of Nursing) confirmed the facility had not received December 2022 or January 2023 pharmacy consultation reports as of yet. Review on 2/24/23 of facility assessment titled Medication Regimen Reviews, revised on May 2019, revealed . 8. Within 24 hours of the MRR [Medication Regimen Review], the Consultant Pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to tracking of antibiotics prescribed and the appropriate use of antibiotics for 3 out of 3 months reviewed for antibiotic use (Resident identifiers are #5, #11, #12, #21). Findings include: Review on 2/24/23 of the facility infection surveillance line list for December 2022 through February 2023 revealed the following: - December 2022 - no entries for antibiotic use; - January 2023 - Resident #5 was treated for a urinary tract infection with antibiotics from 1/4/23 through 1/11/23, McGeers Criteria was not met as urgency and pain were only symptoms and the urinalysis obtained was negative with no culture and sensitivity completed; - February 2023 - no entries for antibiotic use. Review on 2/24/23 of facility generated report of all antibiotics ordered from December 2022 through February 2023 revealed: December 2022 - Resident #21 prescribed Cephalexin 500 milligrams (mg) for cellulitis start date of 12/22/22 December 2022 - Resident #21 prescribed Cefpodoxine Proxetil tablet 200 mg for cellulitis on 12/28/22; January 2023 - Resident #11 prescribed Amoxicillin-Pot Clavulante oral tablet 875-125 mg for cellulitis on 1/18/23; February 2023 -Resident #12 prescribed Ciprofloxacin HCL [hydrochloride] oral tablet 500 mg for hematuria on 2/8/23. Interview on 2/24/23 at approximately 11:00 a.m. with Staff A (Interim Director of Nursing) confirmed the monthly antibiotic tracking was incomplete and that the facility could not confirm if antibiotics were prescribed appropriately following the criteria approved by the facility antibiotic stewardship program. Review on 2/24/23 of the facility's policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised on December 2016, revealed: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information will include: a. Resident name and medical number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic; e. Start date of antibiotic; f. Pathogen identified; g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and l. Adverse events. Review on 2/24/23 of the facility policy titled Antibiotic Stewardship- Orders for Antibiotics revised December 2016, revealed .1. Prior to calling a physician/prescriber to communicate a suspected infection, the nurse will obtain and have the following information available: a. Clinical signs and symptoms of suspected infection (based on approved definitions of infection) .3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) .7. When a culture and sensitivity (C&S) is ordered, it will be completed , and: a. Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .

Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan for 1 of 1 resident reviewed for accidents and 1 of 1 resident reviewed for anticoagulant medication side effects in a final sample of 12 residents (Resident identifiers are #3 and #14). Findings include: Resident #3 Review on 2/24/23 of Resident #3's medical record revealed an initial admitted [DATE] and diagnoses including: unsteadiness on feet, hemiplegia/hemiparesis following cerebral infarction affecting left aide, and history of falling. Resident #3's 10/25/22 Fall Evaluation score was 11 - At Risk for falls. Review on 2/24/23 of Resident #3's medical record further revealed a fall on 1/5/23 after bumping into furniture resulting in a left superior pubic ramus (pelvic) fracture. Review on 2/24/23 of Resident #3's care plan revealed no fall prevention focal area or interventions dated prior to the fall on 1/5/23. Interview on 2/24/23 at approximately 2:40 p.m. with Staff C (Assistant Director of Nursing) confirmed the finding. Review on 2/24/23 of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframe's; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; Resident # 14 Review on 2/24/23 of Resident #14's current physician orders revealed an order for Eliquis (anticoagulant) 2.5 milligrams twice a day, with a start date of 7/12/22. Review on 2/24/23 of Resident #14's current care plan revealed that there interventions identifying that they were taking an anticoagulant or at risk for increased bruising and bleeding. Interview on 2/24/23 at approximately 2:40 p.m. with Staff C (Assistant Director of Nursing) confirmed the finding.

Based on interview and record review, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to duration identified by provider for 1 of 5 residents reviewed for unnecessary medication in a final sample of 12 residents (Resident identifier is #4). Findings include: Review on 2/24/23 of Resident #4's February 2023 Medication Administration Record (MAR) revealed the following active PRN lorazepam orders: Lorazepam 0.5 milligrams (mg) every 6 hours as needed for increased anxiety, with a start date of 1/13/23 and no identified duration or end date Lorazepam 0.5 mg every 6 hours as needed for increased anxiety .order expires in 2 months, with a start date of 12/20/22 and no stop date. Interview on 2/24/23 at approximately 12:00 p.m. with Staff C (Assistant Director of Nursing) confirmed the above information. Review on 2/24/23 of facility policy Psychotropic Medication Use, revised July 2022, revealed .PRN orders for psychotropic medications are limited to 14 days .For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extent the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration of the PRN order .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure food was properly dated, labeled, and stored for food safety to prevent foodborne illness in the walk in refrigerator in 1 out of 2 kitchens (Main Kitchen and Skilled Kitchen) observed. Findings include: Observation on 2/22/23 at approximately 10:00 a.m. of the walk-in refrigerator with Staff B (Culinary Staff) revealed: - One (1) container of cooked asparagus with no label or use by date; - One (1) container of diced tomatoes with no label or use by date; - One (1) container of shredded cheese with no label or use by date. - Nine (9) wilted lemons with visible dark spots in a box not labeled or a received date - Four (4) wilted limes with visible dark spots in a box not labeled or a received date. Interview on 2/22/23 at approximately 10:00 with Staff B confirmed that the above food items were not labeled and dated. Staff B stated the lemons and limes should have been discarded. Review on 2/24/23 of the facility's policy titled, Food Receiving and Storage, revised July 2014, revealed Policy Interpretation and Implementation: 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated [use by date]. Review on 2/24/22 of the facility's policy titled, Refrigerators and Freezers, revised December 2014, revealed Policy Interpretation and Implementation: 5. All food should be appropriately dated to ensure proper rotation by expiration dates. Received dates [date of delivery] will be marked on cases . Use by dates will be completed with expiration dates on all prepared food in refrigerators .

Based on interview and record review, it was determined that the facility failed to employ, at least on a part time basis, an Infection Preventionist that completed specialized training in infection prevention and control. Findings include: Interview on 2/22/23 at 9:12 a.m. during entrance conference with Staff A (Interim Director of Nursing (DON)) revealed that the facility did not have an Infection Preventionist (IP) and that he/she had been acting as the IP for the facility while being the full time DON. Staff A confirmed that he/she had successful completion of infection control and prevention in 2019. Staff A stated that they delegate portions of the Infection Preventionist role out to others, specifically antibiotic tracking, COVID vaccination tracking of staff and residents, and update letters for COVID positives in facility. Review on 2/22/23 of the facility's form 672 Resident Census and Conditions of Residents revealed that the facility census was 21. Cross Reference F881: Antibiotic Stewardship Program and F885: Reporting- Residents, representatives & families.

Based on interview and record review, it was determined that the facility failed to notify resident representatives and families of those residents in the facility by 5 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection for 4 of 5 days reviewed in February 2023. Findings include: Review on 2/22/23 at approximately 12:00 p.m. of facility line list of COVID-19 positives for staff and residents revealed the facility had positive cases of COVID-19: 2/15/23 1 staff member; 2/18/23 2 residents; 2/20/23 2 staff; 2/21/23 3 residents; 2/22/23 1 staff. Review on 2/23/23 at approximately 9:00 a.m. of the facillity's COVID updates for February 2023 revealed that the following COVID-19 updates had been sent: 2/20/23 at 11:36 a.m. Over the weekend, we had two [facility name omitted] residents test positive for COVID .; 2/22/23 at 12:25 p.m.Yesterday, we had three additional residents test positive on the skilled unit . Interview on 2/23/23 at approximately 9:00 a.m. with Staff A (Interim Director of Nursing) confirmed the above information. Review on 2/23/23 of facility policy titled Coronavirus Disease (COVID-19)- Reporting Facility Data to Residents and Families, initiated May 2020, revealed .1. Residents and their representatives and families are notified when there is a single confirmed case of COVID-19, or three or more residents or staff with new onset of respiratory symptoms that occur within 72 hours of each other. 2. Notices of the above information are provided to residents, representatives and families no later than 5 p.m. of the calendar day following the occurrence(s) .

Based on observation and interview, the facility failed to maintain the dishwasher rinse temperature to manufacturer's instructions to ensure sanitary conditions in 1 of 2 kitchens observed. Findings include: Observation on 4/18/22 at approximately 9:20 a.m. of dishwasher in main kitchen revealed a rinse cycle temperature reading of 170°F (degrees Fahrenheit). Interview on 4/18/22 at approximately 9:22 a.m. with Staff A (Kitchen Operations Manager) confirmed above findings. Review on 4/18/22 of The Ridge-Main Dish Machine Log revealed .all items run through the machine .a final rinse temp of at least 180° . Review on 4/18/22 of the Main Dish Machine Log for the high temperature dishwasher from 4/1/22 to 4/18/22 revealed that kitchen staff documented the following temperatures below 180° F: On 4/4/22 rinse temperature for morning was 172 ° F. On 4/5/22 rinse temperature for morning was 170 ° F, afternoon 175 °F. On 4/6/22 rinse temperature for morning was 168 °F, afternoon 174 °F. On 4/7/22 rinse temperature for morning was 168 °F, afternoon 176 °F. On 4/8/22 rinse temperature for morning was 168 °F, afternoon 170 °F. On 4/9/22 rinse temperature for morning was 170 °F. On 4/10/22 rinse temperature for morning was 172°F. On 4/11/22 rinse temperature for morning was 170 °F, afternoon 179 °F. On 4/12/22 rinse temperature for morning was 172°F. On 4/13/22 rinse temperature for morning was 172 °F. On 4/14/22 rinse temperature for morning was 175 °F. On 4/15/22 rinse temperature for morning was 164 °F. On 4/16/22 rinse temperature for morning was 168 °F. On 4/17/22 rinse temperature for evening was 173 °F. On 4/18/22 rinse temperature for morning was 178 °F. Review on 4/19/22 of dishwasher manufacturer's instructions revealed . Operating temperatures for all models . Recommended Rinse 180 °F . Review on 4/19/22 of facility's policy titled Dishwasher Machine Use revealed .The operator will check temperatures using the machine gauge with each dishwashing cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately . Interview on 4/19/22 at approximately 1:17 p.m. with Staff B (Dining Administrator) revealed he/she did not have documentation that a supervisor had been notified of above mentioned temperatures.

Based on interview and medical record review, it was determined that the facility failed to employ interventions for dysphagia that resulted in actual harm that is not immediate in which the resident was hospitalized for aspiration pneumonia for 1 resident out of a final sample size of 16 residents. (Resident identifier is #9.) Findings include: Review on 4/2/21 of Resident #9's diet order with start date 1/12/21 revealed a diet of Puree (all solid foods), extra side of gravys and sauces with special instruction to discontinue lip plate and resident to be assisted with all meals and no sandwiches. Review on 4/2/21 of Resident #9's Nursing to Rehab Communication form dated 1/17/21 revealed that Resident #9 has been recently coughing with thin liquids. Resident #9 also has been drinking and cannot seem to stop drinking once he/she starts. Staff needs to physically pull the drink away from Resident #9 so he/she can take a breath. Further review also revealed that on 1/19/21 speech therapist screen results indicated that Resident #9 required full feeding assist, discontinue use of straw and that 2 LNA's (Licensed Nursing Assistant) reported that Resident #9 drinks thin liquids without difficulty if given small sips and from a cup. Review on 4/2/21 of Resident #9's nutrition care plan dated 10/3/19 revealed Resident #9 has feeding deficit and potential for chewing/swallowing difficulty related to dementia. Further review revealed that nutrition care plan was updated on 1/13/21 indicating Resident #9 history of dysphagia (difficulty swallowing) requiring pureed diet for best tolerance. Further review also revealed that the care plan was not updated in regards to speech therapist screening results to discontinue straws dated 1/19/21. Review on 4/2/21 of Resident #9's nurse's note dated 2/3/21 revealed 0800 [8:00 a.m.] Resident up in bed, more alert that usual. Receives PO [by mouth] medications, crushed in applesauce, without difficulty. Strawberry [supplement] introduced with straw. Resident started a small sip and appeared to begin choking slightly, suddenly appeared to be having [CONDITION(S)]-like activity: leaning forward, clenching fists and becomes stiff and face turns blue. Small amount of blood appeared at lips. Gurgling breathing noted. This RN [Registered Nurse] retrieved DON [Director of Nursing] to assess. Decision made to call 911. DON calls report to PCP [Primary Care Provider], [physician], [physician] confirmed decision to send resident to ED [Emergency Department]. [spouse] at bedside. Resident resumed normal breathing pattern. EMS [Emergency Medical Services] arrives .transfer resident to [hospital] ED .1530 [3:30 p.m.]: [physician] reports that resident will remain in hospital to be treated with IV [Intravenous] abx [antibiotic] for RUL [Right Upper Lobe] pneumonia . Review on 4/2/21 of Resident #9's hospital history and physical report dated 2/3/21 revealed .[pronoun omitted] was drinking a strawberry shake and had an episode of choking and per [facility] account, became apneic and possible bite [pronoun omitted] tongue as [pronoun omitted] did have some bright red blood within the mouth to the side. [pronoun omitted] was hypoxic at 86% [percent] and EMS was called for evaluation and transferred to the hospital . .Given [pronoun omitted] event this morning, [pronoun omitted] also underwent a chest x-ray that shows possible developing right upper lobe pneumonia, unclear timing of this, as [pronoun omitted] choking event happened this morning [pronoun omitted] does have some secretions in her upper airway, but no other focal deficits . .Diagnostic Imaging .CT head .impression: Chronic atrophy and ventriculomegaly similar on comparison with prior imaging. Communicating [CONDITION(S)] may be present. No acute process is other wise noted . .Chest X-ray findings: .Impression: possible developing right upper lobe infiltrate superimposed upon chronic lung changes . .Acute hypoxic [CONDITION(S)] likely in the setting of aspiration. The patient will be admitted to the hospital .The event happened several hours ago. [pronoun omitted] chest x-ray is being read as possible developing right upper lobe infiltrate and given [pronoun omitted] advancing dementia it is likely that [pronoun omitted] does have some sort of aspiration event . Review on 4/2/21 of Resident #9's hospital discharge summary dated 2/5/21 revealed .discharge instruction next provider: patient admitted to the hospital after witnessed aspiration event which resulted in [CONDITION(S)] requiring oxygen support. [pronoun omitted] significantly improved with IV antibiotics and was weaned off of oxygen . Interview on 4/2/21 at approximately 1:00 p.m. with Staff E (Director of Health Services-Woods) confirmed the above findings. Staff E stated that there was a miss in communication. Staff E also stated that the speech therapist made recommendations to discontinue straws and that was not communicated to the physician for a physician order. Staff E also stated that speech recommendations should have been addressed immediately. Staff E also stated that care plan should have been updated to reflect recommendations. Interview on 4/2/21 at 1:30 p.m. with Staff J (speech therapist) revealed that Staff J stated that he/she screened Resident #9 regarding coughing with thin liquids. Staff J also stated that they would received a nursing to rehab communication form from nursing to screen a resident to determine services and recommendations. Once resident is screened the screen results are written on the nursing to rehab communication form then nursing communicates the screen results and follows up with the physician for orders and care plan updates. Interview on 4/2/21 at 2:50 p.m. with Staff K (Registered Nurse) confirmed above findings related to the nurse's notes dated 2/3/21. Staff K stated that he/she was on orientation and was giving Resident #9 strawberry supplement with a straw. Staff K was unaware of Resident #9's speech recommendations from 1/19/21. Staff K also stated that he/she would rely on the diet order for any changes of diet and any special instructions. Interview on 4/2/21 at 2:55 p.m. with Staff L (Licensed Practical Nurse) revealed that Staff L stated that he/she was training Staff K on 1/19/21. Staff L stated that he/she was aware that Resident #9 had swallowing difficulties and Resident #9 was on pureed diet. Staff L also stated that Resident #9 takes his/her medication crushed and thin liquids with straw. Staff L was unaware of the speech recommendation on 1/19/21. Staff L also stated that he/she would rely on the diet order for any changes of diet and any special instructions. Interview on 4/2/21 at 3:00 p.m. with Staff C (Registered Nurse) revealed that Staff C stated that he/she was aware that speech therapist told him/her that Resident #9 should not have straws with fluids/drinks. Staff C does not remember when he/she was told by the speech therapist. Staff C also stated that he/she would rely on the diet order for any changes of diet and any special instructions. Review on 4/2/21 of facility's policy titled, Dysphagia-clinical protocol, dated September 2017, revealed that .Assessment and Recognition .If a swallowing problem is identified or suspected, a health care practitioner, in conjunction with nursing and the SLP [Speech Language Pathologist], will identify pertinent information .Treatment/Management .if a modified consistency diet or other restrictions are indicated (that is, the risk of clinically significant aspiration or other complications outweighs the benefits of an unaltered or minimally altered diet), nursing will obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, it was determined that the facility failed to monitor for expired food items the dry goods storage rooms at 1 of 3 unit kitchens observed for food storage observed in accordance with professional standards for food service safety. Findings include: Dry Storage for Winnisquam Lodge at The Boulders Interview on [DATE] at approximately 9:35 a.m. with Staff G revealed the he/she stored dry food for the Skilled Nursing Unit in the [NAME] kitchen (Assisted Living Unit) and the Main kitchen areas. Observation on [DATE] at 10:05 a.m. of the dry storage in the [NAME] kitchen revealed the following: -Six 1 quart thickened orange juice with a use by date of [DATE]; -Twelve 46 ounce boxes of grape juice that had a best by date of [DATE]; -Four 13.5 ounce boxes of butter crackers with a best by date of [DATE]; -Two 16 ounce boxes of saltine crackers that had a date stamp of [DATE]. There was one sleeve opened in the box and crackers were visible. Interview on [DATE] at 10:05 a.m. with Staff H (Dietary Aide) revealed that the [NAME] storage was used to store food items used for the Skilled Nursing Unit. Staff H confirmed that the above food items were beyond the use by or best by date; and did not know when the crackers had been opened. Observation on [DATE] at 10:15 a.m. of the Main Kitchen dry storage revealed the following: -Eighteen jars of [NAME] sauce (a raspberry fruit sauce) that did not have any visible date or record of when received at facility; -Fourteen 4.4 ounce boxes of wheat crackers with a best by date of [DATE]; -Twelve bags of barley with a best by date of [DATE]; -Four bags of 4 pound of [NAME] with a best by date of [DATE]; -Three undated plastic bins containing loose bulgur, lentils and red lentils. Interview on [DATE] at approximately 10:15 with Staff I (Culinary Operation Manager) confirmed the above findings. Interview on [DATE] at 8:15 a.m. with Staff I revealed that the facility had no record of when the [NAME] sauce had been delivered. Staff I stated that all of the above items in the dry storage had been thrown out. Review of the facility's undated policy titled Food Receiving and Storage read, in part, Food shall be received and stored in a manner that complies with safe food handling practices Dry food that are stored in bins will be removed from original packaging, tabled, and dated (use by date) All foods stored in the refrigerator .will be .labeled, and dated (use by date) Other opened containers must be dated and sealed or covered during storage

Based on observation, interview, and record review, it was determined that the facility failed to make prompt efforts to resolve resident and group grievances, keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale for the response for 1 resident out of a final survey sample size of 16 and some of the members of the resident council meeting. (Resident identifier is #48). Findings include: Interview on 3/31/21 at 12:12 p.m. with Resident #48 revealed complaints about the food being cold and how the food was cooked. Resident #48 stated he/she had made multiple complaints about the food to staff, but it was still an issue for him/her. Observation on 4/01/21 at 8:45 a.m. revealed Resident #48's breakfast tray had not yet been delivered. Interview on 4/1/21 at approximately 9:00 a.m. with Staff F (Director of Health Services-Boulders) revealed that Staff F stated that there were no grievances for the past 2 years. Observation on 4/1/21 at 9:10 a.m. during medication pass, Resident #48 was observed telling Staff K (Registered Nurse) that he/she had just received breakfast and that it was cold. Review of Resident #48's progress notes revealed the following: -On 3/20/21 Resident c/o [complained of] cold, disgusting hamburger and look at that, no dessert -On 3/31/21 Resident continues with c/o food being poor quality, [he/she] finds it unappealing and wont [sic] eat it. -On 4/1/21 Resident c/o poor food quality, not receiving .breakfast in a timely manner this AM . Review on 4/1/21 of the facility's Resident Council meeting minutes revealed the following: -For Riverwoods Monadnock Lodge: On the 1/28/21 minutes it was documented that the food often arrives cold; On the February 2021 (no day was noted) minutes it was documented that many mistakes are still being made when filling the trays; On the March 2021 (no day was noted) minutes it was documented the the food often arrives cold. - For Winnisquam unit: On the January 2021 (no day was noted) minutes it was documented that meals in general are lukewarm at best. Interview on 4/1/21 at approximately 11:15 a.m. during Resident Council Meeting revealed that there were complaints of the food quality and temperatures of the resident's meals. Additionally, there was a complaint that often meal trays were missing items such as dessert. Resident #48 was in attendance of this meeting and had complaints about the temperature of the food. All residents at the meeting did not know how to file a grievance. Interview on 4/1/21 at 2:20 p.m. with Staff O (Life Engagement Facilitator) revealed that he/she takes concerns from Resident Council and sends them to the department head. Review on 4/1/21 of Staff O's printed emails for Monadnock revealed Staff O emailed the following concerns to the dietary department in response of the resident council concerns: -On 1/27/21 Resident . noted that their food often arrives cold. -On 2/26/21 Resident . noted that food often arrives cold . -On 3/26/21 .resident noted that food often arrives cold. Interview on 4/1/21 at approximately 3:25 p.m. with Staff P (Senior Director of Culinary Operations) confirmed that there had been no written response to the Resident Council concerns about the food. Interview on 4/2/21 at 8:20 a.m. with Staff I (Culinary Operation Manager) revealed he/she had heard of no complaints about the food quality or temperatures over the past few months. Interview on 4/2/21 at 10:00 a.m. with Staff C (Registered Nurse) revealed that Resident #48 had complained about the food sometime in mid-March; however, Staff C was not sure if the issues had been resolved. Interview on 4/2/21 at 11:30 a.m. with Staff G (Sous Chef) revealed he/she does not get concerns from the Resident Council meetings. Interview on 4/2/21 at 11:35 a.m. with Staff E (Director of Health Services) revealed that the facility handles concerns in the moment and that if a resident has a concern the staff will email or tell the department head. Interview on 4/2/21 at 12:40 p.m. with Staff Q (Dining Services) revealed that he/she had no complaints regarding food temperatures. Interview on 4/2/21 at approximately 1:30 p.m. with Staff M (Senior Director of Healthcare Services) confirmed that Staff M was the grievance official for the facility and confirmed that the facility had not had any grievances. Staff M stated that he/she would get concerns verbally and by email, including for food complaints, but that they were not official grievances and therefore not tracked or documented. Staff M was asked what would make an official grievance and responded if it was on paper. Review of the facility's policy and procedure titled Resident Grievance Procedure for the Health Center, revised 6/1 read, in part, . Any grievance presented to a staff member is reported to the Grievance Official . All grievances will be promptly reported to the Administrator/Senior Director of Health Services and investigated. The resident and/or resident's representative will be appropriately apprised of progress towards resolution 3. Residents, resident representatives (sponsors), family members or appointed advocates have the right to file their grievances or complaint orally (meaning spoken) or in writing as well as the right to file grievances anonymously . The resident, or person filing the grievance or complaint on behalf of the resident, will be informed of the findings of the investigation . within five (5) working days of the filing of the grievance Documentation demonstrating the result of all grievances for a period of no less than 3 years from the issue of the grievance decision will be maintained . Review of the facility's policy titled Resident Council revised April 2017 read, in part, . 5. The staff representative attending will notify respective department leadership of council minutes and concerns. The facility department related to any issues will be responsible for addressing the items(s) of concern

1. Based on interview and medical record review, it was determined that the facility failed to ensure PRN (as needed) orders for [CONDITION(S)] drugs are limited to 14 days and to document their rationale in the resident's medical record and indicate the duration for the PRN order for 2 residents out of 7 residents reviewed for unnecessary medications in a final sample size of 16 residents. (Resident identifiers are # 37 and #42.) Findings include: Resident #42 Review on 3/31/21 of Resident #42's current physician's order revealed a physician's order for Lorazepam (anti-anxiety) 0.25 mg (milligram) by mouth once daily as needed for anxiety with an order start date of 11/10/20. Further review of Resident #42's Lorazepam PRN order revealed no duration of use. Review on 4/2/21 of Resident #42's November 2020 Electronic Medication Administration Record (EMAR) revealed that Resident #42 did not receive any PRN Lorazepam. Review on 4/2/21 of Resident #42's December 2020 EMAR revealed that Resident #42 received PRN Lorazepam on 12/1/20 and 12/7/20. Review on 4/2/21 of Resident #42's January 2021 EMAR revealed that Resident #42 received PRN Lorazepam on 1/19/21 and 1/24/21. Review on 4/2/21 of Resident #42's February and March 2021 EMAR revealed that Resident #42 did not receive any PRN Lorazepam. Review on 4/2/21 of Resident #42's physician notes dated 11/24/20, 11/25/20, 11/30/20 and 12/7/20 revealed that there were no documentation regarding Resident #42's PRN Lorazepam duration of use and rationale of extended use beyond 14 days. Review on 4/2/21 of Resident #42's progress notes from January 2021 to April 2021 revealed no documentation regarding Resident #42's PRN Lorazepam duration of use and rationale of extended use beyond 14 days. Interview on 4/2/21 at approximately 9:30 a.m. with Staff F (Director of Health Services-Boulders) confirmed the above findings. Staff F stated that he/she could not find documentation of duration of use and rationale of extended use beyond 14 days in Resident #42's medical records. Resident #37 Review on 4/2/21 of Resident #37's current physician's orders revealed an order for lorazepam 0.5 milligrams every 4 hours PRN (as needed) with a start date of 2/15/21. Interview on 4/2/21 at 11:23 a.m. with Staff C (Registered Nurse) confirmed that there was not a stop date for the PRN lorazepam. Staff C stated that he/she thought that since Resident #37 was under hospice care the medication did not need a stop date for the medication. Review on 4/2/21 of Resident #37's pharmacy consultation report dated 3/10/21 revealed that the pharmacy had identified that Resident #37 had a PRN order for lorazepam which had been in place for greater than 14 days without a stop date and recommended to either discontinue the medication or add a stop date/reevaluation date. Interview on 4/2/21 at 11:35 a.m. with Staff E (Director of Health Services - Woods) confirmed that Resident #37 did not have a stop date for the lorazepam. 2. Based on interview and medical record review, it was determined that the facility failed to ensure that consent was obtained for a resident's [CONDITION(S)] drug for 1 resident out of 7 residents reviewed for [CONDITION(S)] medication use in a standard sample size of 16 residents. (Resident identifier is #37.) Review on 4/2/21 of Resident #37's current physician's orders revealed an order for lorazepam 0.5 milligrams (an antianxiety [CONDITION(S)] medication) every 4 hours PRN (as needed) with a start date of 2/15/21. Review on 4/2/21 of Resident #37's medical record revealed there was no documented informed consent for the PRN lorazepam from the resident or the resident's representative. Interview on 4/2/21 at 11:23 a.m. with Staff C confirmed that there was no documentation of informed consent for the lorazepam in Resident's #37's medical record. Review of the facility's policy titled [CONDITION(S)] Medication Use last revised on 11/28/16 read, in part, . 2. Facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical record 5. PRN [as needed] [CONDITION(S)] medications should be ordered for no more than 14 days. Each resident who is taking a PRN [CONDITION(S)] drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month. 6. For [CONDITION(S)] medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record 13. Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of [CONDITION(S)] medications, per facility policy or application state regulation.

1. Based on observation, interview and medical record review, it was determined that the facility failed to ensure that drugs used in the facility were labeled in accordance with currently accepted professional principles for 1 out of 3 medication carts observed. (Resident identifier is #22.) Findings include: Observation on 3/31/21 at 11:21 a.m. with Staff D (Registered Nurse) at the Suncook unit's even medication cart revealed that Resident #22's open [MEDICATION(S)] 0.2% (percent) eye drop container and bottle had no open date. Further observation of the [MEDICATION(S)] 0.2% bottle revealed a pharmacy sticker label that indicated to date when open and discard after 28 days with dispense date of 2/19/21. Observation on 3/31/21 at 11:22 a.m. with Staff D at the Suncook unit's even medication cart revealed that Resident #22's open Dorzolamide 2% eye drop container and bottle had an open date of 2/28/21. Further observation of the Dorzolamide 2% bottle revealed a pharmacy sticker label that indicated to date when open and discard after 28 days. Interview on 3/31/21 at 11:22 a.m. with Staff D confirmed the above findings. Staff D stated that Resident #22's [MEDICATION(S)] 0.2% eye drop should have an open date. Staff D also stated that Resident #22's Dorzolamide 2% eye drops open date were beyond the 28 days that the bottle label indicated. Review on 4/2/21 of the facility's pharmacy policy titled, Oral, Enteral, Ophthalmic, Otic, and Topical Medications, dated March 2020, revealed .Ophthalmic Products .Storage recommendations .Date when opened and discard unused portion after 28 days . 2. Based on observation, interview, and record review, it was determined that the facility failed to ensure that food/drink was not stored with medications in 1 of 2 medication rooms observed. Findings include: Observation on 3/31/21 at 11:00 a.m. of the Winnisquam Lodge at The Boulders' medication refrigerator (in the medication room) revealed 11 individual size puddings stored with medications. Interview on 3/31/21 at 11:00 a.m. with Staff B (Interim Director of Nursing - Boulders) confirmed that the puddings were kept in the medication refrigerator and not in the kitchenette refrigerator so that staff would have puddings for medication pass. Review on 4/1/21 of the facility's undated policy titled Food Receiving and Storage read, in part, .Medications .may not be store in the same refrigerator with food Review on 4/2/21 of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on 10/31/16 read, in part, .3.6 Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medication and biologicals are stored

Based on medical record review and interview, it was determined that the facility failed to assess the need for as needed (PRN) medication and the resulting resident level of comfort after receiving medication, for two residents in a survey of 15 residents (Resident identifiers are #5 and #10). Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 699 Prescribers must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 1070 Nurses administer and monitor interventions ordered by primary health care providers (HCPs) for pain relief Resident #5 Review on 6/6/17 of Resident #5's Medication Administration Records for 5/1/17 through 5/31/17 and for 6/1/17 through 6/30/17 revealed that Resident #5 had orders for [MEDICATION NAME] 0.5 MG (milligram) 1 TAB (tablet) by mouth every day as needed for severe agitation. Further review revealed that Resident #5 also had an order for [REDACTED]. Review of Resident #5's May and June 2017 nurses' notes revealed that Resident #5 received as needed [MEDICATION NAME] on 5/7/17, 5/8/17, 5/12/17, 5/13/17, 5/14/17, 5/15/17, 5/22/17, 5/28/17, 5/31/17, 6/1/17, 6/3/17, 6/4/17 and 6/6/17. The behaviors documented in the nurses' notes for the indicated use of the [MEDICATION NAME] included agitation, aggression, anxiety, yelling out for a family member, attempting to climb out of bed and wheelchair, restlessness, pulling off clothes, ripping at clothes, looking for a piece of clothing that Resident #5 could not find, anxiously asking about an unseen flood that Resident #5 needed to help with, anxiety related to rug shampooing and air blowing machines, and tossing bedding around. Review of Resident #5's May and June 2017 nurses' notes revealed that Resident #5 received as needed Quetiapine [MEDICATION NAME] on 5/7/17, 5/8/17, 5/14/17, 5/15/17, 5/16/17, 5/31/17, 6/2/17, and 6/3/17. The behaviors documented in the nurses' notes for the indicated use of the Quetiapine [MEDICATION NAME] included agitation, restlessness, yelling out, yelling out for a family member, trying to climb out of wheelchair and bed, combative with staff, and throwing bedding. Interview on 6/6/17 At approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed that the two different medications were given for the same behaviors and that there was no clear indication of when to administer which medication to Resident #5. Resident #10 Review on 6/7/17 of Resident #10's medical record and Medication Administration Record (MAR) revealed that the facility failed to document pre and post numeric assessments for PRN (as needed) pain medications. Review of the facility policy and procedure Pain assessment dated ,[DATE] revealed under the Procedure sections #3 and #6: #3. An appropriate pain scale, numeric 0-10 or Wong-Baker Faces 0-10, based on resident assessment will be documented on the MAR. #6. Resident's response to PRN pain medication will be documented on the back of the MAR. Review of Resident #10's 4 months of MAR's and nursing notes revealed the following: 3/17- 6 PRN doses of Tylenol were given for pain without pre and post numerical pain assessments. 4/17-11 PRN doses of Tylenol were given for pain without pre and post numerical pain assessments. 5/17-20 PRN doses of Tylenol and [MEDICATION NAME] were given for pain without pre and post numerical pain assessments. 6/17-7 PRN doses of [MEDICATION NAME] were given for pain without pre and post numerical pain assessments. Review on 6/7/17 of the nursing notes from March 2017 through June 2017 revealed that there were some notes that included some pre and some post numerical assessments. These notes were not consistent with the doses that were administered. Interview on 6/7/17 at approximately 9:00 a.m. with Staff A (Registered Nurse) revealed that pre and post numerical assessments should be documented with all PRN pain medication administration.

Based on medical record review and interview, it was determined the facility failed to ensure a plan of care was updated for 1 resident in a survey sample of 16 residents. (Resident identifier is #1.) Findings Include: Review of Resident #1's MDS (Minimum Data Set) Admission assessment dated [DATE] indicated that Resident #1 was independent in bed mobility and was independent with transfers moving between surfaces and standing. Review of Resident #1's Quarterly MDS dated [DATE] indicated Resident #1's bed mobility has declined and Resident #1 is not independent in bed mobility. The MDS codes Resident #1 as 2-2 which indicates limited assistance is required. Interview on 7/28/16 with Staff D (Assistant Director of Nursing) confirmed Resident #1's LNA (Licensed Nursing Assistant) had reported that Resident #1's abilities had declined and was requiring increased physical assistance. Staff D also confirmed that Resident #1 is not on a scheduled turning or repositioning program. Review of Resident #1's care plan was not updated to identify that Resident #1's ability to reposition in bed had declined nor that Resident #1 needed or required physical assistance with bed mobility for turning or repositioning for prevention of skin breakdown.

Based on medical record review and interview, it was determined that the facility failed to follow the professional standard of practice for pronouncing at the time of death for 1 resident and failed to follow the professional standard of practice for the administration of medications for 5 resident in a survey sample of 16 residents. (Resident identifiers are #5, #6, #12, #15 and #16.) Findings include: Reference is Fundamentals of Nursing, 7th Edition, MOSBY/ELSEVIER, 2009, Evolve, pages 479 - 480, reveal the following: Federal and state laws require that institutions develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care .Documentation of death provides a legal record of the event. Follow agency policy and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death . Nursing documentation becomes relevant in risk management or legal investigations into a death, underscoring the importance of accurate, legal reporting . Documentation of End-of-Life Care .Time and date of death and all actions taken to respond to the impending death Name of health care provider certifying the death Persons notified of the death (e.g. health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and who comes to the setting at the time of death Request for organ or tissue donations made and by whom Special preparations of the body (e.g., desired or required religious/cultural rituals) Medical tubes, devices, or lines left in or on the body Personal articles left on and secured to the body Personal items given to the family with description, date, time, to whom given Location of body identification tags Time of body transfer and destination Any other relevant information or family requests that help clarify special circumstances. Pages 1063 and ,[DATE] reveal the following: .One of the most subjective and therefore most useful characteristics for the reporting of pain is its severity, or intensity. A variety of pain scales are available for clients to communicate their pain intensity. Although different clients prefer different pain scales, it is important for you to select and consistently use the same scale with a specific client. You do not use a pain scale to compare the pain of one client to that of another client. Evaluation of pain is one of many nursing responsibilities the require effective critical thinking .The client's behavioral responses to pain-relief interventions are not always obvious. Evaluating the effectiveness of a pain intervention requires you to evaluate the client after an appropriate period of time. You need to continually assess whether the character of the client's pain changes and whether individual interventions are effective .You are successful in treating pain when the client's expectations of pain relief are met. Use evaluative criteria in determining the outcome of pain-relief interventions. Effective communication of a client's assessment of pain and his or her response to intervention is facilitated by accurate and thorough documentation. This communication needs to happen from nurse to nurse, shift to shift and nurse to other HCPs. It is the professional responsibility of the nurse caring for the client to report what has been effective for managing the client's pain. A variety of tools such as pain flow sheet or diary will help centralize information about pain management. The client expects you to be sensitive to his or her pain and to be attentive in attempts to manage that pain. Effectively communicating with primary HCPs will assist you in achieving optimal pain relief for clients. Review on [DATE] of Resident #12's nurses notes dated [DATE] revealed the following: [DATE] (,[DATE]) Resident died @ 5:20 p.m. peacefully, .was present ., PCP notified. Released to funeral home @ . Interview on [DATE] at 3:40 p.m. with Staff A (Vice President of Health Services) reviewed the above findings and Staff A confirmed that there was no documented evidence of an assessment at the end of life for the pronouncement of Resident #12. Review on [DATE] of Resident #12's Medication Administration Record [REDACTED] [MEDICATION NAME] 30 mg/ml liquid 0.25 ml po (by mouth)/sl (sublingual) q (every)1 (hour) prn (as needed), pain, SOB (shortness of breath) or dyspnea and [MEDICATION NAME] 20 mg/ml liquid 0.5 ml po/sl q (every) 1 (hour) prn, SOB (shortness of breath) or dyspnea. Further review of this MAR indicated [REDACTED]care & comfort. No documented evidence for the monitoring of the effectiveness of the individual doses of PRN (as needed) [MEDICATION NAME] was found during record review. Interview on [DATE] at approx. 3:40 p.m. with Staff A reviewed the above findings and Staff A confirmed that the documentation showed care and comfort listed for the reason that [MEDICATION NAME] 0.25 ml was administered and that there was no documentation for the 13 individual doses of [MEDICATION NAME] to show the effectiveness. There was no documentation to show that a higher dosage of [MEDICATION NAME] 0.5 ml was offered to Resident #12 to relieve pain, shortness of breath or dyspnea due to the lack of documentation for the effectiveness for the lower dose of [MEDICATION NAME] 0.25 ml. Resident #5 Review of Resident #5's Medication Administration Record [REDACTED] [MEDICATION NAME] Sodium 220 mg - 1 Tab by mouth every 12 hours as needed Resident #6 Review of Resident #6's Medication Administration Record [REDACTED] Tylenol 325 mg -650 mg by mouth every 4 hours as needed max 5 doses/3250/day [MEDICATION NAME] 10 milliters by mouth every 6 hours as needed [MEDICATION NAME] Migraine ,[DATE] mg tab by mouth every 6 hours as needed [MEDICATION NAME] 10 mg suppository rectally every day as needed [MEDICATION NAME] ,[DATE] 1 tab by mouth every 6 hours as needed [MEDICATION NAME] 25 mg tab 12.5 mg every day as needed [MEDICATION NAME] 220 mg by mouth every pm as needed do not exceed 3 tabs every 24 hours [MEDICATION NAME] 440 mg every day at bedtime as needed do not exceed 3 tabs every 24 hours Trazadone 50 mg tab 25 mg by mouth every day as needed Resident #15 Review of Resident #15's Medication Administration Record [REDACTED] Cal-Gest Assorted Flavors 200(500) mg tab chew, ,[DATE] tabs by mouth as needed - not within 4 hours of Levothyroxin Resident #16 Review of Resident #16's Medication Administration Record [REDACTED] [MEDICATION NAME] 5 mg by mouth every 8 hours as needed [MEDICATION NAME] ,[DATE] mg 1 by mouth every 6 hours as needed [MEDICATION NAME] 17 grams by mouth every day as needed Interview on [DATE] at approx. 1:45 pm with Staff C (RN) agreed that the indications for use were missing from the above orders.