Every finding on record at Whispering Pines Nursing & Rehab Center

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 27 residents whose MDS assessments were reviewed (Resident #67 and Resident #28).Findings included:1. Resident #67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease.Record review revealed Resident #67 had elected hospice care on 6/17/25.Hospice Nurse Practitioner documentation dated 5/30/26 noted Resident #67 likely has less than six months of survival and is appropriate for hospice.Review of Resident #67's most recent annual MDS assessment dated [DATE] was not coded that hospice care had been received. An interview with the MDS Coordinator was conducted on 7/30/26 at 2:00 PM. She explained an off-site MDS Nurse had coded Resident #67's MDS, and not including hospice care had been an error. During an interview with the Administrator on 7/30/26 at 3:06 PM she stated she expected MDS assessments to be completed accurately.2. Resident #28 had been admitted to the facility on [DATE].A Progress Note dated 5/21/26 at 11:47 AM indicated Resident #28 had been discharged home with home health services.Review of Resident #28's discharge return not anticipated MDS assessment dated [DATE] noted the discharge was unplanned.An interview with the MDS Coordinator was conducted on 7/30/26 at 2:00 PM. She explained staff use a discharge communication form and after reviewing one dated 5/20/26 she stated she had missed seeing Resident #28 was planning to discharge on [DATE]. She explained that Resident #28 had filed an appeal with the insurance company to continue her stay at the facility, but it had not been granted, and when Resident #28 discharged she thought it was unplanned. She stated this had been an error.During an interview with the Administrator on 7/30/26 at 3:06 PM she stated she expected MDS assessments to be completed accurately.

Based on record reviews and interviews with staff and the Physician, the facility failed to notify the physician when a resident with dysphagia (difficulty swallowing) had a choking incident when she was being fed dinner by a facility staff member for 1 of 3 residents reviewed for notification (Resident #42). Findings included:Resident #42 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type II, hemiplegia (complete or near-complete paralysis of one side of the body) and hemiparesis (partial weakness of one side the body) following cerebral infarction (stroke) affecting right non-dominant side and dysphagia.During an interview on 7/28/26 at 7:04 PM, Medication Aide (MA) #1 reported that on 9/14/25 at approximately 5:45 PM, Resident #42 had a choking episode while she (MA #1) was feeding Resident #42 her dinner meal. MA #1 explained that she had fed Resident #42 most of her meal and was feeding her breaded okra that had been cut to about 1/4 inch long pieces and were soft. MA #1 stated that she had fed Resident #42 some okra and there were about 2 pieces remaining when Resident #42 started coughing and MA #1 immediately called Nurse #1 to the room who came to assess Resident #42.A nursing progress note written by Nurse #1 dated 9/14/25 at 8:32 PM indicated Nurse #1 was called to Resident 42's room at around 5:45 PM. Resident #42 was observed to be discolored and had choked on a piece of okra. Nurse #1 placed Resident #42 on her left side and gave her back blows. A piece of Okra was expelled out orally and Resident #42's color returned to normal. Vital signs: Blood pressure: 124/82, Pulse: 84 beats per minute, Temperature: 97.0 degrees Fahrenheit, oxygen saturations: 94% on room air. Resident began talking and joking as usual.An interview was conducted on 7/28/26 at 7:09 PM with Nurse #1 she reported that she was called to Resident #42's room on 9/14/25 at around 5:45 PM by MA #1. When Nurse #1 entered the room, Resident #42 was coughing and trying to get the food out but continued to have difficulty. Nurse #1 stated that Resident #42 was unable to clear her throat and her skin looked discolored. Nurse #1 reported that she could not visibly see the food in the resident's mouth to perform a mouth sweep, so she positioned Resident #42 on her left side and performed back blows to expel the food. Resident #42 was able to successfully expel the food which appeared to be a piece of okra with the back blows. Resident #42 returned to her baseline and was laughing and joking with staff immediately after the episode. Her vital signs were stable and her lungs were clear. Nurse #1 stated that she entered a note of the incident in Resident #42's medical record but did not think to inform the physician or Resident #42's Responsible Party (RP) because Resident #42 was back to her baseline. Nurse #1 further stated that she could not recall if she had mentioned the choking episode to the oncoming night shift nurse (Nurse #4). Nurse #1 indicated that Nurse #3 who was the Registered Nurse (RN) Supervisor during that shift, was aware of the incident as she came into the room when Nurse #1 was assisting Resident #42 to expel the food.Attempts to interview Nurse #4 were unsuccessful.During an interview on 7/28/26 at 4:17 PM with Nurse #3 she revealed that she was the RN Supervisor on 9/14/25 when Resident #42 had a choking incident. Nurse #3 reported that when she entered the room Resident #42 was positioned on her left side and she was actively coughing out the food. She indicated that Resident #42 went back to her usual state after the coughing episode and her vital signs were stable. She indicated that she did not report it to anyone because she expected Nurse #1 to follow facility protocol and notify the physician and RP.During an interview with the Physician on 7/28/26 at 2:45 PM he reported that he could not recall exactly when he was notified of Resident #42's choking incident. He reported that he expected the facility to notify him or the on-call provider when any resident had a change in condition. He further stated that had been notified of Resident #42's incident on 9/14/25, the treatment would not have changed since Resident #42 was stable once she coughed up the food that she was having difficulty swallowing.An interview was conducted on 7/28/26 at 3:20 PM with the Director of Nursing (DON) and the Director of Operations. The DON reported that she became aware that Resident #42 had a choking incident when she was being fed dinner on 9/14/25 when she was in a regularly scheduled interdisciplinary team (IDT) meeting to discuss residents' conditions and go over progress notes on 9/16/25. The DON reported that when she read Nurse #1's progress note from 9/14/25 and asked Nurse #1 about the incident she realized that the physician had not been notified. The DON referred Resident #42 to speech therapy for evaluation and notified the physician of the choking incident with no new orders at that time. The DON indicated Nurse #1 should have notified the physician and Resident #42's RP on 9/14/25 when Resident #42 choked on her food on 9/14/25 during dinner. The DON reported that nursing staff were to follow facility policy and notify the physician and RP of any residents' change in condition or acute episodes that were out of the norm that could require further evaluation or change in treatment.The facility provided the following corrective action plan.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 9/14/2025 Resident #42, began to have difficulty with her meal. Medication Aide#1 was assisting Resident#42 with her meal and immediately notified Nurse #1. Nurse#1 came to room and assisted the resident with expelling the food by placing resident on her side and performing back thrusts. Resident #42 was able to cough and successfully expel the food. Nurse#1 reported that after Resident #42 expelled the food, Resident #42 immediately returned to baseline and was laughing and talking with staff. Nurse #1 obtained Resident #42's vital signs which were within normal limits as follows: Blood pressure: 124/82, Pulse: 84 beats per minute, Temperature: 97.0 degrees Fahrenheit, oxygen saturations: 94% on room air. The Medical Doctor (MD) and Resident Responsible Party (RP) were not notified of the incident by Nurse #1 per facility protocol.Resident #42 remained stable on 9/14/25 after the incident through 9/16/2025. Vital signs remained stable, oxygen saturation stable, and no further difficulty with meals.On 9/16/2025, the Director of Nursing (DON) became aware of choking incident during morning review of residents' notes. The physician was notified and a speech evaluation was requested. Resident #42 was stable.On 9/16/2025, Resident #42 was evaluated by the speech therapist and no change in diet was recommended. Resident #42 was able to safely tolerate mechanical soft diet with chopped meats and thin liquids as ordered.On 9/17/25, RP became aware of Resident #42's choking incident that occurred on 9/14/25 when Nurse #2 was notifying RP of physician orders for chest x-ray and blood work (complete blood count [CBC] comprehensive metabolic panel [CMP]) due to Resident #42's altered mental status on 9/17/25. During this conversation, RP stated that they were never notified that Resident #42 had a choking incident on Sunday, 9/14/25.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 9/17/25, Corporate Clinical Nurse Liaison completed 100% audit of resident documentation from 9/1/25 to 9/16/25 to ensure physician and RP notification of change in condition. There were no negative findings. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.100% of licensed nurses were in-serviced by the DON and/or designee in person, regarding physician and RP notification for resident change of condition and acute episodes. Education was completed on 9/17/2025, and any licensed nurse not in-serviced by that date received education prior to their next scheduled shift. Newly hired nurses would be trained on timely notification of residents' change in condition to physician and RP by the DON or designee. Nursing staff were educated to document residents' change in condition and notification in the residents' electronic records. Nursing staff were also educated to document in the residents' chart if a voicemail was left or if the nurse was unable to leave a voicemail.Beginning 9/17/25, nurse's notes would be reviewed by Interdisciplinary Team (IDT), daily during clinical IDT daily meeting. Any noncompliance was addressed by the DON and/or designee. If the physician and/or RP were not notified, notification was completed by end of that day. Nurses' notes were reviewed during the daily clinical IDT meeting for 3 months.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Notification of resident changes/acute episodes to RP and/or physician were audited by the DON by reviewing nurses' progress notes weekly x 4 weeks and then bi-weekly x 4, results were reported to QAPI (Quality Assurance and Performance Improvement) quarterly x 2 and any changes and updates were made as recommended by the team beginning with the September 2025 meeting.Alleged Date of Compliance: 9/18/25.Onsite validation of the corrective action plan was completed on 7/30/26. Interviews with nursing staff confirmed they received in-service training on immediately notifying RP and physician of a resident's change in condition or any acute episodes out of the norm. A review of sign off rosters revealed all licensed nurses had been trained on timely notification of residents' change in condition or acute episodes to RP and physician. A review of the audit tools revealed auditing had been completed as documented in the plan of correction.The corrective action plan compliance date of 9/18/25 was validated.

Based on record review and staff interviews, the facility failed to submit a request for an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted to the facility with diagnoses including post-traumatic stress disorder (PTSD) and depression for 1 of 3 residents reviewed for PASRR (Resident #2).Findings included:A PASRR Determination Notification letter dated 9/29/25 revealed Resident #2 had a Level I PASRR with no expiration date.A review of a North Carolina PASRR Level I screening form provided by the facility Director of Transitional Services revealed the hospital Social Worker had submitted a PASRR evaluation on 9/29/25 for Resident #2 that did not include the diagnoses of PTSD or depression.Resident #2 was admitted to the facility on [DATE] with diagnoses that included depression and PTSD.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #2's active psychiatric/mood disorder diagnoses included PTSD and depression. She received an antidepressant medication during the MDS assessment review period. During an interview on 7/29/26 at 10:35 AM with the facility Director of Transitional Services, he revealed that he was responsible for submitting requests for PASRR evaluations. He stated that Resident #2 was admitted to the facility with diagnoses of PTSD and depression and that her PASRR Level I screening form had been submitted by the hospital prior to her admission to the facility. He verbalized that he had not verified what diagnoses were included in the PSARR Level I screening that was submitted at the hospital prior to being made aware during this interview. He further stated that he should have verified that all of Resident #2's mental health diagnoses were included in the application and if not submitted another screening to ensure all the diagnoses were included. An interview was conducted on 7/30/26 at 10:03 AM with the Administrator. She stated that the Director of Transitional Services should have submitted a request for a PASRR evaluation for Resident #2 with all the diagnoses to include PTSD and depression when Resident #2 was admitted to facility. The Administrator explained that the Director of Transitional Services was supposed to review the admission diagnoses and request a PASRR evaluation within a month of admission.

Based on record review, Nurse Practitioner, and staff interviews, the facility failed to provide care safely when Nursing Assistant (NA) #1 and NA #2 transferred a resident who was dependent on staff assistance and unable to bear weight from his bed to chair by holding the resident under his arms. Resident #62 sustained an acute displaced left humeral (long bone in the arm between shoulder and elbow) neck fracture requiring use of a sling, orthopedic follow up, and resulted in pain for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #62). Findings included: Resident #62 was admitted to the facility on [DATE] and his most recent re-admission to the facility was on 1/23/23. His diagnoses included dementia, heart failure, osteoarthritis, and Parkinson's disease. Resident #62's Care Guide summary (no date) indicated he was totally dependent with transfers; he was non weight bearing and he required a sling lift for transfers. Resident #62's care plan initiated 1/23/23 indicated he was at risk for falls related to history of falls, increased weakness/decreased endurance, safety/impaired or decreased safety awareness. He displayed poor safety awareness and insight and was very impulsive in behavior. History of falls: 12/3/19 fall with no injury, 12/9/19 fall with no injury, 12/17/19 fall with no injury, 2/3/20 fall with no injury, 2/8/20 fall with no injury, 11/15/21 fall with no injury, 12/5/21 fall with no injury, and 3/20/23 fall with no injury. Interventions included: before transfers ensure floor surrounding bed is free from obstacles, whether in bed or chair ensure proper and safe body alignment, positioning and parameters for resident to maximize safety, assist to change position frequently for comfort. Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as cognitively intact. Resident #62 was dependent for transfers and required the assistance of 2 or more people. Resident #62 was coded as not exhibiting behavioral symptoms and not exhibiting rejection of care behaviors. He was coded as utilizing a manual wheelchair and was dependent on staff to utilize the wheelchair. He had no pain and was not receiving opioids. He was coded as having had a fall without injury. During an interview on 2/14/24 at 1:52 PM with NA #1, she stated she was told by Nurse #1 to transfer Resident #62 from the bed to the chair since his feet were hanging off the bed on 9/1/23 during the third shift that began at 11:00 PM and ended on 9/2/23 at 7:00 AM. She transferred Resident #62 from the bed to the chair with NA #2 without using the mechanical lift. She (NA #1) indicated she stood on one side of Resident #62 and NA #2 stood on the opposite side and they supported him by the arms and transferred him to the chair. NA #1 stated Resident #62 did not bear any weight or assist with the transfer. NA#1 verbalized she was aware based on Resident #62's Care Guide that he required a mechanical lift for transfers, but they went ahead with the transfer without obtaining the lift anyway since Resident #62's feet were off the bed. NA #1 verbalized Resident #62 did not complain of any pain during the transfer or after the transfer on 9/1/23 during the third shift that began at 11:00 PM and ended on 9/2/23 at 7:00 AM. Attempts to interview NA #2 were unsuccessful. During an interview on 2/15/24 at 8:07 AM with Nurse #1, she stated she had asked NA #1 and NA#2 on 9/1/23 11:00 - 7:00 AM shift to transfer Resident #62 to the chair since he had his foot hanging out of the bed. She stated they got Resident #62 out of bed because he was agitated and had his foot hanging off the bed. Nurse #1 verbalized she realized NA #1 and NA #2 had not used the mechanical lift to transfer Resident #62 out of bed because there was no sling under him when she came back to check on him shortly after he was transferred. She explained that he was seated at the Nurse's station. He did not complain of pain on 9/1/23 during the11:00 PM - 7:00 AM shift. During an interview on 2/15/24 at 8:07 AM with Nurse #1 she stated she became aware of pain/injury on 9/2/23 during the shift that began at 11:00 PM and ended on 9/3/23 at 7:00 AM when Resident #62 reported 4 out of 10 pain level to the right shoulder. Tylenol was administered for pain and was effective. An x-ray was done on 9/3/23 and showed he had a fracture to the left humerus. Resident #62 no longer resided at the facility and was unavailable for interview. A physician's order dated 9/3/23 indicated order stat (immediate) x-ray, 2 view of the left shoulder. Resident #62's x-ray radiology interpretation dated 9/3/23 findings indicated a fracture involving left humeral neck with slight medial displacement and mild osteoporosis. The impression was acute displaced left humeral neck fracture. A physician's order dated 9/3/23 indicated place arm in a sling and refer to Orthopedist next week. Nursing progress note dated 9/3/23 indicated Resident #62 requested pain medication, Tylenol (acetaminophen) was given and was effective. Resident #62's September 2023 Medication Administration Record (MAR) indicated a pain evaluation on a scale of 0 to 10 was conducted on each shift. Resident #62's pain level on 9/3/23 7:00 AM - 3:00 PM shift was documented as 4 out of 10, 3:00 PM - 11:00 PM shift was documented as 3 out of 10 and 11:00 PM - 7:00 AM shift was 0 out of 10. On 9/5/23 at 9:03 AM pain level was documented as 7 out of 10 and 650 milligram acetaminophen was administered. The pain level was documented as 0 or 1 out of 10 all the other days in September 2023. Resident #62's Emergency Department (ED) after visit Summary dated 9/5/23 indicated Resident #62 was seen at the ED for a shoulder injury. The diagnosis was encounter for closed fracture of left humeral head. Discharge instructions were to follow up with bone doctor, continue to use sling in place to avoid further bone injury and use over the counter pain medication. A physician's order dated 9/7/23 indicated to monitor sling in place to Resident #62's left arm every shift. Resident #62's Orthopedics assessment plan dated 9/27/23 indicated initial encounter for nondisplaced fracture of upper end of left humerus. The note stated he will continue with sling for comfort, extra strength Tylenol 2 tablets 3 times a day can be used for pain, follow up in 3 weeks. The physician's order dated 9/7/23 related to sling monitoring every shift was discontinued on 10/25/23. Facility Investigative Summary Review submitted on 9/7/23 by facility Administrator for Resident #62 indicated the resident complained of pain in his right shoulder on 9/3/23 at approximately 6:00 AM and he had swelling to the right shoulder. The resident stated the pain began about two days ago. An in-house x-ray was performed on 9/3/23 at approximately 4:05 PM, the x-ray report revealed a fracture involving the left humeral neck with slight medial displacement. Resident #62 was ordered a sling and ordered to follow up with orthopedic doctor. Staff investigations indicated Resident #62 was agitated on the night of 9/1/23 and Nurse #1 noted him with his foot hanging off the bed. Nurse #1 told Nursing Assistant #1 (NA #1) and Nursing Assistant #2 (NA #2) to get Resident #62 out of bed. NA #1 and NA #2 transferred Resident #62 from bed to chair without the lift. Facility actions indicated staff were in-serviced on transfer policy-not lifting/handling resident limbs, kardex following completing transfers and reporting incidents/accidents. On 9/2/23 education was initiated by the charge nurse with the nursing assistants (NA #1 and NA #2) who transferred the resident without the lift. Re-education again on 9/3/23 and on 9/7/23 one on one return demonstration and re-education was completed by the Director of Nursing with the two nursing assistants who provided the wrong transfer ensuring they check the Kardex before transfers and they must follow the plan of care. An interview was conducted with the Nurse Practitioner on 2/14/24 at 12:43 PM. She stated that an x-ray was ordered when Resident #62 complained of right shoulder pain (9/3/23) which showed a fracture to the left humerus. An order was given for the Resident to wear a sling. Pain was managed with Tylenol, and he was sent to the ED when he had increased pain (9/5/23). The ED and orthopedics discharge indicated to continue with same treatment, to wear sling and pain medication as needed. The NP stated NA #1 and NA #2 should have used the lift to transfer Resident #62 on 9/1/23 to ensure it was a safe transfer. An interview was conducted with the facility Administrator and Corporate Consultant on 2/15/24 at 2:20 PM. The Administrator stated Resident #62 complained of right shoulder pain on 9/3/23 and an X-ray was done on 9/3/23 which showed an acute fracture to the left humeral neck. The doctor gave an order to place the arm in a sling, pain medication and follow up with orthopedics the following week. The Administrator verbalized the facility completed a 24-hour report on 9/3/23 and conducted an investigation. The investigation revealed NA #1 and NA #2 had transferred Resident #62 from the bed to the chair on 9/1/23 during the third shift that began at 11:00 PM and ended on 9/2/23 at 7:00 AM without utilizing the mechanical lift. The Administrator explained, the 2 NAs stood on each side of Resident #62 and supported the Resident under his arms and transferred the Resident to the chair, Resident #62 did not bear any weight during the transfer. Resident #62 was sent to the Emergency Department (ED) on 9/5/23 due to increased pain. Diagnosis at the ED on 9/5/23 was closed fracture of the left humeral head. The Administrator stated under no circumstances should facility staff transfer Residents by their body limbs such as arms or legs. She further stated NA #1 and NA #2 should have used the lift to transfer Resident #62 on 9/1/23. The facility provided the following plan of correction with a compliance date of 9/8/23: 1. Corrective action for resident(s) affected: - On 9/3/23, Resident complained of pain to right shoulder pain. Nurse notified the doctor of the pain and an order was received for an x-ray to the left shoulder. The nurse instructed staff to get Resident out of bed to prevent him from trying to get up on his own. The two nursing assistants were interviewed, and they did get resident up into the chair without the mechanical lift, shortly after coming onto shift on 9/1/23 at approximately 11:20 pm. Staff got resident up and placed at the nurse's station. Resident had snack and was placed back to bed by the nursing assistants and the nurse using the mechanical lift. Charge Nurse verbally educated nursing assistants that they were supposed to use the lift. Charge Nurse did demonstrate proper use of the lift and assisted the nursing assistants with safe transfer of the resident back into bed according to the Resident's plan of care on 9/2/23 when the resident was put back to bed. - On 9/3/23 X-ray revealed fracture to the left shoulder. The doctor was notified of the results of x-ray and ordered sling to the left arm and Tylenol. - On 9/5/23 Resident reported increased pain and the doctor gave the order to send to the emergency room (ER) for evaluation. ER report stated closed fracture of humeral head, no dislocation on 9/5/23 x-ray, and no new orders were given from previous facility doctor's orders. ER stated to follow-up with orthopedics doctor. 2. Corrective action for resident(s) with the potential to be affected. - On 9/2/23, education began by the charge nurse with the nursing assistants who transferred the resident without the lift. Reeducation again on 9/3/23, and on 9/7/23, one on one return demonstration and re-education was completed by the Director of Nursing with the two nursing assistants who provided the wrong transfer ensuring they check the Kardex before transfers and they must follow the plan of care. - In-service was conducted with all other staff beginning 9/3/23 on the no-lift policy (no lifting residents by body parts such as arms, legs) and additional in-servicing was added on 9/7/23 checking the Kardex before transfers, and incident/accident reporting and protocols. 3. What measures/systems will be put into place to ensure the deficient practice does not occur again? - Facility implemented a Transfer Audit tool to monitor compliance with resident transfers to ensure residents are transferred according to the plan of care. 4. How will performance be monitored and how often? - Transfer audit log audits will be completed weekly x4 and monthly x3 thereafter by the Executive Director and quarterly thereafter to ensure compliance. Findings of the transfer audit compliance will be presented to the Quality Assurance Committee quarterly. Any non-compliance will be addressed by the QA Committee and the plan will be modified as needed. Compliance Date: 9/8/23 On 2/16/24 the facility's plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 9/3/23 and was completed on 12/27/23. Staff interviews with NAs and nurses verified education was provided on reviewing the kardex prior to providing care for residents. The training content included: locate and identify transfer status for resident, demonstrate proper mechanical pad placement, demonstrate proper use of mechanical lift from bed to chair/chair to bed, demonstrate proper stand and pivot technique with one/two person using gait belt and education on importance of facility no lift policy. The Director of Nursing (DON), Quality Assurance Nurse and Corporate Consultant verbalized they had conducted the initial training. Training check off sheets were noted to have DON's signature as the instructor. In-service for all facility staff started 9/3/23 and was completed on 9/7/23. The facility Executive Director (Administrator) stated she was responsible for ensuring all new hires were in-serviced. The Director of Nursing or Designee was responsible for transfer audits and monitoring compliance to ensure residents are transferred according to the plan of care. Transfer audits were noted to have been completed by DON and Quality Assurance Nurse. On 2/16/24 at 12:01 PM NA #3 and NA #4 were observed transferring a resident utilizing the mechanical lift according to the plan of care. The facility's plan of correction was validated to be completed as of 9/8/23.

Based on record review, Nurse Practitioner, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the focused infection control and complaint investigation survey of 8/18/22. This was for one deficiency in the area of Accidents/Hazards (F689) that was recited on the current recertification and complaint investigation survey of 2/16/24. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This tag is cross referenced to: F689: Based on record review, Nurse Practitioner, and staff interviews, the facility failed to provide care safely when Nursing Assistant (NA) #1 and NA #2 transferred a resident who was dependent on staff assistance and unable to bear weight from his bed to chair by holding the resident under his arms. Resident #62 sustained acute displaced left humeral (long bone in the arm between shoulder and elbow) neck fracture requiring use of a sling, orthopedic follow up, and experienced pain for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #62). During the focused infection control and complaint investigation survey of 8/18/22 the facility was cited at F689 for failing to ensure a resident, who was on an anticoagulant, did not fall from bed while care was being rendered with the bed in the elevated position. An interview was conducted on 2/16/24 at 12:59 PM with facility Administrator and Corporate Consultant. The Administrator stated the QAPI committee met monthly and committee members included: Administrator, Medical Director, Director of Nursing (DON), Nurse Manager, Dietary Manager, Dietician, Admissions Coordinator, Minimum Data Set (MDS) Coordinator, Environmental Services Director, Treatment Nurse, Social Services Director, Therapy Director, and Activities Director. The Administrator stated the committee discussed ongoing identified concerns to include prevention of accidents.

Based on record review and staff interviews, the facility failed to accurately code a resident's Minimum Data Set (MDS) assessment for 1 of 17 assessments reviewed (Resident #26). The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #26's significant change MDS, dated [DATE], revealed the facility had indicated Resident #26 had not been evaluated for a level II Preadmission Screening and Resident Review (PASSR) for question A1500. A review of Resident #26's medical record revealed a PASSR Level II Determination Letter Notification, dated 07/27/2021, with no expiration date. During an interview with the MDS Coordinator on 10/14/22 at 11:10 a.m., the coordinator stated Resident #26 was assessed as a PASSR Level II. The coordinator explained due to human error she had answered no to the question (A1500) on the assessment when she should have answered yes. The coordinator stated she had submitted a corrected assessment after it was brought to her attention. During an interview with the Administrator on 10/14/22 at 11:06 a.m., the Administrator explained the assessment had been coded incorrectly possibly due to human error. The Administrator stated it was her expectation that residents' MDS assessments are coded accurately.

Based on observation, record review, resident interview, and staff interview the facility failed to assure one (Resident # 2) of three residents reviewed for dental services received a dental referral for lost dentures. The findings included. Resident # 2 was initially admitted to the facility on [DATE]. The resident had three hospitalization s since initial admission; with his last facility readmitted documented as 6/10/22. Resident # 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 2's Minimum Data Set, dated dated [DATE], was coded as a significant change assessment. This assessment coded the resident as cognitively impaired, being edentulous, and as having no significant weight loss issues. Resident # 2's care plan, reviewed on 8/5/22, revealed staff had noted Resident # 2 wore dentures and might require assistance with placement, cleaning, and storing for safety when not in use. This had been added to the care plan initially on 10/13/21 and remained as an active part of his care plan as of the date of 8/17/22. The care plan included staff instructions on how to care for and store Resident # 2's dentures. It also noted, Be aware that resident may remove dentures and place on their food tray, night table, overbed table, etc. They may even wrap them in a tissue or napkin. Inspect surroundings to ensure dentures do not get disposed of in the trash. Resident # 2 was interviewed on 8/18/22 at 10:25 AM and reported the following. He had dentures at one time but they got gone. He had told someone but did not recall who he had told. They had looked for them and said they could not find them. He was able to eat his food okay, but if he had dentures, he would wear them. Resident # 2 was observed during this time to have no teeth or dentures. Nurse Aide (NA # 1) was interviewed on 8/18/22 at 1:50 PM and reported the following. She had cared for Resident # 2 directly and she never recalled he had dentures. She recalled that he had said he had lost them at the hospital when he first was admitted to the facility. NA # 1 reported she had worked with the resident in restorative dining and he had no problems chewing a mechanical soft diet. According to the record, Resident # 2 had two individuals who shared guardianship of his care. One of these individuals (Guardian # 2) was interviewed on 8/17/22 at 11:30 AM and reported the following. Resident # 2 had dentures when he was initially admitted to the facility and it was her recollection that they had been lost sometime after he was admitted . She had spoken to someone around December 2021 about them. According to Guardian # 2, the dentures had fit appropriately and Resident # 2 would wear them but there had been no efforts to replace them. The MDS (Minimum Data Set) nurse was interviewed on 8/18/22 at 12:50 PM and reported the following. Resident # 2 had an upper denture plate when he was initially admitted to the facility. She did not recall if he had ever had a lower denture plate. She had always invited the guardian to care plan and no one had reported that the dentures were lost or there was a need for him to see a dentist and therefore she had not realized there was a problem and he did not have dentures. The facility social worker was interviewed on 8/18/22 at 1:10 PM and reported the following. She had become employed as the social worker on 5/24/22 and no one had mentioned to her that Resident # 2 needed a dental consult or that his dentures were missing. It was the facility's procedure that if a resident lost their dentures, then the staff would try to locate them. If the dentures could not be found, then a consent would be obtained from the family/resident to be seen by the dentist. The facility had a dentist who came to the facility to see residents. She had not placed Resident # 2 on a list as a resident in need of a dental consult because she did not know there was a need. The Administrator and Facility Corporate Employee were interviewed on 8/18/22 at 9:15 AM and reported the following. It was validated that Resident # 2 had dentures when he was initially admitted to the facility but it was not known when they were lost or if they had possibly been lost during one of the hospital admissions. Guardian # 2 had called the corporate office on 6/30/22 and expressed a concern with the condition of his teeth but did not expound further. Following that the facility had obtained a dental consult and it took place on 7/7/22. The dentist had identified that that the resident needed services for an exposed root and they were in the process of getting consent to be signed for the exposed root. At the current time, he was still in need of that procedure. No one had mentioned to the Administrator that the resident had lost his dentures and he needed a new pair. The resident had never been seen by a dentist while at the facility prior to the date of 7/7/22. They tried to make sure all residents were seen annually by the contracted dentist who came into the facility, but no one had brought to their attention Resident # 2 needed to be seen prior to the date of 6/30/22. They were hoping to get the consent signed that day (8/18/22) for the exposed dental root and the work done that day also. A follow up interview was conducted with the Administrator on 8/18/22 at 1:20 PM. According to the Administrator it would be her expectation that if her staff knew the resident had dentures at one point and no longer saw he was using them or that he had lost them, it should have been brought to her attention so that he could be seen by the visiting dentist.

Based on observation, record review, resident interview, staff interview, and physician interview the facility failed to assure a resident, who was on an anticoagulant, did not fall from bed while care was being rendered with the bed in the elevated position. This was for one (Resident # 7) of three residents reviewed for falls. The findings include: Resident # 7 was admitted to the facility on [DATE]. The resident was [AGE] years of age and had a diagnosis of Alzheimer's disease, [CONDITION(S)], and muscle weakness. Resident # 7 was currently prescribed the anticoagulant [MEDICATION(S)] 20 milligrams every day. This medication had been initiated on 5/10/22. Resident # 7's admission Minimum Data set Assessment, dated 5/16/22, coded the resident as moderately cognitively impaired and as needing extensive assistance from two staff members for bed mobility. The resident was also coded as having experienced a fall during the month prior to admission. Resident # 7's quarterly MDS Assessment, dated 8/5/22, coded the resident as cognitively intact and as needing extensive assistance with bed mobility from two staff members. This quarterly assessment coded the resident as not experiencing any falls since the admission assessment. Resident # 7's care plan, last updated on 8/17/22, revealed the staff identified the resident needed help with her activities of daily living due to weakness, decreased endurance, and decreased motivation. This had been originally added to the care plan on 5/17/22 and remained as part of the active care plan. Staff were directed on the care plan that sometimes residents may not be aware of their physical limitations. Identify and intervene for impulsive actions or altered judgement of resident's abilities and intervene PRN (as needed) for safety .ie assistance walker lock wheelchair etc. Resident # 7's care plan also identified she was at risk for falls related to multiple factors including hx (history) of falls (recent), increased weakness/decreased endurance, meds that may compromise balance, safety/impaired or decreased safety awareness/lack of coordination, pain associated with dx/new and unfamiliar environment, cognitive/communication deficits/sensory deficits/etc. This had also been added to the resident's care plan on 5/18/22 and remained as part of her active care plan. One of the interventions directed staff to ensure adequate staff support for safety compromising activities for resident and staff safety .be aware resident may require more staff support at times depending on time of day, fatigue, pain associated with dx (diagnosis), emotional status, etc. Adjust support to accommodate resident's current needs. Resident #7's August 2022 ADL Assistance Support log was reviewed. This log contained documentation by the resident's nurse aides regarding the amount of assistance the resident had required each day for bed mobility. From 8/1/22 to 8/17/22, of 87 entries noting assistance, the following was documented for bed mobility. The number 4 was documented 39 of the 87 times; indicating total staff assistance was rendered for bed mobility. The number 3 was documented 24 of the 87 times; indicating extensive assistance was rendered for bed mobility. The number 2 was documented 23 of the 87 times; indicating limited assistance was rendered for bed mobility. The number 0 was documented one of the 87 times; indicating the resident was independent. For each of the 87 times, the Nurse Aides documented they rendered bed mobility with one person assist. On 8/15/22 at 9:26 PM, Nurse # 1 documented the following. Writer was notified @ 2:08 PM by Med Aide (MA # 1). Writer observe NA (Nurse Aide # 2) and resident on left side of bed, bed still in high position, resident lying on R (right) side with back facing the window head to the head of bed and legs stretch out on the floor with even and unlabored breathing with no signs of distress. R arm was tucked under resident. Resident was dressed with brief only. Writer asked NA what happen. NA stated she was giving resident a bed bath and changing the linen when resident was resting on left side bilateral legs was hanging off bed and when she went to pull the fitted sheet resident rolled out of bed. Writer asked resident what happened resident stated she felt a push and rolled out of the bed. Resident complains of pain to R shoulder 5/10, bruise to R knee, hematoma to R elbow with skin tear, bleeding noted. Treatment follows: cleanse w/ns (With normal saline), pat dry, apply ABD pad, cover w/[MEDICATION(S)] (dressing) daily. Redness noted to R side of face, no discoloration bruising noted at this time. Resident assist back to bed assist X 4, + ROM (range of motion), PEARRLA (pupils equal, round reactive to light and accommodation). The nurse further documented the physician was notified and orders received to do a right shoulder x-ray. The resident's vital signs were also documented to be temperature 97.3, pulse 79, respirations 19, blood pressure 150/81 and oxygen saturation 96%. Further review of the record revealed the staff continued to perform neuro checks with no change in the resident's neurological status noted. A nurse noted on 8/16/22 at 6:28 AM that the resident had slept all night without distress. A nurse noted on 8/16/22 at 8:15 AM that the resident's right shoulder x-ray was negative for fracture and acute process. NA # 2 was interviewed on 8/16/22 at 3:10 PM and again on 8/17/22 at 5:10 PM and reported the following about the incident. She had completed a bed bath for the resident and was in the process of changing the resident's linens with the resident in the bed. If entering the room, the head of the bed was against the left wall and the window was on the other side of the bed. She (the NA) had been standing on the doorway side of the bed and she (the NA) had the resident turned on her left side facing the window (away from her) when the incident occurred. There was a partial rail at the top of the bed and it was up. Resident # 7 was in the middle of the bed while she was changing the linen. The resident was holding onto the partial rail during the linen change. Then the resident let go of the rail and as she did her whole body went down and into the floor. The bed was flat at the time. It happened quickly. The resident landed on the window side of the bed (the way she had been turned to). She (the NA) stayed with the resident and called immediately for help. She felt she had done everything she had been trained to do and did not know how the resident could have fallen out of bed. Her feet were not dangling before she turned loose of the rail, but as she turned loose from the rail her whole body started to move. NA # 2 reported some days were better than other days in regards to the resident's mobility, and the resident usually followed directions. Nurse # 1 was interviewed on 8/16/22 at 1:28 PM and reported the following. She had been notified by a medication aide that NA # 2 was reporting Resident # 7 had fallen. When she entered the room, the resident was on the floor next to the window. She had a hematoma to the right arm, skin tear to right arm, and a bruise to the knee. She could tell from observing the partially placed bed linens that NA # 2 had been in the midst of changing the resident's linens. She (Nurse # 1) checked the resident's neurological status and continued to do so. Her neurological status remained fine. The Rehab Director was interviewed on 8/17/22 at 10:10 AM and reported the following. They had recently worked with Resident # 7 and she had been discharged to restorative. The resident needed contact guard assistance for bed mobility and she could ambulate approximately 20 to 30 feet in the parallel bars. She did not know how the resident could have fallen out of bed during care. A Facility Corporate Nurse was interviewed on 8/17/22 at 12:30 PM and reported the following. The facility administrative staff had talked to Nurse Aide # 2, investigated the fall, and had not found anything the Nurse Aide had failed to do correctly. The Facility Corporate Nurse stated the resident had been assessed by the rehabilitation staff to need one person assist and that was being provided at the time. According to the Facility Corporate Nurse, she felt the resident had initiated movement that NA # 2 did not anticipate, and the fall was unavoidable. Resident # 7 was interviewed on 8/17/22 at 11:10 AM and reported the following. She stated she was okay from the fall. She recalled the incident occurring and that she was closer to the side of the bed rather than the middle of the bed when the incident occurred. Resident # 7's psychiatrist was interviewed on 8/18/22 at 12:00 PM and reported Resident # 7 had significant cognitive deficits related to her dementia and underlying depression. Resident # 7's physician was interviewed on 8/18/22 at 11:18 AM and reported it was his opinion that the resident had not experienced any significant harm from the incident.

Based on staff interview and record review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for a resident with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #11 coded as moderately cognitively impaired needed extensive assistance with bed mobility, toilet use, and dressing and needed total dependence on staff for transfers. The comprehensive care plan dated 08/21/2021 had focus' of a cognitive, communication deficits. This deficit may result in behavior issues, indifference, unmet needs, increased confusion with wandering behaviors, paranoia, impulsive/unsafe behavior, perseveration (fixation on/repetition of) and may progress requiring adjustments to treatment/care plan to enhance quality of life. A reviewed of the North Carolina Department of Health and Human Services PASRR level I determination notification dated 07/12/2017 revealed the level I screen and PASRR number remains valid for the individual's stay. A copy of this notice should be transferred with the individual if he/she relocates to another nursing facility. No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the diagnosis/history sheet dated 10/12/2021 revealed Resident #11 was diagnosed with vascular dementia without behavioral disturbance 10/10/2017, vascular dementia without behavioral disturbance 05/01/2020, vascular dementia with behavioral disturbance 04/23/2020, [CONDITION(S)] with hallucinations 05/01/2020, unspecified [CONDITION(S)] not due to a substance 10/19/2017, other specified depressive episodes 05/01/2020. An interview with the Social Worker (SW) was conducted on 10/12/2021 at 3:58 PM. The SW stated when there is a new mental health diagnosis, they are supposed to refer the resident for a new PASRR level II screening. The SW also stated she was a new employee that started 10/04/2021. An interview with the Administrator was conducted on 10/12/2021 at 4:22 PM. The Administrator stated when a resident has a new mental health diagnosis, there should be a screening for a PASRR level II. The Administrator also stated a PASRR level II screening was not in place due to a letter from the Physicians stating the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS, a tool used for resident assessment) for 1 of 37 resident assessments reviewed (Resident #84). The findings included: Resident # 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge Minimum Data Set ((MDS) dated [DATE] indicated Resident # 84 was discharged to acute hospital. Review of the nurse notes dated 4/26/2019 and the medical record indicated Resident # 84 was discharged home . During the interview on 6/20/2019 at 1:29 PM, Minimum Data set (MDS) nurse reviewed the discharge MDS and confirmed it was inaccurate. The MDS nurse explained it was coded in error as Resident # 84 was discharged home not in acute hospital. During an interview on 6/20/2019 at 2:30pm with the DON (Director of Nursing), she indicated that discharge to the community should have been coded on Resident # 84's MDS dated [DATE]. During Further interview with DON, she stated that it is her expectation that the MDS should be coded accurately.

Based on record review, observation and staff interview the facility failed to cover catheter bags for 1 of 1 resident (Resident #236) reviewed for catheter care. Review of Resident #236's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Minimum Data Set (MDS) assessment data was not available at the time of the Recertification Survey. Review of Resident #236's most recent MDS dated [DATE] coded the resident as severely cognitively impaired. Resident #239 required extensive assistance of 2 staff with bed mobility, transfer, dressing, personal hygiene and toilet use and limited assistance of 1 staff with eating. He was assessed as needing total assistance with bathing. On 06/18/19 at 11:44 AM Resident #236 was observed in bed with bilateral nephrostomy tubes with each tube connected to a catheter bag. There were no privacy covers to either of the drainage bags. Resident #236 was alert and oriented, able to recall some of his medical history and had a clear understanding of the purpose of his nephrostomy tubes. On 6/19/19 at 09:40 AM, Resident #236 was preparing for a Doctor's appointment. The Nephrostomy collection bags were noted and there were no privacy covers on either of Resident #236's drainage bags. On 06/19/19 at 0950 AM, the Medication Tech (MT) #1 stated that the resident was preparing to leave the facility for an appointment. The resident had come to the facility from the hospital with catheter bags as they were. She further stated that normally Med Tech's or the Nurses will replace these bags when there is no cover and she was waiting for staff to bring them so she could change them out. 6/20/19 at 08:50 AM Resident #236 was observed in his bed with no privacy bags noted to his left and right nephrostomy tube drainage bag. The resident stated they were still trying to locate something to go over the bags, but he was not sure what it was called. On 06/21/19 at 10:24 AM, the Director of Nursing (DON) stated that Resident #236 had catheter bags attached that came from the hospital. The facility did not have privacy catheter bags available and they had to be obtained from a sister facility. Resident #236's catheter bags have now been covered as of the evening of 6/20/19. All catheter bags should have a cover for the privacy and dignity of the resident.

Based on record review and staff interview the facility failed to notify a resident of a room change for 1 of 1 resident reviewed for room change (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #49's most recent Minimum Data Set (MDS) assessment dated [DATE] coded her as cognitively intact. Resident #49 required extensive assistance of 2 staff with bed mobility, transfer, dressing, personal hygiene and toilet use. She was assessed as needing total assistance with bathing. Review of facility records indicate Resident #49 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER]B. Review of the facility's Room Change/Roommate Assignment Policy revised (MONTH) 2008 states Prior to changing a room or roommate assignment all parties involved in the change/assignment will be given a written advanced notice of such change, and will include the reason(s) for such change. Review of a facility note dated 06/21/19 from the Admissions Coordinator stated On 06/14/19, I advised the housekeeping supervisor to in-service his staff of the room change process: room changes only occur once the email notice has been sent. 06/18/19 05:26 PM Resident #49 stated during an interview that she was aware that she was changing rooms due to her therapy being complete but did not know when or where she was going. She asked several of the staff and no one was able to tell her any information about her transfer. Resident #49 stated that it caused a lot of confusion for her as well as her family because they would not know where to find her. She stated that she had requested to be close to the bathroom, so she could wheel herself to the bathroom unassisted by staff. Resident #49 stated that she was transferred from the 500 hall to the 200 hall on 06/13/19. On 06/21/19 at 02:15 PM during an interview with the Admissions Coordinator, she stated Resident #49's room change was discussed in stand-up meeting on 06/13/19 and she was made aware that the resident requested to be moved to a room with her bed close by the bathroom. On the evening of 06/13/19, the housekeeping staff moved the resident without the proper notice. On the morning of 06/14/19, when she was made aware of this, she immediately knew the procedure had not been followed because the resident's assigned bed was not close to the bathroom as Resident #49 had requested. On 06/21/19 at 03:18 PM The Housekeeping assistant supervisor stated normally receive an email about bed changes. Once the room is cleaned, a tent card is placed on the bed notifying nursing staff to make the bed. After the room is ready, housekeeping staff gathers resident's belongings and transports the resident to new location and nursing staff transports the resident. The Housekeeping assistant supervisor stated she was not on duty during the transfer but was aware that a transfer was pending from the stand-up meeting on 06/13/19. An interview was conducted with the Social Worker (SW) on 06/21/19 at 3:30 PM. The SW stated that Resident #49's room change was discussed in the 6/13/19 morning meeting, however, it was not finalized from Admissions. She further stated that Resident #49 was moved after she left for the day on 06/13/19 and when she returned on 06/14/19, she was made aware of the transfer. No notice had been sent out, so she was unsure what occurred during the transfer. Normally after all paperwork is completed, the Department heads receive the room change notice via email and the Nursing staff are notified via a written notice that it is okay to move the resident. She further stated that she did not notify the resident of the room change. An interview with the Director of Nursing (DON) was conducted on 06/21/19 at 10:24 am. She stated that there was a breakdown in communication regarding the transfer of Resident #49 within the housekeeping department. The housekeeping supervisor has been advised to in-service his staff of the room change process so that room changes only occur once the email notice has been sent.

Based on record review and staff interviews the facility failed to develop a Care plan for [MEDICAL CONDITION] drug use for 1 of 5 residents reviewed for [MEDICAL CONDITION] medication (Resident # 68). The findings included: Resident # 68 was admitted to the facility on ,[DATE]/ (YEAR) and had a [DIAGNOSES REDACTED]. The significant Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, required extensive assistance with activities of daily living (ADLs). The MDS revealed the resident was taking antianxiety and antidepressant medication 7 days. The Care Area Assessment (CAA) summary sheet revealed [MEDICAL CONDITION] drug use was not completed and problem area was not checked to be addressed in the resident's care plan. Review of the resident ' s Comprehensive Care Plan dated 11/06/2018 and reviewed on 2/16/2019 contained no information or interventions regarding the [MEDICAL CONDITION] drug use. Review of Medication Administration for Resident # 84 revealed the resident was taking the following medications: [REDACTED] [MEDICATION NAME] and [MEDICATION NAME]. An interview was conducted with MDS Nurse #1 on 6/19/2019 at 1:15 PM. The MDS Nurse was observed to review the Care Plan for Resident # 68. The MDS Nurse stated she did not complete a Care Plan for [MEDICAL CONDITION] drug use for the resident and stated, I missed it. The Administrator stated in an interview on 6/19/19 at 12:52 PM she expected [MEDICAL CONDITION] drug use to be care planned per results of the Care Area Assessment.

Based on observation, staff interviews, and facility policy review, the facility failed to dispose/discard expired medications in 1 of 2 medication storage rooms (100/200 hall) and 1 of 5 medication cart (300/400/500 medication cart) observed for medication storage. Findings included: A review of the facility policy titled, Medication Storage In The Facility with an effective date of 10/1/17, that was provided by the Director of Nursing (DON) read in part: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. 1. An observation of the 100/200 hall facility medication storage room was conducted on 7/11/18 at 9:05 am. During the observation, there were seven boxes of 5 milliliter (ml) multi dose Influenza Vaccine vials, noted to have an expiration date of 6/30/18 in the medication refrigerator. During an interview with Nurse #1 at 9:09 AM on 7/11/18, the nurse verified that the vials were expired. She said that she had looked through the refrigerator earlier in the week, and had missed seeing those vials. She said the vials should have been discarded. 2. The nurse medication cart for 300/400/500 hall was observed with an expired open vial of [MEDICATION NAME] 10% for nebulizer treatment. The vial was opened on 6/22/18 and the medication instruction stated it's only good for 96 hours. Nurse #2 was interviewed right after the medication cart audit and she stated that the medication should have been removed from the cart. An interview was conducted with the Director of Nursing (DON) on 7/12/18 at 3:40 PM. The DON validated that the vials were expired, and should have been discarded.

Based on observation, record review, resident interviews, family interviews and staff interviews for one (Resident # 1) out of three sampled residents with a history of falls, the facility failed to assure a nurse aide followed facility fall prevention training to prevent injuries. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the resident's quarterly MDS (Minimum Data Set) assessment, dated 2/7/17, revealed the resident was severely cognitively impaired. The MDS also coded the resident as having impaired vision and the need for two staff members to assist for transfers. Review of the resident's care plan revealed the staff identified on the resident's care plan on 1/14/16 that Resident # 1 was at risk for falls. A problem was entered on this care plan as, (Resident # 1) is at risk for falls r/t (related to) her impaired mobility, dependence on staff, restless behavior/poor safety awareness, use of diuretics, narcotic analgesics and overall compromised health status. There were multiple interventions added to the care plan to address the resident's risk for falls. One of these interventions was that she required two staff members to assist with transfers. Review of nursing notes revealed an entry on 4/20/17 at 7:46 PM by Nurse # 1 noting that the resident had been found on the bathroom floor at 5:30 PM with her brief and pants lowered around her thighs. Review of x-ray reports, dated 4/20/17 and 4/25/17, revealed the resident was identified to have fractures of the 4th, 5th, 6th, 7th, and 8th ribs following this incident. Interview with the Administrator and DON (Director of Nursing) on 5/16/17 at 12:45 PM and again at 4:55 PM revealed the following information. The facility had conducted an investigation into the incident and found Nurse Aide (NA) #1, who had been involved in the incident, had ignored her facility training by transferring the resident without assistance and by leaving the resident unattended while in the bathroom. According to the DON and Administrator the facility provided training upon orientation to every nursing staff member in regards to the facility's fall prevention program, and continued to provide ongoing training even after employment. The Administrator and DON provided documentation verifying that NA # 1 had received training on multiple occasions regarding fall prevention policies in the facility. The DON and Administrator provided the content material which was covered within their program. The program material included information to staff that residents with dementia and with a history of previous falls were considered high risk for future falls. It also included the information that residents, who were at high risk, were to never be left in the bathroom alone. Within the fall prevention program staff were directed to be aware of residents' care plans and the kardex (care guide). According to the DON and Administrator, on the evening of the accident, NA # 1 had assisted Resident # 1 by herself to the bathroom around dinner time. The Administrator and DON stated the resident at times needed a longer time in the bathroom and NA # 1 had stayed with her for a time period when she heard the announcement that dinner trays were on the hall. The Administrator and DON stated NA # 1 then left the resident to go and start delivering dinner trays, and checked on her in between passing trays. According to the Administrator and DON, staff were trained that all residents are considered at risk for falls due to the fact that they are not in their home environment. The Administrator and DON stated for more than a year there had been signs in all residents' bathrooms directing staff that a resident should never be left unattended on the toilet. The DON stated NA # 1 acknowledged she saw the sign, but still decided to go and deliver the dinner trays. The DON and Administrator stated on the evening of the incident, another NA heard the resident calling and discovered her on the bathroom floor. NA # 1 was interviewed on 5/16/17 at 2:15 PM. NA # 1 stated on the evening of the incident she had not checked the resident's kardex before her shift. She stated she had cared for Resident #1 before. She stated the medication aide told her around dinner time that Resident # 1 needed to go to the bathroom, and she assisted her onto the toilet without getting assistance from another staff member. The NA stated she stayed with her for about five minutes before hearing the announcement that dinner trays were on the hall. NA # 1 stated she told Resident # 1 she was going to check on the dinner trays and she would be right back. She said the resident responded, Okay. NA # 1 stated she went across the hall and delivered one tray and returned to find Resident # 1 still was not done. NA # 1 stated she told her again she would be back and went to deliver another tray. The NA stated before she could return from delivering this tray, another NA came to her and told her Resident # 1 was on the floor. The NA stated she had not thought Resident # 1 would try to stand up while she was gone. On 5/16/17 at 3:45 PM it was observed that there was a visible sign in the resident's bathroom located above the toilet that read, Do not leave resident unattended on toilet. Resident # 1's responsible party and a family member of Resident # 1's roommate were present at this time. Both of these family members stated the sign had been present prior to Resident # 1's fall on 4/20/17. Nurse Aide # 2 was interviewed on 5/16/17 at 4:06 PM. The NA stated she had been employed by the facility for two years and the signs to not leave residents in the bathroom unattended had always been there during that time. The NA stated she was taught this during her initial orientation at the facility. NA # 3 was interviewed on 5/16/17 at 4:15 PM and stated she had been employed for three years. NA # 3 stated she had been taught not to leave a resident unattended on the toilet in the bathroom. NA # 4 was interviewed on 5/16/17 at 4:20 PM. The NA stated she had been employed for two years, and as long as she could recall there had always been signs in residents' bathrooms to not leave residents unattended on the toilet. The NA stated she had also received training regarding resident safety on orientation and throughout her employment at intervals. Interview with the Administrator and DON on 5/16/17 at 12:45 PM and again at 4:55 PM revealed they had addressed the incident within their quality assurance program and had initiated a plan of correction starting 4/21/17 and completed in-services and audits by 5/8/17. Specifically the Administrator and DON provided documentation the following measures were taken. In regards to Resident # 1 the resident was evaluated by the NP (nurse practitioner) on 4/21/17 and 4/24/17, and also evaluated by the physician on 4/24/17 and 4/27/17. Both the NP and physician provided orders to address the resident's pain management and measures to prevent respiratory complications following the rib fractures. On 4/21/17 a physical therapy evaluation was conducted to determine the resident's transfer status during the healing process. The facility met with the resident's family on 4/21/17 to discuss the incident. They had evidence of a thorough investigation into the incident. They provided evidence an initial report was filed within 24 hours and a final report within five days to the state health care personnel investigations regarding the incident. On 4/21/17 they confirmed Resident # 1's transfer status was correct within the Kardex system and the care plan. They placed on Resident # 1's Kardex and care plan not to leave her unattended on the toilet. They provided evidence they had identified other residents at risk for similar accidents. On 4/21/17 they began reviewing 100% of their residents' Kardex and care plans to assure accuracy. This was completed by 5/2/17. They reviewed nursing staff files to determine if each employee had a skills checklist completed within the past year, and for those who had none within the past year, they required the checklist to be completed by 5/8/17. Regarding measures to prevent the reoccurrence they did the following. Within their review of the Kardex system, they placed each resident's cognitive status on the Kardex information to alert staff to the severely cognitively impaired residents. The Administrator and DON stated they still continued their policy that no residents should be left unattended in the bathroom, but they also reinstated their fall leaf program to alert staff to those residents who had greater risk factors. This information was included on the Kardex. They re-inserviced their staff on transfers, fall prevention, and accessing the Kardex/care plan system. The inservices were completed on 4/26/17. Through audits, they required all of their NAs to show they could access the Kardex system correctly and transfer the resident per the resident's plan of care which was on the Kardex. Audits were completed on 4/29/17. The facility planned to continue the transfer audits weekly and the findings were to be discussed within clinical meetings. Ten percent of their residents were to be audited weekly on an ongoing basis to assure care was being provided by the Kardex system/care plan. Any non-compliance issues identified in their audits were to be discussed on an ongoing basis within their quality assurance monthly program. The following measures were taken to verify the facility's implementation of their correction plans. Interviews were conducted with nurse aides during the complaint investigation, and the nurse aides were able to validate they were knowledgeable regarding fall prevention policies of the facility and where to access residents' care plan information. Other residents, who had sustained falls since Resident # 1's incident, were reviewed and these reviews did not reveal deficient practice in regards to the facility's fall prevention program.

Based on observation, record review, resident interview, and staff interviews the facility failed to give pain medication per the plan of care for one (Resident #6) of six sampled residents who were interviewed regarding their care. The findings included: Record review revealed Resident # 6 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of records revealed that prior to his facility residency, the resident had been hospitalized from [DATE] to 4/3/17 due to an abscess and [MEDICAL CONDITION]. A physician documented in the resident's hospital history and physical that the resident was alert and oriented. The physician also noted Resident # 6 experienced pain both from his wound and also from bilateral fractures of his feet which he had sustained in the six months prior to his hospitalization . Review of Resident # 6's admission care plan, dated 4/3/17, revealed the facility had identified pain was a problem for the resident. The facility's goal for the resident was that he be as comfortable as possible. One of the listed care plan interventions was to administer pain medications as ordered. Review of Resident #6's orders revealed a 4/3/17 order for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) to be administered every six hours PRN (as needed) for pain. According to the order the resident was to receive 1 tablet if he reported his pain to be a 4 to 7 on a pain scale of 1 to 10. The resident was ordered to receive 2 tablets if he reported his pain to be an 8 to 10 on a pain scale of 1 to 10. Review of Resident #6's MAR (medication administration record) revealed on 4/4/17 at 6:35 PM Medication Aide # 1 had documented Resident # 6's pain was an 8. According to Resident # 6's controlled drug record the resident received only one tablet of [MEDICATION NAME]-[MEDICATION NAME]. Resident # 6 was interviewed on 4/5/17 at 9:00 AM and reported he had not rested well the previous night. Resident # 6 stated he had broken both of his ankles recently, and at times he experienced spasms and sharp pain that would run up his leg. The resident stated he was supposed to get two pain pills if his pain was an 8 or more on a pain scale. The resident stated the medication person was supposed to have given him two pain pills the previous night and he only received one. Resident # 6 stated the one pain pill only worked for about 45 minutes to an hour and he had talked to the medication person about the incorrect number of tablets he had received. Resident # 6 stated the medication person acknowledged he was supposed to have received two tablets instead of one, but she never gave him another pain pill. The resident stated he couldn't understand why she would acknowledge he was supposed to receive more but still not give it to him. The resident stated since the medication person knew he should have gotten two pills instead of one and didn't do anything about it, he then decided not to bother the staff anymore that night. Nurse # 1 was interviewed on 4/5/17 at 1:15 PM. Nurse # 1 reviewed the record and stated Resident # 6 should have received two pain pills the previous night. Nurse # 1 stated there was a way the pain medication order could have been entered into the computer system in order that it would have alerted a medication aide or nurse to give the correct number of tablets based on a resident's report of pain level. Nurse # 1 stated Resident # 6's [MEDICATION NAME] order had not been entered into the computer in this manner when Resident # 6 was admitted on [DATE]. Therefore Nurse # 1 stated the computer had not flagged to the medication aide that she was not giving the correct number of tablets. Nurse # 1 was observed on 4/5/17 at 1:15PM to correct how the order was entered into the computer. Medication Aide (MA) # 1 was interviewed on 4/6/17 at 12:45 PM. MA # 1 stated she had only given Resident # 6 one [MEDICATION NAME]-[MEDICATION NAME] tablet when she should have given him two tablets on the night of 4/4/17. The MA stated Resident # 6 did bring it to her attention that he should have received two pain tablets rather than one, and she had acknowledged to him that he was correct and she had made an error. The MA stated three or four hours had passed when Resident # 6 brought it to her attention, and she did not give him the second tablet at that time. MA # 1 stated she feared if she had done so and Resident # 6 then requested pain medication at the six hour PRN interval he might have had three pain pills within too close of a timeframe. MA # 1 stated she therefore asked Resident # 6 to wait until a full dose would be available, and she would tell the nurse he could have two. MA # 1 attributed the pain medication error to having too many demands placed on her. MA #1 stated residents, families, and nursing assistants would interrupt her while she was trying to concentrate on accuracy of her medication pass. MA # 1 stated 4/4/17 was such a demanding night and in addition to making the error with Resident # 6's pain medication, she also almost gave another resident the wrong medication. MA # 1 stated she was stopped by this other resident who was alert enough to recognize the error. MA # 1 stated she had come to the conclusion she could not safely administer medications and meet the other demands of the unit, and she had submitted her resignation as a MA the next day. Nurse # 2 was the licensed night nurse for Resident # 6 on 4/4/17. Nurse # 2 was interviewed on 4/6/17 at 5:30 PM. Nurse # 2 stated on the night shift of 4/4/17, MA # 1 had reported to her Resident # 6 could have pain medication again at 12:45 PM. Nurse # 2 stated when she had checked on the resident during the night she had found him to be sleeping. Nurse # 2 stated the unit, on which Resident # 6 resided, was a very demanding unit and there were often interruptions in a staff member's work. The DON (Director of Nursing) was interviewed on 4/6/17 at 3:15 PM. The DON stated MA # 1 worked part time and had not been as familiar with Resident # 6's unit. The DON stated medication aides were asked to try to meet residents' other requests if they could do so while giving medications.

Based on record review, resident interview, and staff interviews the facility failed to implement the plan of care related to pain management for one (Resident #6) of six sampled residents who were interviewed regarding their care. The findings included: Record review revealed Resident # 6 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of hospital records revealed that prior to his facility residency, the resident had been hospitalized from [DATE] to 4/3/17 due to an abscess and [MEDICAL CONDITION]. A physician documented in the resident's hospital history and physical that the resident was alert and oriented. The physician also noted in the history and physical Resident # 6 experienced pain both from his wound and also from bilateral fractures of his feet which he had sustained in the six months prior to his hospitalization . Review of Resident # 6's admission care plan, dated 4/3/17, revealed the facility had identified pain was a problem for the resident. The facility's goal for the resident was that he be as comfortable as possible. One of the listed care plan interventions was to administer pain medications as ordered. Review of Resident #6's orders revealed a 4/3/17 order for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) to be administered every six hours PRN (as needed) for pain. According to the order the resident was to receive 1 tablet if he reported his pain to be a 4 to 7 on a pain scale of 1 to 10. The resident was ordered to receive 2 tablets if he reported his pain to be an 8 to 10 on a pain scale of 1 to 10. Review of Resident #6's MAR (medication administration record) revealed on 4/4/17 at 6:35 PM Medication Aide # 1 had documented Resident # 6's pain was an 8. According to Resident # 6's controlled drug record the resident received only one tablet of [MEDICATION NAME]-[MEDICATION NAME]. Resident # 6 was interviewed on 4/5/17 at 9 AM and reported he had not rested well the previous night. Resident # 6 stated he had broken both of his ankles recently, and at times he experienced spasms and sharp pain that would run up his leg. The resident stated he was supposed to get two pain pills if his pain was an 8 or more on a pain scale. The resident stated the medication person was supposed to have given him two pain pills the previous night and he only received one. Resident # 6 stated the one pain pill only worked for about 45 minutes to an hour and he had talked to the medication person about the incorrect number of tablets he had received. Resident # 6 stated the medication person acknowledged he was supposed to have received two tablets instead of one, but she never gave him another pain pill. The resident stated he couldn't understand why she would acknowledge he was supposed to receive more but still not give it to him. The resident stated since the medication person knew he should have gotten two pills instead of one and didn't do anything about it, he then decided not to bother the staff anymore that night. Nurse # 1 was interviewed on 4/5/17 at 1:15 PM. Nurse # 1 reviewed the record and stated Resident # 6 should have received two pain pills the previous night. Medication aide (MA) # 1 was interviewed on 4/6/17 at 12:45 PM. MA # 1 stated she had only given Resident # 6 one [MEDICATION NAME]-[MEDICATION NAME] tablet when she should have given him two tablets on the night of 4/4/17. The MA stated Resident # 6 did bring it to her attention that he should have received two pain tablets rather than one, and she had acknowledged to him that he was correct and she had made an error. The DON (Director of Nursing) was interviewed on 4/6/17 at 8:45 AM. The DON stated she had talked to Medication Aide # 1 and had confirmed the resident's pain medication had not been given as ordered and Resident # 6 should have received two pain tablets the previous evening.

Based on record review and staff interviews the facility failed to assure medical information was relayed to a consulting physician for one (Resident # 2) out of three sampled residents who had outside consultation appointments. The findings included: Resident # 2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident # 2's medical record revealed the resident was routinely seen by a consulting neurologist at the neurologist's office. Review of the 1/18/17 neurologist's consultation report revealed his plan was to obtain a MRI (magnetic resonance imaging) study of the brain and complete a CBC (complete blood count), CMP (complete metabolic panel) and a [MEDICATION NAME] level. These 1/18/17 neurologist's orders were noted on the consult form and also written on prescriptions that were located on the resident's facility record. Record review revealed the CBC, CMP, and [MEDICATION NAME] level were completed on 1/19/17. The MRI was completed on 1/25/17. Record review revealed the resident was next seen by the consulting neurologist on 2/14/17. Review of the neurologist's note revealed he documented, No MRI of brain done. A staff member at the neurologist office was interviewed on 4/6/17 at 11:55 AM. This staff member stated the MRI and lab work had not been sent with Resident # 2 for her 2/14/17 appointment. The staff member stated the neurologist had planned to discuss the results with the family member during the 2/14/17 appointment, but the facility had not sent the results until the following date of 2/15/17 at 10:08 AM. The facility DON (Director of Nursing) and transportation aide were interviewed on 4/6/17 at 9:30 AM. The transportation aide stated she picked up prepared paperwork from the nurses prior to transporting residents for appointments. Interview with the DON (Director of Nursing) revealed licensed nurses were responsible for preparing a resident's paperwork in order that the transportation aide have it available to take to a consulting physician. Interview with the DON revealed that nurses routinely sent the following paperwork with a resident: a consultation form on which a consulting physician could communicate their findings and orders to the facility; a list of a resident's medications; a medical history; and any other information which had been requested by a physician to be sent. Interview with the DON revealed Resident # 2's MRI and lab work results should have been sent with her on 2/14/17 or faxed to the neurologist prior to the resident's appointment date.

Based on observations, record review, and staff interview, the facility failed to maintain the medication error rate below the acceptable rate of 5% (9.4% error rate, 3 errors out of 32 observed opportunities, Resident #50). Findings included: Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimal Data Set assessment dated [DATE] indicated that the resident was moderately cognitively intact and did not have a history of displaying any behaviors or mood changes. The assessment confirmed that the resident did require extensive assistance for most activities of daily living. The physicians orders for Resident #50 included [MEDICATION NAME] ER (extended release) 20 milligrams (mg), Give 2 tablets (= 40 mg) by mouth every morning and every evening for chronic pain , [MEDICATION NAME] 17 grams in 8 ounces of fluid, Give by mouth every Monday, Wednesday, and Friday for constipation, and Senna-[MEDICATION NAME], Give 2 tablets by mouth twice daily. 1. Medication administration observation for Resident #50 was conducted on 12/8/15 at 8:45 AM, while the resident was lying on the bed in her room. The Medication Aide measured out the [MEDICATION NAME], mixed it with water, and administered the medication to the resident on Tuesday, 12/8/15. The Medication Aide was interviewed on 12/8/15 at 1:49 PM about the days of [MEDICATION NAME] administration. She stated I didn't see on the order that the [MEDICATION NAME] is supposed to be given only on Mondays, Wednesdays, and Fridays. I did give it today, and today is Tuesday. I am nervous today. The Director of Nursing was interviewed on 12/8/15 at 1:55 PM. She stated I expect that all medication aides give their residents the correct medication, as it is prescribed, and watch the residents swallow them. 2. Medication administration observation for Resident #50 was conducted on 12/8/15 at 8:45 AM, while the resident was lying on the bed in her room. The Medication Aide took two tablets of regular Senna 8.6 mg each and administered them to Resident #50. The Medication Aide was then asked to check her medication cart to pull out both the stock bottles of Senna-[MEDICATION NAME] and Senna. The Medication Aide confirmed that her cart did not contain a bottle of Senna-[MEDICATION NAME], it only contained a bottle of Senna. She confirmed that she used the bottle of Senna to retrieve the 2 tablets to administer to Resident #50 and that the resident did not receive the [MEDICATION NAME] portion of the medication. The Director of Nursing was interviewed on 12/8/15 at 1:55 PM. She stated I expect that all medication aides give their residents the correct medication, as it is prescribed, and watch the residents swallow them. 3. Medication administration observation for Resident #50 was conducted on 12/8/15 at 8:45 AM, while the resident was lying on the bed in her room. During the time that the resident was still taking the medications from the medication cup and in the process of swallowing the medications, the Medication Aide left Resident #50's bedside to go wash her hands in the in-room bathroom. At this time of the Medication Aide's absence, Resident #1 spit out 2 green tablets from her mouth; one of which landed inside of her cup of [MEDICATION NAME] fluid, and the other which landed on her bed sheet. The Medication Aide returned from the bathroom, administered a medicated nasal spray, and continued conversing with Resident #50 for an additional 20 minutes, which included positioning herself very closely to the resident for a hug, prior to exiting the room. The Medication Aide confirmed that she was entirely finished with the process of medication administration for Resident #50 prior to having the spit out medications pointed out to her. She then scooped up the medications with a spoon and re-attempted to administer them to Resident #50, at which time Resident #50 verbalized her refusal to take them. The Medication Aide stated The resident has never behaved like this; I did not think that she would do this (spit out medications) when I went to go wash my hands. The Director of Nursing was interviewed on 12/8/15 at 1:55 PM. She stated I expect that all medication aides give their residents the correct medication, as it is prescribed, and watch the residents swallow them.

Based on observations and staff interviews, the facility failed to store stock medications in a secure and limited access environment. Findings included: Medication storage observations was conducted with the Quality Care Coordinator on 12/7/15 at 4:40 PM. Although the facility had two locked medication storage rooms available, each one located behind the nurses ' stations, the stock medication supply was found to be stored in the Nursing Secretary ' s office which was unlocked during observation. The stock medications were stored on an open metal warehouse shelving device within the secretary ' s office. The office did have a door to which there was locking capability, however during observation it was found to be closed and unlocked. The Quality Care Coordinator was interviewed at 4:45 PM on 12/7/15. She stated Yes, this office is where we store the stock medication supply. I don ' t really know why we don ' t store them in our locked medication rooms. The medications were moved here by our former Director of Nursing, who last worked at the facility sometime during this past summer. The Director of Nursing was interviewed on 12/7/15 at 4:53 PM. She confirmed that she did not know why the stock medications were stored outside of the locked and designated medication rooms. She stated I know that the nursing secretary locks her office when she leaves the facility for the day but she does not lock it every time she leaves her office. I didn ' t know that the stock medication supply access needed to be restricted.

Based on record review, staff interviews and physician interview, the facility failed to assess 1 of 2 residents (Resident #1) exhibiting signs and symptoms of acute changes in condition, nor timely assessment for immediate care. Resident #1 was admitted to the hospital with [REDACTED]. The immediate Jeopardy began on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE] at 5:35 pm.The Immediate Jeopardy was removed on [DATE] at 5:15 pm when the facility provided a Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Review of the facility policy on Acute Condition Changes revised [DATE] indicated "The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired. The same MDS assessment revealed the resident was totally dependent for transfers and required the assistance of one person. The assessment further indicated the resident required extensive assistance with dressing. The MDS assessment indicated the resident was unsteady with surface to surface transfer. The same assessment further indicated resident had limited range of motion to both upper and lower extremities. A review of Resident #1 's nursing care plan last updated [DATE] revealed the resident was at risk for falls. The care plan further indicated the resident was transferred with the mechanical lift. A review of the facility [DATE] Accident log revealed Resident #1 had a fall on [DATE]. The Incident/Accident report was completed by Nurse # 1 on [DATE] after the resident was diagnosed with [REDACTED]. During an interview on [DATE] at 11:28 am, the Director of Nursing (DON) stated she had Nurse #1 to come in and complete an incident report for Resident #1 after the resident was diagnosed with [REDACTED]. The DON further indicated the fall was not reported at the time of occurrence and the facility did not learn about the fall until days later. A review of a typed entry per the Director of Nursing dated [DATE] at 10:00 am indicated "Called to resident's room to assess left leg abnormality. Noted the affected left lower extremity was shorter than unaffected extremity and the left lower extremity rotated. Nurse called attention to the left upper thigh area. Noted swelling, tightness and warmth. Resident appeared less responsive and was not exhibiting the normal behavior per resident which is yelling out when touched. Hip rocked. Resident moaned in discomfort. Instruction was given for nurse to update MD on the findings and to request in house X-ray." During an interview on [DATE] at 11:28 am, she stated, "It was a classic sign of a [MEDICAL CONDITION]. " Review of the Witness Interview Form dated [DATE] by Nurse #1 revealed she was notified by NA #3 on [DATE] at 10:30 pm that Resident #1's left leg was swollen. Nurse #'1's witness statement further revealed an assessment of the affected extremity had been conducted, and that the left leg was "[MEDICAL CONDITION] and abducted as opposed to the right leg. No s/sx (sign and symptom) of pain or discomfort upon manipulation. MD (Medical Doctor) answering service was then called to advise of findings." Review of the Witness Interview Form did not reveal the date or time the answering service was notified. Review of the local Physician Paging log undated revealed one call "Date [DATE], time 12:12 am, Reason for call: possible leg fracture." A review of a nurse's note by Nurse #3 dated [DATE] at 12:30 pm revealed "Left upper leg noted to be swollen, reddened and shorter than right leg. PA (Physician Assistant) notified at 10:15 am. Stat x-ray ordered. X-ray called in at 10:20 am. X-ray company entered the facility at 10:45 am. PA notified of results. Order was given to send the resident to the hospital for evaluation of left displaced oblique fracture. EMS called at 12:15 pm. Vital signs prior to leaving ,[DATE]-[DATE] temp, with 97 % oxygen saturation on room air. EMS entered the facility at 12:32 pm and left at 12:40 pm." Review of the nurse's note did not reveal first aid treatment or medication was administered. Review of a nurse's note by Nurse #1 dated [DATE] at 4:55 pm revealed the following "Late entry for [DATE]- ,[DATE] shift (10:30 pm) CNA on duty notified this writer that resident leg "looked swollen" Upon assessment, resident leg/ hip appeared [MEDICAL CONDITION], slightly abducted in comparison to right leg. Resident displayed no s/sx (sign and symptom) of pain or discomfort upon ROM (range of motion) of left leg. Resident noted to be lying on back at time of assessment. MD answering service called so that on call MD or PA on duty may be notified of findings and to seek further guidance. Information passed on to nurse of oncoming shift so that information of findings may be conveyed to on call MD or PA of information when call back received." Review of the nurse's note did not reveal first aid treatment or medication was administered. A review of the facility 24 hour report dated [DATE] revealed "no return call from MD related to left leg/knee for Resident #1." Review of the Witness Interview Form by NA (Nursing Assistant) #1 dated [DATE] indicated he sat the resident up on the side of the bed to pull her dress down and she slid to the floor. The Witness Interview Form further indicated NA #1 transferred Resident #1 into the chair with the assistance of NA #2 after the fall. There were no nurse 's notes in the medical record related to Resident #1 's status from [DATE] until [DATE] at 10:30 pm. On [DATE] at 09:02 am during an interview, Nurse #2 revealed she was informed by Nurse #1 that she had paged the on call physician to notify the doctor about swelling in Resident #1 left thigh. Nurse #2 further indicated swelling in an extremity is an abnormal finding and could indicate an injury. She stated she did not document her assessment of Resident #1's swollen leg in the nurse's notes. She added that she did not place the resident on acute charting report. She further stated "Screaming is her normal baseline. So with her, you really wouldn't know if she is in pain." Nurse #2 stated she did not make any further attempts to notify the physician during her shift from 11pm through 7am about the swelling in Resident #1's leg. She stated she documented the doctor's failure to return the call back to the facility on the 24 hour report and reported it on to the day shift nurse during the change of shift verbal report. In an interview on [DATE] at 11:39 am, Nurse #1 indicated that NA #3 reported to her on [DATE] that Resident #1's left leg looked swollen. She stated, "The left leg was more swollen than the right and the left foot was more slanted." Nurse #1 further indicated abduction is an abnormal finding that would indicate the need to notify the doctor and that further medical evaluation would be needed. Nurse #1 stated she did not place the resident on acute charting status for closer monitoring or implement precautions related to assessment of the abducted leg. On [DATE] at 11:07 am, during an interview, NA (Nursing Assistant) #1 revealed he sat Resident #1 up on the side of the bed and tried to put her dress on her on [DATE] between 9 and 11 am. He stated the dress was too small and she slid off the bed. NA #1 further indicated "It was an accident and I feel bad about it." NA #1 further revealed that he always sat the resident up on the side of the bed to dress her. He stated he left the resident on the floor beside the bed while he went to the door and yelled down the hall for help. NA #1 stated he was not able to tell the nurse about the fall because she was off the floor to lunch but he had planned to tell her when she returned. He further stated he forgot to inform the nurse about the fall on [DATE]. NA #1 stated the resident did not show any signs of pain before she was placed in the chair. During an interview on [DATE] at 1:22 pm, Nurse # 3 revealed she was informed by Nurse #2 on [DATE] of swelling to Resident #1's left thigh during the shift change report. She further revealed she was informed of the attempt to notify the physician the night before with no return call. She stated "I don't know why I did not attempt to call the doctor again. "Nurse #3 revealed she assessed Resident #1's swelling to the left thigh at 8:00 am and obtained a set of vital signs. She further revealed she and the nursing assistant went back in the resident's room at 10:00 am and that the resident was not yelling out as she normally does. Nurse # 3 indicated she was aware that Resident #1 had episodes of vomiting and changes in appetite on [DATE] and [DATE]. She further stated she thought it was just isolated incidents. On [DATE] at 2:05 pm during an interview, NA #4 indicated Resident #1 had a vomiting episode on [DATE] after breakfast. She indicated Resident #1 normally had a good appetite. She further indicated Resident #1 exhibited additional changes to include decreased yelling and decreased appetite at lunch on [DATE] which was reported to Nurse #3. On [DATE] at 11:48 am, in an interview with NA #2, she indicated she was called out of another resident 's room by NA #1 to assist with transferring Resident #1 into the gerichair. NA #2 further revealed that Resident # 1 was sitting on the bottom of the gerichair and the back of the chair was standing off the floor in the back. She indicated her immediate response was to help NA #1 to get the resident on up into the chair. NA #2 further stated NA #1 informed her not to tell anyone. NA #2 indicated this incident occurred on Monday [DATE]. She further stated NA #1 was irrate and angry on the day of the fall. Review of a written statement undated by NA #3 revealed Resident #1 did not eat or drink during evening meal on [DATE]. The witness statement for NA #3 further indicated "I first checked her at 3:30 pm and she didn't seem like she felt good. Her eyes were fixed on the ceiling and she seemed to be out of it." NA #3's witness statement further revealed "I went in her room again on my last round which was 10:00 pm and I noticed her leg did not look right so I went and got the nurse." NA # 3 was not available during the investigation. She could not be reached at the telephone number provided by the facility on two attempts, [DATE] at 11:00 am, and [DATE] at 11:55am. Review of the hospital History and Physical dated [DATE] revealed Resident #1 was admitted with a left proximal femoral fracture with displacement and left hip swelling. The history and physical further revealed a [DIAGNOSES REDACTED]. Patient will need a blood transfusion." Review of the hospital Discharge summary dated [DATE] revealed "drop in hemoglobin and hematocrit level could have been from the left [MEDICAL CONDITION]. She received a total of four units of packed red blood cells. She was found to have a hemoglobin level of 6.6 on admission." She was evaluated by cardiologist for preoperative risk assessment and had a 2D echocardiogram done which showed normal ejection fraction. The discharge summary further indicated multiple discussions with power of attorney confirming that the goal of care was comfort. Despite treatment, the patient continued to decline. The discharge summary further indicated resident was being discharged back to the skilled nursing facility with hospice services. A review of the physician telephone order dated [DATE] indicated "Hospice to evaluate and admit." A review of the Hospice Certification and Plan of Treatment revealed resident was admitted to services on [DATE]. A review of the record of death revealed resident expired [DATE] at 10:05 pm. On [DATE] at 3:00 pm, during an interview, the attending physician stated "She lost a lot of blood." She further stated "The nurses need to be sure to call when they notice the changes in the resident's condition." She stated the low hematocrit and hemoglobin could be due to the delay in treatment from the time of the fall to the time of hospitalization . She further stated the resident never fully recovered from the [MEDICAL CONDITION] surgery and the goal became to keep the resident comfortable. She indicated the purpose of the surgery was to control the pain and the bleeding. The attending physician further stated if the nurse assessed the resident's leg with swelling and abduction, and the on call physician did not call back, she should have called 911 and sent the patient to the emergency room . The facility provided the following Credible Allegation on [DATE] at 5:15 pm: Credible Allegation of Compliance for F309: Resident #1 was noted to have swelling to her left leg on [DATE] (1030 PM). Investigation started. On [DATE] investigation revealed that the incident occurred on [DATE]. Resident was admitted to a local hospital on [DATE] and had surgery on [DATE] to repair the [MEDICAL CONDITION]. Resident was readmitted to Whispering Pines Nursing and Rehabilitation Center on [DATE] under Hospice care and expired in the facility on [DATE]. CNA (NA#1) was terminated on [DATE] for failure to notify the nurse of an incident on [DATE] when it occurred. As all residents have the potential for a change in condition, the plan established will address all residents in the facility. Each resident will continue to be monitored as of [DATE] through routine assessment and observation by the unit nurse and/or nursing supervisor. Should a resident experience an episodic event, it will be noted on the 24 hour report by the unit nurse or nursing supervisor and the acute assessment and charting process will begin and continue every shift for a minimum of 72 hours by the unit nurse or until resident episodic event resolves. Notification of physician and responsible party is part of episodic charting and will be documented. All licensed nursing staff were assigned on-line learning course "Effective Communication " which includes the SBAR tool for communication to the physician for completion of [DATE]. Licensed nursing staff and C.N.A.s have be re- inserviced by the DON or appropriate designee regarding the following u Facility Policy on Change in Resident Status which includes notification of physician u Quality Assurance of Acute Care u Practice Guideline for Notification of Changes u Documentation of Notification Licensed nursing staff were re-inserviced by the Corporate Director of Clinical Operations on ,[DATE] and ,[DATE] as to the standard criteria for monitoring resident ' s condition as listed below, but not limited to: Acute Condition Changes Clinical Protocol; VS (TPR, BP, Pulse Ox); Level of Consciousness and Responsiveness; Level of Cognition All licensed staff have been re-inserviced on Documentation Standards in acute/episodic charting, SBAR, reporting change in status to physician/RP to include additions of new medications by the Corporate Director of Clinical Operations on [DATE] and [DATE] Any licensed staff member who has not been inserviced as of [DATE] will not be allowed to report for duty until training is complete. This information will be included as additional training in licensed nursing orientation and annual re-orientation as shown on the licensed nurse skills checklist. All nursing assistants were in-serviced by the DNS on [DATE] regarding the " STOP and WATCH " method of noticing a change in resident condition and alerting the nurse to that change. After the nurse addresses the issue on the STOP and WATCH the form is returned to the DON and reviewed in the morning clinical meeting to monitor for follow-through. This information will be included as additional training in CNA orientation and annual re-orientation and has been added to the CNA skills checklist. On [DATE] at 5:15 pm, verification of the credible allegation was evidenced by interviews of direct nursing care staff related to monitoring and reporting acute changes in condition. The direct nursing care staff was aware of the STOP and WATCH change alerting tool to be given to the nurses with a copy to be submitted to management. The Licensed Nurses were aware of Acute Changes Protocol to include vital signs with documentation of notification in the medical record.

Based on record review, staff interviews and physician interview, the facility failed to assure that 1 of 5 residents reviewed for accidents (Resident #1) was properly supervised during routine care to prevent the resident from sliding to the floor and causing a fracture. The administrator was notified of the Immediate Jeopardy on [DATE] at 5:35 pm. The Immediate Jeopardy began on [DATE] at the time of the nurse aide allowed the resident to slip to the floor during care. The Immediate Jeopardy was removed on [DATE] at 5:15 pm when the facility provided a Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired. The same MDS assessment revealed the resident was totally dependent for transfers and required the assistance of one person. The assessment further indicated the resident required extensive assistance with dressing. The MDS assessment indicated the resident was unsteady with surface to surface transfer. The same assessment further indicated resident had limited range of motion to both upper and lower extremities. A review of Resident #1's nursing care plan last updated [DATE] revealed the resident was at risk for falls. The goal stated for this problem was that the resident would have no falls over the next 90 days. Interventions listed for this problem included providing non restrictive side rails, giving the resident verbal reminders to use the call bell for assistance, providing an environment with adequate lighting that is free of glare, monitor the resident for at risk for behaviors which could lead to falls, keeping the resident in the geri-chair when out of bed, placing the call bell and other frequently used items within easy reach of the resident to prevent the resident from reaching for items. The care plan further indicated resident was transferred with the mechanical lift. A review of the facility [DATE] Accident log revealed Resident #1 had a fall on [DATE]. The Incident/Accident report was completed by Nurse #1 on [DATE] after the resident was diagnosed with [REDACTED]. During an interview on [DATE] at 11:28 am, the Director of Nursing (DON) stated she had Nurse #1 to come in and complete an incident report for Resident #1 after the resident was diagnosed with [REDACTED]. The DON further indicated the fall was not reported at the time of occurrence and the facility did not learn about the fall until days later. Review of the Witness Interview Form by NA (Nursing Assistant) #1 dated [DATE] indicated he sat the resident up on the side of the bed to pull her dress down and she slid to the floor. The written witness statement further indicated NA #1 transferred Resident #1 into the chair with the assistance of NA #2 after the fall. On [DATE] at 11:07 am, during an interview, NA (Nursing Assistant) #1 revealed he sat Resident #1 up on the side of the bed and tried to put her dress on her on [DATE] between 9 and 11am. He stated the dress was too small and she slid off the bed. NA #1 further indicated " It was an accident and I feel bad about it." NA #1 further revealed that he always sat the resident up on the side of the bed to dress her. He stated he left the resident on the floor beside the bed while he went to the door and yelled down the hall for help. NA #1 stated he was not able to tell the nurse about the fall because she was off the floor to lunch but he had planned to tell her when she returned. He further stated he forgot to inform the nurse about the fall on [DATE]. NA #1 stated the resident did not show any signs of pain before she was placed in the chair. On [DATE] at 11:48 am, in an interview with NA #2, she indicated she was called out of another resident ' s room by NA #1 to assist with transferring Resident #1 into the gerichair. NA #2 further revealed that Resident # 1 was sitting on the bottom of the gerichair and the back of the chair was standing off the floor in the back. She indicated her immediate response was to help NA #1 to get the resident on up into the chair. NA #2 further stated NA #1 informed her not to tell anyone. NA #2 indicated this incident occurred on Monday [DATE]. She further stated NA #1 was irrate and angry on the day of the fall. Review of a nurse's note by Nurse #1 dated [DATE] at 4:55 pm revealed the following "Late entry for [DATE]- ,[DATE] shift (10:30 pm) CNA on duty notified this writer that resident leg "looked swollen." Upon assessment, resident leg/ hip appeared edematous, slightly abducted in comparison to right leg. Resident displayed no s/sx (sign and symptom) of pain or discomfort upon ROM (range of motion) of left leg. Resident noted to be lying on back at time of assessment. MD answering service called so that on call MD or PA on duty may be notified of findings and to seek further guidance. Information passed on to nurse of oncoming shift so that information of findings may be conveyed to on call MD or PA of information when call back received." A review of the Incident/ Accident Report for Resident #1 dated [DATE] completed by Nurse #1 indicated swelling was noted to the left thigh on [DATE] at 10:30 pm. Review of the Incident/Accident Report indicated first aid was not administered. A review of a typed entry per the Director of Nursing dated [DATE] at 10:00 am indicated "Called to resident's room to assess left leg abnormality. Noted the affected left lower extremity was shorter than unaffected extremity and the left lower extremity rotated. Nurse called attention to the left upper thigh area. Noted swelling, tightness and warmth. Resident appeared less responsive and was not exhibiting the normal behavior per resident which is yelling out when touched. Hip rocked. Resident moaned in discomfort. Instruction was given for nurse to update MD on the findings and to request in house X-ray." A review of a nurse's note by Nurse # 3 dated [DATE] at 12:30 pm revealed "Left upper leg noted to be swollen, reddened and shorter than right leg. PA (Physician Assistant) notified at 10:15 am. Stat x-ray ordered. X-ray called in at 10:20 am. X-ray company entered the facility at 10:45 am. PA notified of results. Order given to send the resident to the hospital for evaluation of left displaced oblique fracture. EMS called at 12:15 pm. Vital signs prior to leaving ,[DATE]-[DATE] temp, with 97 % oxygen saturation on room air. EMS entered the facility at 12:32 pm and left at 12:40 pm." Review of the hospital History and Physical dated [DATE] revealed Resident #1 was admitted with a left proximal femoral fracture with displacement and left hip swelling. The history and physical further revealed a [DIAGNOSES REDACTED]. Patient will need a blood transfusion." Review of the hospital Discharge Summary dated [DATE] revealed "drop in hemoglobin and hematocrit level could have been from the left hip fracture. She received a total of four units of packed red blood cells. She was found to have a hemoglobin level of 6.6 on admission. "She was evaluated by cardiologist for preoperative risk assessment and had a 2D echocardiogram done which showed normal ejection fraction. The discharge summary further indicated multiple discussions with power of attorney confirming that the goal of care was comfort. Despite treatment, the patient continued to decline. The discharge summary further indicated resident was being discharged back to the skilled nursing facility with hospice services. A review of the physician telephone order dated [DATE] indicated "Hospice to evaluate and admit." A review of the Hospice Certification and Plan of Treatment revealed resident was admitted to services on [DATE]. A review of the Record of Death revealed resident expired [DATE] at 10:05 pm. On [DATE] at 3:00pm, during an interview, the attending physician stated "She never fully recovered from the hip fracture surgery and the goal became to keep the resident comfortable. " She indicated the purpose of the surgery was to control the pain and the bleeding. The facility provided the following Credible Allegation on [DATE] at 5:15 pm: Credible Allegation of Compliance for F323: Resident #1 was noted to have swelling to her left leg on [DATE] (1030 PM). "The nurse assessed the leg and noted it to "appeared edematous, slightly abducted in comparison to the right leg" . Investigation started. On [DATE] investigation revealed that the incident occurred on [DATE]. Resident was admitted to a local hospital on [DATE] and had surgery on [DATE] to repair fractured hip. Resident was readmitted to Whispering Pines Nursing and Rehabilitation Center on [DATE] under Hospice care and expired in the facility on [DATE]. CNA (NA#1) was terminated on [DATE] for failure to notify the nurse of an incident on [DATE] when it occurred. An incident report was completed and an investigation was initiated by the Director of Nursing Services immediately on [DATE] due to this being an injury of unknown origin. CNA involved in the incident was interviewed on [DATE] by the DON, and QCC and disciplinary action was initiated due to failure to notify the nurse of the incident. This failure of notification resulted in termination of employment on [DATE]. On [DATE], nursing management reviewed Fall Risk Assessments for all current residents who had had a fall since [DATE] and all new admissions since [DATE] still residing in the facility. Any new fall prevention interventions were initiated and care planned. New admission residents will continue to be evaluated for fall risk upon admission and preventive interventions will be put into place for residents at risk. Residents at risk of falling will be identified at each nurse ' s station as a member of the Falling Leaf Club effective [DATE]. All licensed nursing staff were in-serviced by the DON and Quality Care Coordinator regarding the policy for Acute Condition Changes/Clinical Protocol on [DATE] which address how to notify the physician. Transfer status of all residents were reviewed with the care plan updates and posted inside the resident closets on [DATE] for CNAs to easily access. New admits will continue to be assessed for care needs and Kardex and closet postings will be updated as needed by the IDT Team. Nursing staff, including CNAs, were in-serviced by the DON and Quality Care Coordinator on [DATE] regarding the following: Reporting Abuse to Facility Management (this policy includes injuries of unknown origin); Change in Resident Condition or Status; Repositioning; and the Falling Leaf Club. Staff were also in-serviced on the INTERACT STOP and WATCH communication tool on [DATE] by the DON. New employee Orientation Sheet was revised on [DATE] to include the Falling Leaf Club and STOP and WATCH tool to ensure all new employees will be trained. Fall IDT will continue to review all incidents of falls each morning in the stand-up meeting to initiate prevention interventions. Interventions will be added to the care plan. The Fall IDT began using the CCME Five Whys Worksheet on [DATE] to determine the root cause of the fall in order to initiate appropriate interventions. All licensed nursing staff was in-serviced on [DATE] on the Falls and Fall Risk Management policy and Fall Prevention Team Interventions by the DON and QCC. Fall Prevention Team Interventions were posted at each nurse ' s station on [DATE] so that nurses would be able to immediately initiate interventions for falls. The DON and Quality Care Coordinator trained the CNAs on [DATE] regarding safety awareness of residents at risk of falls and on [DATE] regarding using the " buddy System " for transfers, turning and repositioning. All nursing staff were in-serviced on Repositioning; Lifting Machine, Using a Portable; What Constitutes as Fall; and Safe Lifting and Movement of Residents on [DATE], also by the DON and QCC. On [DATE] at 5:15 pm, verification of the credible allegation was evidenced by interviews of direct nursing care staff related to safety awareness of residents at risk for falls. The direct care nursing staff was aware of what constitutes a fall, to look into the closets for the specific transfer need for the particular resident, and to use the buddy system for transfers.

Based on record review, staff interviews and physician interviews, the facility failed to notify the physician for 1 of 2 residents (Resident #1) exhibiting signs and symptoms of acute changes in condition. Resident #1 was admitted to the hospital with [REDACTED]. The Immediate Jeopardy began on [DATE] at the time the nurse aide allowed the resident to slip to the floor during care. The administrator was notified of the Immediate Jeopardy on [DATE] at 5:35 pm. The Immediate Jeopardy was removed on [DATE] at 5:15 pm when the facility provided a Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Review of the facility policy on Acute Condition Changes revised [DATE] indicated "The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less). The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired. The same MDS assessment revealed the resident was totally dependent for transfers and required the assistance of one person. The assessment further indicated the resident required extensive assistance with dressing. The assessment indicated the resident was low risk for falls. A review of the facility [DATE] Accident log revealed Resident #1 had a fall on [DATE]. A review of the Incident/ Accident Report for Resident #1 dated [DATE] completed by Nurse #1 indicated swelling was noted to the left thigh on [DATE] at 10:30 pm. Review of the Incident/Accident Report indicated first aid was not administered. Review of the Witness Interview Form dated [DATE] by Nurse #1 revealed she was notified by Nursing Assistant (NA) #3 on [DATE] that Resident #1's left leg was swollen. Nurse #1's witness statement further revealed an assessment of the affected extremity had been conducted, and that the left leg was "[MEDICAL CONDITION] and abducted as opposed to the right leg. No s/sx (sign and symptom) of pain or discomfort upon manipulation. Medical Doctor (MD) answering service was then called to advise of findings." Review of the Witness Interview Form by Nurse #1 did not reveal a date and time the answering service was notified. On [DATE] at 11:39 am, during an interview Nurse #1 indicated she was notified by NA #3 on [DATE] at 10:30 pm that Resident #1's left leg was swollen. She stated "The left leg was more swollen than the right and the left foot was more slanted. "Nurse #1 stated she placed a call to the answering service after leaving the resident 's room on [DATE] at 10:30 pm and informed the oncoming nurse (Nurse #2) that she had placed the call prior to leaving shift. Review of the local Physician Paging log undated revealed "Date [DATE], time 12:12 am, Reason for call: possible leg fracture." A review of the facility 24 hour report dated [DATE] revealed "no return call from MD related to left leg/knee for Resident #1." Review of a nurse's note by Nurse # 3 dated [DATE] at 12:30 pm revealed "Left upper leg noted to be swollen, reddened and shorter than right leg. PA (Physician Assistant) notified at 10:15 am. Stat x-ray ordered. X-ray called in at 10:20 am. The X-ray company entered the facility at 10:45 am. PA notified of results. Order was given to send the resident to the hospital for evaluation of left displaced oblique fracture. EMS called at 12:15 pm. Vital signs were documented as prior to leaving ,[DATE]-[DATE] temp, with 97 % oxygen saturation on room air. EMS entered the facility at 12:32 pm and left at 12:40 pm." Review of the hospital History and Physical dated [DATE] revealed Resident #1 was admitted with a left proximal femoral fracture with displacement and left hip swelling. A review of the physician telephone order dated [DATE] indicated "Hospice to evaluate and admit." A review of the Hospice Certification and Plan of Treatment revealed resident was admitted to services on [DATE]. A review of the Record of Death revealed resident expired [DATE] at 10:05 pm. On [DATE] at 09:02 am during an interview, Nurse #2 revealed she was informed by Nurse #1 that she had paged the on call physician to notify the doctor about swelling in Resident #1 left thigh. Nurse #2 further indicated swelling in an extremity is an abnormal finding and could indicate an injury. She stated she did not document her assessment of Resident #1's swollen leg in the nurse's notes. She further stated "Screaming is her normal baseline. So with her, you really wouldn't know if she is in pain. "Nurse #2 stated she did not make any further attempts to notify the physician during her shift from 11pm through 7am about the swelling in Resident #1's leg. She stated she documented the doctor's failure to return the call back to the facility on the 24 hour report and passed it on to the day shift nurse during the change of shift verbal report. During an interview on [DATE] at 1:22 pm, Nurse # 3 revealed she was informed by Nurse #2 on [DATE] of swelling to Resident #1's left thigh during the shift change report. She further revealed she was informed of the attempt to notify the physician the night before with no return call. She stated "I don't know why I did not attempt to call the doctor again." Nurse #3 revealed she assessed Resident #1's swelling to the left thigh at 8:00 am and obtained a set of vital signs. She further revealed she and the nursing assistant went back in the resident's room at 10:00 am and that the resident was not yelling out as she normally does. Nurse # 3 indicated she was aware that Resident #1 had episodes of vomiting and changes in appetite on [DATE] and [DATE]. She further stated she thought it was just isolated incidents. In an interview on [DATE] at 2:42 pm, the Director of Nursing (DON) stated she expected the nurse to attempt to call the doctor again if the doctor did not call back. The DON further indicated in the event of an emergency, she expected the nurse to call 911 and have the resident sent to the emergency room . On [DATE] at 3:00 pm, during an interview, the attending physician stated "The nurses need to be sure to call when they notice the changes in the resident 's condition. "The attending physician stated in this case the wrong physician was paged but the nurse should have placed a call to the paging service again after 15 minutes of not receiving a call back from the on call physician. She further indicated the answering service was required then to call the on call physician directly. The attending physician further stated if the nurse assessed the resident 's leg with swelling and abduction, and the on call physician did not call back, she should have called 911 and sent the patient to the emergency room . The facility provided the following Credible Allegation on [DATE] at 5:15 pm: Credible Allegation of Compliance for F157: Resident #1 was noted to have swelling to her left leg on [DATE] (1030 PM). Investigation started. On [DATE] investigation revealed that the incident occurred on [DATE]. Resident was admitted to a local hospital on [DATE] and had surgery on [DATE] to repair [MEDICAL CONDITION]. Resident was readmitted to Whispering Pines Nursing and Rehabilitation Center on [DATE] under Hospice care and expired in the facility on [DATE]. CNA (NA#1) was terminated on [DATE] for failure to notify the nurse of an incident on [DATE] when it occurred. As all residents have the potential for a change in condition, the plan established will address all residents in the facility. Each resident will continue to be monitored as of [DATE] through routine assessment and observation by the unit nurse and/or nursing supervisor. Should a resident experience an episodic event, it will be noted on the 24 hour report by the unit nurse or nursing supervisor and the acute assessment and charting process will begin and continue every shift for a minimum of 72 hours by the unit nurse or until resident episodic event resolves. Notification of physician and responsible party is part of episodic charting and will be documented. Beginning [DATE], any change in condition identified from the 24 hour report, the appropriate chart will be reviewed for evidence of assessment, treatment plan, monitoring of plan, appropriate notification of physician and responsible party. This monitoring will be completed by the DNS, Clinical Care Coordinator, Nurse Supervisor. All licensed nursing staff have been assigned on-line learning course "Effective Communication" (this is a repeat from the [DATE]). This class includes the SBAR tool for communication with the physician. All nursing assistants were in-servived by the DNS on [DATE] regarding the "STOP and WATCH " method of noticing a change in resident condition and alerting the nurse to that change. After the nurse addresses the issue on the STOP and WATCH the form is returned to the DNS and reviewed in the morning clinical meeting for monitoring of follow-through. This information will be included as additional training in CNA orientation and annual re-orientation and has been added to the CNA skills checklist. The licensed nursing staff were re-inserviced by the Corporate Director of Clinical Operations or appropriate designee on regarding the following areas on [DATE] and [DATE] 157/Notification of Change; facility policy on Change in Resident status with includes notification of physician and responsible party; the Quality of Assurance of Acute Care and monitoring of follow-through. Licensed nursing staff were re-inserviced by the Corporate Director of Clinical Operations on [DATE] and [DATE] as to the standard criteria for monitoring resident's condition as listed, but not limited to Condition Changes, VS (TPR, BP, Pulse Ox) Level of Consciousness and Responsiveness; Level of Cognition. All licensed nursing staff have been re-inserviced by the Corporate Director of Clinical Operations on [DATE] and [DATE] with regards to Documentation Standards in acute/episodic charting, SBAR, reporting status changes to physician and RP to include additions of new medications. Any licensed staff nurse who has not been inserviced by the DNS or appropriate designee as of [DATE] will not be allowed to report for duty until training is complete. This information will be included as additional training in licensed nursing orientation and annual re-orientation and has been added to the licensed nurse skills checklist. On [DATE] at 5:15 pm, verification of the credible allegation was evidenced by interviews of direct care nursing staff and administrative staff related to notification of acute changes in condition. The nurses were aware of the hierarchy of change for all current residents with any acute changes in condition.