**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for five (#31, #198, #73, #58 and #54) of nine out of 33 sample residents. Specifically, the facility failed to ensure: -A timely orthopedic consultation was provided as ordered by the physician to follow up on Resident #31's admitting diagnosis of fractured left clavicle; -A physician order was sought and obtained prior to removing Resident #31's sling and performing range of motion (ROM) and resistance (weight) exercises to the affected left upper extremity (LUE); -The admitting diagnosis of fractured clavicle, and the proper care and precautions, were reflected in Resident #31's care plan. These failures resulted in Resident #31 experiencing increased, severe pain and potentially delayed healing of a fractured clavicle. The facility further failed to ensure: -Neurological assessments were completed per instructions, and abnormal vital signs assessments were reported and followed up on, for Resident #198; -Medications were available for administration for Resident #73; -Neurological assessments was initiated immediately after an unwitnessed fall for Resident #58; -Resident #54's vital signs were taken prior to the administration of a hypertensive medication to ensure the resident was within the physician-ordered parameters. Findings include: I. Failure to ensure proper care for Resident #31's fractured clavicle Cross-reference F697 pain management: the facility failed to prevent increased pain during range of motion (ROM) services by therapy which resulted in the resident experiencing severe pain. A. Resident #31's status Resident #31, less than [AGE] years old, was readmitted on [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included headache, osteoarthritis of knee (unspecified), muscle weakness (generalized), unspecified lack of coordination, history of falling, and cervicalgia. The resident diagnosis of fractured clavicle was not included in the list of diagnoses until 2/26/2020, during the survey. The 11/26/19 minimum data set (MDS) assessment coded the resident as cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had sustained a fracture resulting from falls in the past six months prior to this assessment. No pain experience was recorded. The resident received an opioid for seven days prior to this assessment. The resident did not reject evaluation or care. The resident required one person physical assistance with transfer, walking, locomotion, dressing and personal hygiene. B. Resident status on admission A review of the referral comment portion of the referral note by the referring physician, dated 11/16/19 at 7:43 a.m., reported Resident #31 failed at home. She's had 5 falls with the last fall being last evening. She now has a clavicle fracture. Her family member cannot care for her as she is unable to assist with any of her daily needs. C. Observation Resident #31 was observed on 2/24/2020 at 9:45 a.m. while the resident sat in her bed. The resident had a red/pinkish protrusion around her left clavicle (collar) bone. This protrusion was not observed on the resident's right collar bone. The resident was not wearing a sling. D. Resident interview Resident #31 was interviewed on 2/24/2020 at 9:56 a.m. The resident stated she discharged home in November of 2019 and had a fall at home which resulted in her fractured left clavicle. Specifically, the resident stated, I blacked out and fell in November of 2019 and fractured my collar bone in the process. My family member took me to the emergency room (ER) and I was under observation for three days. An X-ray of the left collar bone was conducted which indicated a fracture. The ER doctor recommended that I follow-up with an orthopedic surgeon. Furthermore, the resident stated, I got readmitted back at the facility, and there has been no ortho follow-up. I have been in constant pain since re-admitting to the facility. She expressed that her most excruciating pain was during range of motion exercises with occupational and physical therapy (OT and PT). Specifically, the resident stated she could feel her bones grinding against each other (referring to her fractured clavicle) and it caused a sensation she described as tormenting and horrible. The resident stated, I have not been spoken to about my orthopedic consultation or appointment since I re-admitted . In fact, I had to look for a business card of a spine surgeon I have used in the past and provided the same to the DON about three days ago in an attempt to speedily ensure that a consultation with the orthopedic surgeon was made as it does not seem the facility was doing anything to make that happen. The resident reported that she had been wearing a sling to her affected arm since her clavicle fracture, but she was instructed by the occupational therapist (OT) to discontinue the use of the sling because her fracture should have healed. She said she did not feel her fracture had healed because it was still painful. E. Record review 1. History and physical - lack of follow-up on recommendations A review of the admitting physician history and physical completed with Resident #31 on 11/19/19 revealed the resident was admitted to a hospital and was diagnosed with left clavicle fracture. There was documentation of no surgical intervention at the hospital, however, the facility was instructed to manage the resident's fracture with a sling and follow-up with ortho. A review of the resident's medical record revealed no consultation was made with ortho since the resident re-admitted in November 2019 and would not be until 2/27/2020, after the survey was initiated. There was no documentation or care planning for providing a sling to support the resident's affected left arm/clavicle. There was no physician order to initiate or discontinue a sling to the resident's affected arm. 2. Therapy notes Review of PT and OT notes revealed the therapists were aware of the resident's fractured clavicle. The precautions/contraindications portion of the exercise sessions with Resident #31 documented: Status post (s/p) left clavicle fracture (fx), fall risk (history of falls) and seizure. a. OT notes The OT progress note dated 2/13/2020 documented that Resident #31 participated in a graded therapeutic exercise to increase strength, endurance and ROM to LUE for functional performance of ADLs. During the session, Resident #31 performed resistance exercise with a theraband to the LUE (there was no order for the resident to partake in such exercise). The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. Complexities/barriers impacting the session were identified as history of left clavicle fracture, unhealed properly. The document also revealed Resident #31 reported that her LUE remaining still was what helped with her pain. According to the OT progress note dated 2/20/2020, Resident #31 participated in a guided therapeutic exercise to increase strength, endurance and ROM to bilateral upper extremities (BUE) for performance of activities of daily living (ADLs). During the session, Resident #31 performed BUE bicep curls, chest presses, internal/ external rotations and overhead presses using three-pound weights for LUE and five-pound weights for RUE (there was no order for the resident to partake in such exercise).The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. The document also revealed that Resident #31 reported that her LUE remaining still was what helped with her pain. The progress note further documented that the resident participated in facilitation of crossing midline and weight shifting with BUE activity. Complexities/barriers impacting the sessions were identified as resident complaint of left shoulder pain. b. PT notes The PT treatment encounter note dated 2/24/2020 documented Resident #31's pain at rest was three out of 10, The frequency was intermittent; the location was her left shoulder. She also reported neck pain and described the pain as aching to sharp. The pain with movement was rated at six out of 10. The frequency of the resident's pain with movement was described as hourly and the location was the resident's shoulder with active range of motion (AROM) like gleno-humeral flexion, abduction or extention beyond comfortable range identified as the cause of pain. The resident also reported neck pain, which was reported as usually worse in the morning. The PT treatment encounter notes documented a pattern of pain descriptions on the following dates: -2/5/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/12/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively; -2/17/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/18/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively; -2/19/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively; -2/21/2020 resident reported pain at rest and with movement as 2/10 and 5/10 consecutively. Documented pain levels on the medication administration records (MARs) were significantly below documented pain levels by therapy. There was no evidence if the resident was pre-medicated for pain prior to the physical or occupational therapy sessions. Therapy notes did not specify the time frame that they worked with the resident. 3. Care plans The resident's pain care plan, initiated on 3/31/16 and last revised on 4/19/18, during her prior admission to the facility, documented the resident was at risk for pain due to diagnoses of chronic pain and Parkinson's disease. The resident's pain was not care planned when she was readmitted to the facility on [DATE] after she suffered a fractured clavicle. The readmitting diagnosis of fractured left clavicle was also not listed as part of the resident's diagnosis and was also not care planned. The care plan also did not document treatment for pain prior to therapy sessions. F. Staff interviews Registered nurse (RN) #2 was interviewed on 2/26/2020 at 3:30 p.m. She said when a resident was admitted to the facility, the admitting nurse was responsible for inputting the necessary referral information such as recommended consults, hospital diagnoses, physician ordered medications and so on. RN #2 said it was important that each resident's admitting diagnoses were listed and care planned to ensure that the resident received necessary treatment to address their diagnoses. She reviewed Resident #31's care plan and verified that the resident's admitting diagnosis of fractured clavicle was not listed as part of the resident's diagnoses and was also not care planned. The discharging physician was interviewed on 2/26/2020 at 10:23 a.m. via telephone. The physician stated it was important to timely follow-up consultation with orthopedics as the resident needed to be evaluated by an expert (orthopedic surgeon) who then made the decision to address the next line of treatment of the fractured bone and the pain associated with it. The OT and PT were interviewed on 2/27/2020 at 9:37 a.m. The OT stated before she treated a resident, she would like to have a clarified physician order which detailed the location, type and frequency of therapeutic exercises the physician wanted with the resident. The OT also said she had done some therapeutic exercises to Resident #31's LUE (referring to the ROM and resistance exercise). She reviewed the resident's medical record and agreed that there was no order from the physician to do so. The OT verified that it was important to obtain a physician order prior to discontinuing Resident #31's use of the sling because the sling helped hold the resident's fractured clavicle in place and required the orthopedic surgeon's review to determine whether or not it was safe to discontinue the resident's use of the sling. The OT acknowledged that she instructed the resident to discontinue her use of the sling without having an order to do so. She also verified she did not document that decision and her rationale for doing so. The PT verified that though Resident #31 had an order for OT and PT, the order was to address the balancing related to the resident's December 2019 fall Resident #31 experienced while at the facility. The PT said there was no order to perform a range of motion exercises to the resident's LUE and that the standard practice was to ensure there was an order in place before conducting any therapeutic exercise. He verified that not having an order for therapeutic exercise could result in doing things that were not beneficial to the resident. The PT stated, Before working on a fractured bone, I would like to see a sign of healing on the fractured bone. The PT however verified that there was no follow-up x-ray on file since Resident #31's re-admission in November 2019. He stated it was important to have an x-ray to guarantee that the bone had healed. The PT agreed that pain could result from moving a body part with a fractured bone. The DON was interviewed on 2/25/2020 at 10:28 a.m. The DON said the resident declined an appointment to see an orthopedic surgeon on two occasions due to the resident needing time to get over her husband's passing which occurred sometimes around mid January of 2020. The DON reviewed the resident's medical record and verified there was no documentation of Resident #31's declining an appointment. The DON further stated, I guess we wanted to give her time to get over the situation with her husband. The DON however acknowledged there had been enough time to schedule an ortho appointment between 11/19/19 and 2/25/2020. The DON also reviewed the resident's physician orders and verified that there was no order to perform PT and OT services to the resident's LUE. The DON further verified that no follow-up x-ray was done since Resident #31 was readmitted . In addition, the DON agreed it was important for nursing and rehab staff to coordinate care to better address Resident #31's pain. Specifically, the DON said, I believe we would have done a better job if nurses and rehab staff had clear communication which addressed the resident's care (pain treatment related to fracture). She added that it was important for rehab staff to schedule their treatment session with consideration of the timeline of Resident #31 pain medication to help minimize her exacerbated pain experience during therapy sessions. The DON also said it was important to keep the sling on the resident pending her appointment with the orthopedic surgeon as it was relevant to at least keep the fractured bone in apposition (properly aligned). She concluded the interview by stating interdisciplinary team had to meet to address the care provided to Resident #31 and make amends going forward. G. Facility follow-up The DON input a late entry note in Resident #31's progress notes, dated 2/25/2020 at 11:58 a.m., which documented: Appointment made 1/17/20 at ortho one and due to husband just passing away last week re scheduled for 2/4 and resident did not want to go to this place but will look for her past orthopedic. On 2/21 the resident brought the card to my office and I explained to her that the offices were closed and I would call on Monday morning to obtain. The DON and the assistant director of nursing (ADON) were interviewed on 2/26/2020 at 11:53 a.m. The ADON stated she would want to see the resident's left clavicle fracture listed as part of her diagnoses and also care planned. She said, It was important to do so in order to ensure there was no lag in the resident's care, particularly since it has to do with addressing her pain. She reviewed the resident's medical record and verified that the fractured clavicle was not listed as part of the resident's medical diagnosis and that it was also not care planned. The DON provided an updated medical diagnosis document on 2/27/2020 at 12:14 p.m., which listed Resident #31's fractured left clavicle as part of her medical diagnosis and revealed that the update was made on 2/26/2020. II. Failure to complete neurological assessments and follow up on abnormal vital signs assessments for Resident #198 A. Facility policy and procedure The Fall Management policy was received from the director of nursing (DON) on 2/26/2020 at 3:00 p.m. The policy documented in pertinent part, In the event a resident has a fall and it has been determined they hit their head or it cannot be determined if they hit their head, neurological checks are completed and documented per instructions. B. Resident #198 status Resident #198, age [AGE], was admitted to the facility on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included congestive heart failure, chronic obstructive pulmonary disease, diabetes, shortness of breath and difficulty walking. The 10/24/19 minimum data set (MDS) assessment documented the resident had short term memory loss, moderately impaired cognitive skills for daily decisions, disorganized thinking and inattention. He required limited one assist with bed mobility, supervision for transfers, dressing, eating, toileting, and personal hygiene. The assessment documented he had no falls since admission. However, the resident had fallen on 10/20/19. He was occasionally incontinent of bowel and bladder, and used a walker for mobility. His balance was unsteady. C. Record review The progress notes were reviewed. On 10/20/19 at 11:25 p.m. the licensed practical nurse (LPN) documented that around 10:15 p.m., the resident was found on the floor in a sitting position, close to the bathroom door. The registered nurse (RN) supervisor was notified and performed a head to toe assessment. There was no noted injury. On 10/21/19 at 12:22 a.m. the RN documented further, Resident was found sitting on the floor with his back resting on his wheelchair, both legs stretched out in front of him. He stated that he tripped over his nasal cannula (oxygen) line while walking to the bathroom by himself. Physical assessment from head to toe completed with no visible injury nor bruises at this time of assessment. Active range of motion (ROM) to both upper and lower extremities completed by this nurse. Resident is verbally responsive to nurse, assisted to standing position and he walked over to his bed without any assistance, at the presence of nurses and staff. Neuro checks started, physician and family were notified by the nurse. Denies any pain. The neurological check assessments dated 10/20/19 at 10:15 p.m. were reviewed. The instructions at the top of the form documented to complete the neurological assessment every 30 minutes times four, then every one hour times four, then every four hours for 24 hours, then every eight hours for the remaining 72 hours. The neurological assessment included checking the vital signs (blood pressure, temperature, respirations, and pulse), level of consciousness, pupil reaction and eye signs, eye, motor and verbal response. The neurological checks were incomplete. The documentation revealed the following: -On 10/20/19 at 10:15 a.m. through 10/21/19 at 4:45 a.m. there was no assessment documented of the residents eye response; -10/21/19 at 2:45 a.m., the resident's vital signs were not checked because he was sleeping; -10/21/19 7:45 p.m., the neurological checks did not include vital signs, pupil reaction or eye signs, or motor response; -10/21/19 at 11:45 p.m., the neurological checks did not include the eye, motor or verbal response; and -10/22/19 at 3:45 a.m., the neurological checks did not include the level of consciousness, pupil or eye signs, eye, motor or verbal response. There were no neurological checks for: -10/22/19 from 3:00 p.m. to 10:00 p.m.; -10/22/19 10:00 p.m. to 6:00 a.m. (except for eye, motor and verbal response); -10/23/19 6:00 a.m. to 2:00 p.m.; -10/23/19 2:00 p.m. to 10:00 p.m.; and -10/23/19 10:00 p.m. to 6:00 a.m. The neurological checks documented multiple low blood pressures. On 10/20/19 at 10:15 at the time of the fall, the resident's blood pressure was 85/51 (older adult normal range 120/80). On 10/21/19 at 1:45 a.m., the blood pressure was 76/43, and at 3:45 a.m. the blood pressure was 69/39. The nurses' progress notes were reviewed. There was no documentation that addressed the resident's low blood pressure. D. Staff interviews The DON was interviewed on 2/27/29 at 9:17 a.m. She reviewed the neurological checks initiated 10/20/19. She said they were not done correctly. She said the neuro checks should have been done even if the resident was sleeping. The DON said the staff should have awakened the resident to complete the assessment and ensure there were no changes to his neurological status. She said it looked as if the resident's blood pressure and pulse were running low and there should have been follow up, including notifying the physician. She said the nurses didn't complete this at all, they did not do a good job. She said, They didn't even do anything from 10/22/19 to 10/23/19. The DON said she did not like the current form they used for neurological checks because it only checked the status every 30 minutes in the beginning. She said she would be ordering a new form. III. Failure to ensure medications were available for administration for Resident #73 A. Facility policy and procedure The Medication Administration policy, revised June 2008, was received from the DON on 2/26/2020 at 3:15 p.m. The policy documented in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Begin new medication orders timely. Begin routine orders on the same day ordered. B. Resident #73 status Resident #73, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included diabetes, polyosteoarthritis, chronic pain and macular degeneration. The 1/9/2020 MDS assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with bed mobility, transfers, dressing, personal hygiene, toileting and bathing. She had frequent complaints of pain. C. Resident interview Resident #73 was interviewed on 2/24/2020 at 3:52 p.m. She said the nurses frequently did not have her medications and she had to go without them. She said she had missed her eye drops for macular degeneration many times because they ran out of them. She said she had not received her eye vitamins and blood pressure medications several times. Resident #73 said they had even run out of insulin and her dilaudid pain medication. She could not recall the dates she missed medications but said it had happened multiple times in the last year. D. Record review The nurse progress notes, medication administration records (MARs), and controlled drug count sheets were reviewed and documented the following: -The resident had orders for Dilaudid 2 mg (milligrams) every eight hours for pain. The controlled drug sheets for January 2020 and MARs were reviewed. The MAR indicated the Dilaudid was scheduled every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. On 1/17/2020, the controlled drug sheet documented that the nurse only signed out doses for 5:00 a.m. and 1:11 p.m. There were no further doses signed off the narcotic count sheet for the 10:00 p.m. dose. On 1/22/19, the 6:00 a.m. dose of Dilaudid was not signed off the controlled drug sheet. In addition, the controlled drug count sheet for the Dilaudid doses administered from 11/28/19 through 12/8/19 was requested three times from the DON, and not received. -On 2/25/2020 at 10:23 a.m, the nurse progress notes documented, Timolol Maleate solution 0.5% eye drops for optic atrophy, was not given because the nurse was waiting for pharmacy to deliver. -On 2/20/2020 at 10:20 a.m, the nurse progress notes documented, Dorzolamide HCL solution 2% eye drops, for optic atrophy, was not given because the nurse was waiting for pharmacy to deliver. -On 1/29/2020 11:04 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/28/2020 10:21 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/27/2020 10:52 a.m., the nurse progress notes documented, Ocular vitamins, eye health supplement, was not given because the nurse was waiting for supply. -On 1/23/2020, 12/26/19, 12/16/19, 12/9/19, 12/8/19, 12/2/19, the nurse progress notes documented, Icy Hot Patch to the left knee at bedtime for knee pain was not administered because it was on order. -On 11/26/19, 11/25/19, 11/22/19 to 11/20/19, the nurse progress notes documented, PreserVision vitamins for supplemental eye health were not given because the nurse was waiting for supply. -On 10/11/19 at 10:19 p.m., the nurse progress notes documented, Novolin insulin 15 units subcutaneously at bedtime for diabetes. Notify physician if the fasting blood sugar is less than 70 or greater than 400. The insulin was not given because the medication was not available, called the pharmacy to order, will be coming after midnight. There was no blood glucose level documented. There was no follow up documentation that the resident received the insulin that night. -On 10/5/19 through 6/21/19 there were more than 10 nurse progress notes documenting that the resident's Cosopt Solution 22.3-6.8mg/ml (milligrams per milliliter) eye drops, for optic atrophy, were not given because it was not available. -On 4/14/19 at 10:37 a.m., the nurse progress notes documented, Novolin insulin 10 units subcutaneous in the morning was not given because the nurse was waiting for the pharmacy to deliver the medication STAT. The blood glucose level was 203. The nurse notified the physician and received orders to check a fasting blood glucose level before dinner and call the physician if the results were over 250 mg/dL (milligrams per decilitre). E. Staff interviews Registered nurse (RN) 31 was interviewed on 2/25/2020 at 10;31 a.m. She said sometimes medications were unavailable. She said medications could be reordered through the computer or by pulling the label on the medication card and faxing it to the pharmacy. She said if medications were not available in her cart, she would check the facility backup supply and call the pharmacy. She did not indicate the physician would be notified. Licensed practical nurse (LPN) #1 was interviewed on 2/26/2020 at 11:32 a.m. She said if she did not have a medication available she would notify the physician and call the pharmacy to get the medication. She said she would also try to get it out of the facility backup supply. She could not answer if medications were frequently unavailable. The DON was interviewed on 2/26/2020 at 11:32 a.m. She said the nurse should notify the physician when medications were not available, call the pharmacy, and attempt to get it from the facility's backup supply. She said she would investigate the omitted medications noted. The DON was interviewed again on 2/27/2020 at 9:29 a.m. She said the resident's Timolol Maleate and Dorzolamide HCl eye drops had not been delivered from the pharmacy because it had been ordered too soon and could not be sent sooner than 30 days from the last supply. She said the nurses could have filled out a form for the facility to cover the cost of ordering the medication early, but they had not done that. The DON said she could not figure out what happened with the missed Novolin insulin doses, but he would be educating the nurses to notify the physician and the DON in this situation. The DON further said there was no reason for the resident to have missed the eye vitamins because the facility had them in house stock. She said Icy Hot was not part of the facility formulary and therefore they did not carry the medication in their house stock. She said she had called the physician today to get the order changed to Biofreeze. The DON said she was still looking for the controlled drug sheet for Diluadid doses 11/28/19 through 12/8/19. She said she was the nurse on duty 1/22/2020 and the resident refused the medication. She said she did not document it properly. The DON said she was still investigating the missed dose from 1/17/2020. IV. Failure to start neurological assessments timely after an unwitnessed fall for Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the February 2020 CPO, diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease, heart failure, paroxysmal atrial fibrillation, epilepsy, myocardial infarction, acute and chronic respiratory failure. The 12/21/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident did not exhibit any behaviors. The resident required extensive staff assistance for bed mobility, dressing, eating, toileting and personal hygiene. B. Record review The care plan for falls, revised on 4/5/19, revealed the resident was at high risk for falls related to muscle weakness and a history of falls. Some of the interventions revealed to anticipate the resident's needs. Place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. Provide prompt response to the resident's use of the call light for assistance. The fall risk assessment, performed on 12/7/19 at 7:43 p.m., revealed the resident had a score of 12 or high risk. The situation, background, assessment, recommendations (SBAR) summary dated 12/29/19 at 7:33 a.m., by a licensed practical nurse (LPN) revealed the resident was assessed by a registered nurse (RN). The resident walked from her bed into the bathroom and fell. The resident's wheelchair was by the closet door in her room. The resident's bed was in the lowest position and the call light was within reach. The fall was unwitnessed and no injuries were observed. The fall risk assessment, performed on 12/29/19 at 6:41 p.m., revealed the resident had a score of 17 or high risk. The interdisciplinary (IDT) post fall review, dated 12/29/2020 at 6:43 p.m., revealed the resident had an unwitnessed fall with no injuries on this date at 7:30 a.m. The location of the fall was in the resident's bathroom. The resident performed an unassisted transfer from her bed. The resident had an unsteady gait, cognitive deficits and a history of falls. The resident wore socks at the time of the fall. The resident was encouraged to use the call light for assistance. The Neurological Record (NR) revealed the facility started the neurological assessments for the fall on 12/29/19 at 3:30 p.m. The fall occurred at 7:33 a.m. There was an eight hour delay in starting the assessments for this unwitnessed fall. The facility nursing staff did not follow the frequency listed on the NR. A nurse note dated 12/30/19 at 3:40 a.m. by an RN revealed the resident fell while coming out of the bathroom. The resident had no complaints of pain and there were no post fall injuries observed. Neurological assessments were at

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure pain management services for one (#31) of four residents reviewed out of 33 sample residents. The facility failed to prevent increased pain during range of motion (ROM) services by therapy for Resident #31 who had a fractured left clavicle. The facility was aware the resident had a history of chronic pain and during a previous admission had required pain medications. However, the facility failed to assess, document, report to the physician and respond to the resident's pain. The nursing staff failed to communicate with therapy and implement a plan to premedicate the resident for pain in preparation for therapy sessions. The occupational and physical therapists performed range of motion and weight-bearing exercises although the resident had a fractured clavicle and verbalized pain during therapy sessions. The resident's pain during therapy sessions was not communicated by therapy to nursing staff or the physician. The facility further failed to develop a comprehensive, person-centered pain management care plan for Resident #31. As a result, the resident stated during interview that she could feel and hear her bones grinding during therapy sessions, and she experienced increased, severe pain, which she described as excruciating, tormenting and horrible. Cross-reference to F684, highest practicable quality of care: the facility failed to ensure a timely orthopedic consultation was provided as ordered by the physician, ensure a physician order was sought and obtained prior to removing Resident #31's sling and performing range of motion (ROM) and resistance (weight) exercises to the resident's affected left upper extremity (LUE), and ensure the resident's fractured clavicle and related pain management issues were included in the resident's care plan. Findings include: I. Facility policy and procedure The nursing home administrator (NHA) provided a copy of the facility's pain policy on 2/26/2020 at 11:13 a.m. The policy, last revised in July 2017, documented in pertinent part: The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a care plan for pain management consistent with the comprehensive care plan and resident's goal and preferences. The care plan is implemented and evaluated for its effectiveness. Acute pain, also known as warning pain, is a discomfort or signal that alerts you something is wrong in your body. Pain results from any condition that stimulates the body's sensors, such as infections, injuries, hemorrhages, tumors, and metabolic and endocrine problems. Acute pain usually abates as the underlying problem is treated. Early management of acute pain may hasten the recovery of the causative problem and reduce the length of treatment. II. Resident #31's status Resident #31, less than [AGE] years old, was readmitted on [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included headache, osteoarthritis of knee (unspecified), muscle weakness (generalized), unspecified lack of coordination, history of falling, and cervicalgia. The fractured clavicle was not included in the list of diagnoses until 2/26/2020, during the survey. The 11/26/19 minimum data set (MDS) assessment coded the resident as cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had sustained a fracture resulting from falls in the past six months prior to this assessment. No pain experience was recorded. The resident received an opioid for seven days prior to this assessment. The resident did not reject evaluation or care. The resident required one person physical assistance with transfer, walking, locomotion, dressing and personal hygiene. III. Resident status on admission The comment portion of the referral note by the referring physician, dated 11/16/19 at 7:43 a.m., reported Resident #31 failed at home. She's had 5 falls with the last fall being last evening. She now has a clavicle fracture. Her family member cannot care for her as she is unable to assist with any of her daily needs. IV. Resident observation and interview Resident #31 was observed on 2/24/2020 at 9:45 a.m. while she sat in her bed. The resident had a red/pinkish protrusion around her left clavicle (collar) bone. This protrusion was not observed on the resident's right collar bone. The resident was not wearing a sling. Resident #31 was interviewed on 2/24/2020 at 9:56 a.m. The resident was grimacing and almost tearful throughout the interview. The resident stated she discharged home in November of 2019 and had a fall at home which resulted in her fractured left clavicle. The resident stated, I got readmitted back at the facility . I have been in constant pain since re-admitting to the facility. She expressed that her most excruciating pain was during range of motion exercises with occupational and physical therapy (OT and PT). Specifically, the resident stated she could feel her bones grinding against each other (referring to her fractured clavicle) and it caused a sensation she described as tormenting and horrible. She added that her pain experience was different every day. V. Record review A. History and physical A review of the admitting physician history and physical completed with Resident #31 on 11/19/19 revealed the resident was admitted to a hospital and was diagnosed with left clavicle fracture. There was documentation of no surgical intervention at the hospital, however, the facility was instructed to manage the resident's fracture with a sling and follow-up with ortho. B. Medication administration records A review of the resident's October 2019 (pre-clavicle fracture) through February 2019 (post clavicle fracture) medication administration records (MARs) revealed a lidocaine patch was the only additional pain medication Resident #31 received after she sustained the fracture to her left clavicle Specifically, the MARs (before and after the clavicle fracture) revealed the resident continued to be on the same pain medication which included: -Aspirin tablet 81 mg, give 1 tablet by mouth in the evening for supplement; -Diclofenac Sodium tablet Delayed Release 75 mg, give 1 tablet by mouth two times a day for inflammation; -Oxycodone-Acetaminophen tablet 10-325 mg, give 1 tablet by mouth three times a day for pain; -Acetaminophen tablet 325 mg, give 2 tablets by mouth every six hours as needed for pain; and -Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacological interventions prior to medicating if appropriate. Document in the progress notes every shift per protocol. Lidocaine Patch 4%, apply to left shoulder topically one time a day for pain, added to the resident's pain management regimen on 11/19/19 at 2:01 p.m., and discontinued on 2/19/2020 at 1:36 p.m. The MAR demonstrated timelines which were not consistent with the timelines during which Resident #31 was receiving therapy which exacerbated her pain. C. Pain assessment The resident's pain assessment, dated 11/22/19, on admission, reported that Resident #31 had in the last five days been on a scheduled pain management regimen, received as-needed (PRN) pain medications, and also received non-medication interventions for pain. The assessment also documented that Resident #31 reported she had frequent pain or hurting during the last 5 days prior to the assessment. Her pain was located in her left fractured clavicle and she described the pain as sharp. It also documented that Resident #31 had a history of generalized pain. The resident rated her pain at a five on a scale of zero through 10. Resting and medication were what relieved her pain. The assessment only listed Percocet 10-325mg three times a day as the medication the resident's pain was being managed with. There was no documentation of an assessment to determine the effectiveness of the lidocaine patch with reference to addressing the resident's pain with her fractured clavicle. There was no documentation of the resident's acceptable level of pain. There was no documentation of whether or not the resident's pain interfered with her daily activities or her sleep. The pain scale documentation of the resident's verbalized pain rating did not reflect her expressed pain concern during the survey. D. Failure to schedule orthopedic consultation and evaluate sling use A review of the resident's medical record revealed no consultation was made with ortho since the resident re-admitted in November 2019 and would not be until 2/27/2020, after the survey was initiated. There was no evidence or observation (see above) of the facility providing a sling to support the resident's affected left arm/clavicle. Likewise, there was no order to initiate or discontinue a sling to the resident's affected arm. E. Therapy notes Review of the resident's physical and occupational therapy (PT and OT) notes revealed the precautions/ contraindications portion of the exercise sessions documented: Status post (s/p) left clavicle fracture (fx), fall risk (history of falls) and seizure. 1. OT notes The OT progress note dated 2/13/2020 documented that Resident #31 participated in a graded therapeutic exercise to increase strength, endurance and ROM to LUE for functional performance of ADLs. During the session, Resident #31 performed resistance exercise with a theraband to the LUE (there was no order for the resident to partake in such exercise). The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. Complexities/barriers impacting the session were identified as history of left clavicle fracture, unhealed properly. The document also revealed Resident #31 reported that her LUE remaining still was what helped with her pain. According to the OT progress note dated 2/20/2020, Resident #31 participated in a guided therapeutic exercise to increase strength, endurance and ROM to bilateral upper extremities (BUE) for performance of activities of daily living (ADLs). During the session, Resident #31 performed BUE bicep curls, chest presses, internal/ external rotations and overhead presses using three-pound weights for LUE and five-pound weights for RUE (there was no order for the resident to partake in such exercise).The pain at rest and pain with movement recorded for this session was zero and four consecutively out of 10. The document also revealed that Resident #31 reported that her LUE remaining still was what helped with her pain. The progress note further documented that the resident participated in facilitation of crossing midline and weight shifting with BUE activity. Complexities/barriers impacting the sessions were identified as resident complaint of left shoulder pain. 2. PT notes The PT treatment encounter note dated 2/5/2020 documented Resident #31's pain at rest was zero out of 10, The frequency was intermittent; the location was her left shoulder. She also reported neck pain and described the pain as aching to sharp. The pain with movement was rated at five out of 10. The frequency of the resident's pain with movement was described as hourly and the location was the resident's shoulder with active range of motion (AROM) like gleno-humeral flexion, abduction or extention beyond comfortable range identified as the cause of pain. The resident also reported neck pain, which was reported as usually worse in the morning. The PT treatment encounter note documented a pattern of pain description similar as that reported for the following days: -2/12/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively -2/17/2020 resident reported pain at rest and with movement as 0/10 and 5/10 consecutively; -2/18/2020 resident reported pain at rest and with movement as 3/10 and 7/10 consecutively -2/19/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively; -2/21/2020 resident reported pain at rest and with movement as 2/10 and 5/10 consecutively -2/24/2020 resident reported pain at rest and with movement as 3/10 and 6/10 consecutively F. Shift by shift nursing pain assessments Documented pain levels on the medication administration records (MARs) were significantly below documented pain levels by therapy, and in many cases indicated zero pain. There was no evidence the resident was pre-medicated for pain prior to the physical or occupational therapy sessions. Therapy notes did not specify the time frame that they worked with the resident or that they requested pain medication prior to therapy. The resident was still receiving therapy services during the survey, mostly for lower extremity exercises and balancing. There was no documentation in therapy or nursing notes that the resident's physician was notified of her pain during therapy sessions. G. Care plans The resident's pain risk care plan, initiated on 3/31/16 and last revised on 4/19/18 during her prior admission to the facility, documented the resident was at risk for pain due to diagnoses of chronic pain and Parkinson's disease. The resident's pain was not care planned when she was readmitted to the facility on [DATE] after she suffered a fractured clavicle. The readmitting diagnosis of fractured left clavicle was also not listed as part of the resident's diagnosis and was also not care planned. The care plan also did not document treatment for pain prior to therapy sessions. VI. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 2/26/2020 at 2:05 p.m. He said he was familiar with the resident. He said Resident #31 was independent with most of her care but that pain affected her independence with activities of daily living (ADLs) sometimes. CNA #10 said when the resident was in a lot of pain from her chronic pain and the pain from her fractured clavicle she could not sleep well sometimes. The CNA said he recalled calling the nurse one day not long ago when Resident #31 was moaning and making sounds and appeared to be in a lot of pain. CNA #10 said, I walked to the nurses' station to get the nurse on duty to address the resident's pain. Registered nurse (RN) #2 was interviewed on 2/26/2020 at 3:30 p.m. She said when a resident was in pain, she would have the resident rate her pain and medicate accordingly. She said nurses did not have access to the computer program the therapists used in documenting their treatment of the residents. She also said that the therapists (referring to OT and PT) did not ask when residents were last given pain medication. She reviewed Resident #31's medication administration record and verified that the Lidocaine patch was the only additional pain treatment the resident got when she compared her medication regimen before and after the incident of her fractured clavicle. The hospital discharging physician was interviewed on 2/26/2020 at 10:23 a.m. via telephone. The physician stated it was important to provide timely follow-up consultation with orthopedics as the resident needed to be evaluated by an expert (referring to the orthopedic surgeon) who then made the decision to address the next line of treatment of the fractured bone and the pain associated with it. The OT and PT were interviewed on 2/27/2020 at 9:37 a.m. The OT said she had done some therapeutic exercises to Resident #31's left upper extremity (referring to the ROM and resistance exercise). She reviewed the resident's medical record and agreed that there was no order from the physician to do so. The OT verified that it was important to obtain a physician order prior to discontinuing Resident #31's use of the sling because the sling helped hold the resident's fractured clavicle in place and required the orthopedic surgeon's review to determine whether or not it was safe to discontinue the resident's use of the sling. The OT acknowledged that she instructed the resident to discontinue her use of the sling without having an order to do so. She also verified she did not document that decision and her rationale for doing so. The PT verified that though Resident #31 had an order for OT and PT, the order was to address the balancing related to the resident's December 2019 fall Resident #31 experienced while at the facility. The PT said there was no order to perform a range of motion exercises to the resident's LUE and that the standard practice was to ensure there was an order in place before conducting any therapeutic exercise. He verified that not having an order for therapeutic exercise could result in doing things that were not beneficial to the resident. The PT stated, Before working on a fractured bone, I would like to see a sign of healing on the fractured bone. The PT however verified that there was no follow-up x-ray on file since Resident #31's re-admission in November 2019. He stated it was important to have an x-ray to guarantee that the bone had healed. The PT agreed that pain could result from moving a body part with a fractured bone. The DON was interviewed on 2/25/2020 at 10:28 a.m. She said when a resident was in pain, the information was communicated to the nurse who documented the location of the pain, the intensity and the frequency of the pain and would medicate or provide non-pharmacological intervention as necessary. The DON stated resident pain management was discussed at weekly interdisciplinary team (IDT) meetings and changes to the pain management regimen were made as necessary, and the initial interventions remained if it was determined that they had proven effective. The DON said the PT and OT were not included in the IDT team who reviewed Resident #31's pain management regimen. She denied being aware that the resident complained of pain during therapy sessions. The DON said it was important for the therapy and nursing department to communicate information pertinent to the resident's care in order to improve the quality of care the resident received from the facility. She concluded the interview stating she would initiate an all inclusive IDT, to ensure all departments responsible for the resident's health care management were included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure a resident with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment to attain the highest practicable mental and psychosocial well-being for one (#81) of six residents reviewed for accommodations out of 33 sample residents. The facility was aware the resident requested female caregivers but failed to routinely schedule female staff to assist Resident #81 with her activities of daily living (ADLs), resulting in the feelings lack of self worth. The resident had a past trauma that left the resident paralyzed and fearful of male caregivers. The resident required extensive assistance of two or more female staff for bed mobility and transferring. The facility was also aware that the resident's need for female staff was frequently not honored, causing the resident anxiety and stress. The facility's failure to accommodate the resident's needs and preferences resulted in extended waits to go to bed, which induced the resident's feelings of stress, anxiety, tearfulness and lack of self worth. The facility was aware of the resident's past trauma, but considered the preferences of staff unit placement over the needs and preferences of the resident. Cross reference to F725, sufficient nursing staff Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, dated February 2017, was provided by the business office manager on 2/27/20 at 2:04 p.m. The policy read in pertinent part: The facility protects and promotes the rights of each resident. The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside of the facility. The facility staff will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.The facility provides equal access to quality care regardless of diagnosis, severity of condition, or payment source. II. Resident #81 status Resident #81, under age [AGE], was admitted on [DATE], with an initial admission date of 9/19/14. According to the February 2020 computerized physician orders (CPO), the resident's diagnoses included unspecified injury at unspecified level of cervical spinal cord, muscle spasms, chronic pain, other specified depressive episodes and muscle weakness. According to the 1/10/20 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS), score of 15 out 15. She required extensive assistance of two or more staff with ADLs for bed mobility, and transfering. She required extensive assistance of one for toileting, dressing, and personal hygiene. III. Resident interview Resident #81 was interviewed on 2/24/20 at 8:56 a.m. She said she was not comfortable with male certified nurse aides (CNAs), providing care to her because of a past trauma with a man, resulting in paralysis. She said the facility was aware that she wanted only female CNAs. Resident #81 said there were usually not enough female aides on her unit to assist her to bed. She said her unit was often staffed with male CNAs and she had to wait for a CNA from another unit to assist her to bed, resulting in long waits to go to bed. She said the lack of female aides available for her care caused her anxiety and frustration. She said she often had to worry that she would have increased pain the following morning because she had to sit in her chair for long periods at a time and not be able to lie down at her preferred bed time. She said she preferred to lie down between 9:00 p.m. and 9:45 p.m. Resident #81 was interviewed on 2/25/20 at 10:33 a.m., during a resident group interview. She said on the night of 2/25/20, she had to wait until 11:00 p.m. for a female CNA to leave their assigned unit and assist her. She said she required a lot of assistance to go to bed, and was not able to lie down until 11:45 p.m. She said she felt it was unfair to her she could not go to bed near her preferred bedtime, because not enough female CNAs were staffed on her unit constantly at night. Resident #81 said the facility knew why she could not have male CNAs. She said the lack of female CNAs scheduled on her unit made her feel that her needs did not matter, causing her to cry out in frustration. The resident was interviewed on 2/27/20 at 1:39 p.m. She said the female nurse would help her sometimes in the morning to get out of bed, but seldom would female nurses help her lie down at night. IV. Record review The social service note on 9/16/19 read Resident #81 discussed with social services that she was in a domestic violence situation that led to her paralysis. The care plan for behavior, revised on 10/22/18, read the resident could become demanding with her cares, had a diagnosis of depression and should be monitored for sadness and worried facial expressions. Interventions included to allow choices and modify environment, situations, and/or treatment to minimize episodes. According to the behavior care plan, the resident needed to accept staffing limitations, and her preferences were identified as a behavior. The care plan further read: This resident chooses only those who she wants within the building to care for her and to turn her. She will not take an alternative solution and she has none (solutions) herself, just does what she wants. I explained that I (unidentified writer) have to staff with those we have to help her. The resident's care plan did not include her preference for female CNAs or how to accommodate those needs. The February 2010 staffing schedule was provided by the staffing scheduler (SCH) on 2/25/20 at 2:19 p.m. The February staffing schedule revealed the 2:30 p.m. to 10:30 p.m. shift on the unit where Resident #81 lived was frequently staffed with male CNAs. According to the schedule, either two male CNAs were assigned to the unit or two male CNAs and one female CNA. The schedule and the SCH indicated the female CNA scheduled was on restricted light duty. The following dates were without a scheduled female CNA able to assist Resident #81 to bed: -2/5/20 -2/10/20 -2/11/20 -2/14/20 -2/17/20 -2/18/20 -2/19/20 -2/24/20 -2/25/20 According to the 2/19/20 schedule, the facility had an opportunity to staff three CNAs in addition to the light duty female CNA. However, the three CNAs were all male. D. Staff interviews The social service director (SSD) was interviewed on 2/27/20 at 8:39 a.m. He said he was new to the facility and still learning the needs of each resident. He said care plans should reflect individual resident needs, be dynamic (ever changing), and person-centered. The SSD reviewed the behavior care plan documented in the medical record of Resident #81. He said the care plan was demeaning towards her and her needs. He said staff needed to treat everyone as an individual, listen and respond to the resident's needs. The resident should not feel that her needs were less than, or be told that this was just how things were going to be, without consideration or accommodation. The SSD said staff should be sensitive to resident needs, especially when the resident had needs related to past trauma. He said staff should honor her wishes, and think outside the box to meet her needs. He said she should have female staff assistance without undue stress or waiting. He said staffing should be adjusted on her unit to meet her needs and preferences. He said he would meet with the resident and advocate for her request. The SSD said the facility needed to improve their practice of handling resident needs related to past trauma. The director of nursing (DON) was interviewed on 2/27/20 at 10:42 a.m. The DON said she was aware of the past trauma of Resident #81, and knew she was not comfortable with men providing care. She said the unit was staffed with one female CNA and a female nurse. The nurse should assist if needed. She said the female CNA assigned should not be a CNA on restricted or light duty. The DON said they had limited female staff available to work on the unit of Resident #81, but the SCH made provisions for another female CNA to leave her assigned unit to attend to Resident #81. She said the provision should not interfere with the time the resident was able to get ready and go to bed. The DON said she would have to move staff from their preferred units to accommodate Resident #81. The DON said moving staff could cause problems and frustrations with the staff. The DON said she instructed the SCH to accommodate by having a female CNA provide resident cares on her preferred assigned unit and also assist Resident #81 who lived on a different unit. The DON said a resident should not have to wait over a half an hour to receive assistance. The DON said Resident #81 had told her that she had to wait over a half hour for staff to assist her to bed which caused her to hurt the following day. The DON said the resident was often anxious about who was going to care for her at night. The DON said her anxiety resulted in the resident exhibiting behaviors such as repeated calls to the SCH and attempting to modify the staffing schedule. The SCH was interviewed on 2/27/20 at 11:41 a.m. with the human resource corporate consultant (CSC). The SCH said she was aware of the past trauma and preferences of Resident #81. She said the resident should always have two female staff available to provide care, one of which should not be a light duty CNA. She said the female light duty CNA identified on the staff schedule could not push, pull, turn or lift the resident due to her restrictions. The SCH said Resident #81 was difficult to assist because of her extensive care needs. The SCH said female staff had complained that she was too hard and turning her hurt their back. The SCH said the resident and the staff would benefit from having the assistance of three female staff to assist the resident to bed. The SCH said she did not have the staff on the unit to have a consistent supply of two to three CNAs to be staffed on the resident's unit. She said she tried to accommodate the needs of Resident #81, by asking a CNA from another unit to assist the resident when she needed to go to bed. The SCH said Resident #81 would frequently call her to ask who was scheduled to assist her at night. The SCH said the resident was directed to contact the DON and/or reach out to the charge nurse for staffing concerns related to who was scheduled to work on her unit. The SCH agreed that lack of female CNAs on the unit caused the resident anxiety. She said the male aides on the unit of Resident #81 were scheduled on that unit because that unit was part of their set assignment. The SCH said the unit was often staffed with more male staff than female staff to allow consistent staff schedules and staff unit preferences to reduce staff stress. She said she usually had more female CNAs available but currently two were out on medical leave. The SCH also said she had several open positions and recently lost some staff related to poor attendance. She said she recently added a female CNA to the unit from a staffing agency. The SCH said the staffing challenges and sometimes residents, including Resident #81, caused residents to have to wait for care because staff were handling other residents' needs. The human resource corporate consultant (CSC) said the facility staff challenges should not cause a resident undue stress or make her have to wait for care. He said the facility needed to provide care that best suited the resident. He said staff needed to accomodate the needs of all residents. The CSC said the staffing schedule should have been modified to ensure Resident #81 had female staff available on a consistent basis. The SCH said resident needs should be the facility's number one priority and residents should not have to feel stressed related to staffing challenges. A licensed practical nurse (LPN) who provided care for Resident #81 was interviewed on 2/27/20 at 1:35 p.m. She said she was aware of the resident's preference for female staff. She did she helped get Resident #81 up in the morning when she was available but did not work on the evening shift to help the resident go to bed. She said the resident had expressed to her that she had to wait awhile for staff to assist her to bed at night. She said the resident expressed pain and frustration in the morning when her time preferences to lie down in the 9:00 p.m. hour and get up out of bed at or shortly after 7:00 a.m. were not met. She said Resident #81 frequently complained of pain at a level of seven out of 10 (severe pain) in the morning. The SSD and the SCH were interviewed again on 2/27/20 at 1:45 p.m. The SCH said she and the SSD met with the resident and determined that a lot of the resident's stress was related to the fear of the unknown in regards to who was going to provide her care. The SCH said she had met with staff and adjusted the schedule to ensure the resident had more female staff scheduled on her unit seven days a week to limit the resident's anxiety and provide consistent female staff to help her needs without undue waiting and frustration. She said a staff schedule identifying who was scheduled to work with Resident #81 each day would be provided to the resident in her room. The SSD said he would also provide any needed supportive assistance and frequent visits with her, to make sure she felt her needs were met. He said he would continue to assist her and staff to work towards a solution. He said the facility needed to improve communication with her so she felt safe, comfortable and heard. The nursing home administrator (NHA) was interviewed on 2/27/2020 at 2:15 p.m. The NHA said he was aware Resident #81 preferred only female staff. The NHA said she only wanted the people she wanted. He said he was working on other solutions. He said he was not aware of her associated signs of distress or related behaviors. He said the resident did not self seclude, hide in her room, or avoid participating in community activities. The NHA said he spoke with Resident #81 daily and felt she tried to control things that no one could control. The NHA said he tried to meet her needs as best as he could.