Every finding on record at Bradford Village Healthcare Center

Based on observation, record review and interview, the facility failed to: a. ensure expired medications were removed from circulation for three (#8, 46, and #56) of 10 sampled residents reviewed with controlled medications; and b. medications were administered as ordered for one (#24) of five sampled residents reviewed for unnecessary medications. The administrator identified 81 residents resided in the facility. Findings: The MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy, dated 01/2022, read in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1. Resident #8 had diagnoses which included chronic obstructive pulmonary disease. A Physician Order, dated 05/18/24, documented hydrocodone-acetaminophen (an opioid) tablet 5-325 mg give one tablet by mouth every four hours as needed for pain. An Individual Resident's Narcotics Record, dated 05/18/24, documented the last dose of hydrocodone-acetaminophen 5-325 mg was administered to Resident #8 on January 25th. The remaining count was 62 tablets. On 02/10/25 at 9:59 a.m., CMA #2 stated the facility reordered medications on the computer, usually one to two times a week. On 02/10/25 at 10:06 a.m., CMA #2's medication cart was observed. Resident #8 had two medication cards for hydrocodone-acetaminophen 5/325, one with a count of 17 and the other with a count of 45. Both medications were observed to have an expiration date of 09/22/24. CMA #2 stated, Nobody caught it. They stated what they would do was write up a piece of paper and let the nurse know, and call hospice to get new cards. CMA #2 stated the medication was last administered on 01/25/25 at 9:00 a.m. 2. Resident #56 had diagnoses which included chronic obstructive pulmonary disease and paroxysmal atrial fibrillation. An Individual Resident's Narcotics Record, dated 05/22/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #56 on 09/09/24. The remaining count was 8. A Physician Order, dated 09/10/24, documented lorazepam (an antianxiety) oral tablet 0.5 mg give one tablet by mouth two times a day for anxiety. The order summary report provided by the facility did not contain an order for the liquid lorazepam. An Individual Resident's Narcotics Record, dated 05/29/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #56 on July 7th. The remaining count was 26. 3. Resident #46 had diagnoses which included chronic kidney disease and paroxysmal atrial fibrillation. The order summary report provided by the facility did not contain an order for the liquid lorazepam. An Individual Resident's Narcotics Record, dated 05/16/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #46 on 10/09/24. The remaining count was 24. On 02/10/25 at 10:20 a.m., the following medications were observed in the locked box in the refrigerator in the medication storage room for halls 5, 6, 7, and 8: a. Resident #56's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 8 with an expiration date of 08/13/24. LPN #1 stated the medication expired on 08/13/24; b. Resident #56's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 26 with an expiration date of 08/27/24. LPN #1 stated, These are expired; and c. Resident #46's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 24 with an expiration date of 11/15/24. LPN #1 stated the expiration date was 11/15/24. LPN #1 stated staff usually checked medications weekly for expiration dates through the cart audit. LPN #1 stated staff or the pharmacist would check them in the cubbies and in the carts. LPN #1 stated staff would pull expired and discontinued medications. On 02/10/25 at 12:50 p.m., the DON stated the medication aides were responsible for monitoring the expiration dates on medications. They stated staff would write the medication up with the destruction logs and they would get destroyed. 48344 4. Resident #24 had diagnoses which included generalized anxiety, major depressive disorder, and insomnia. Physician orders, dated 11/21/23, documented buspirone HCl (an antianxiety) 10 mg, give one tablet by mouth one time a day for anxiety at 10:00 p.m. every night; and doxepin HCl (an antidepressant) to give 150 mg by mouth one time a day for insomnia at 10:00 p.m. every night. The December 2024 MAR documented blanks at 10:00 p.m. for buspirone and doxepin on the 5th, 6th, 13th, 20th, 21st, 25th, 26th, 28th, 29th, and 30th. The January 2025 MAR documented blanks at 10:00 p.m. for buspirone and doxepin on the 4th, 16th, 19th, 21st, 23rd, 25th, 27th, and 29th. On 02/05/25 at 2:48 p.m., CMA #1 reviewed Resident #24's December 2024 and January 2025 MAR. They stated the blanks meant the medications were not administered. On 02/06/25 at 11:33 a.m., the DON stated the process for administering medications was to punch, initial, give, and to notify the nurse if a resident refused medication. On 02/06/25 at 11:36 a.m., the DON reviewed Resident #24's December 2024 and January 2025 MAR. They stated the blanks on the MAR could mean the medication was not administered or the staff forgot to initial as given.

Based on record review and interview, the facility failed to notify the physician when a resident's blood pressure was abnormal for one (#24) of five sampled residents reviewed for unnecessary medication. The administrator identified 81 residents resided in the facility. Findings: Resident #24 had a diagnosis of hypertension. A physician's order, dated 12/01/22, documented valsartan (an antihypertensive) 160 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 05/10/23, documented amlodipine besylate (an antihypertensive) 5 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 07/24/24, documented to obtain blood pressure and heart rate one time a day for monitoring if systolic blood pressure 170 or greater refer to as needed hydralazine (vasodilator) order. The January 2025 Medication Admin Audit Report documented amlodipine besylate was initialed as given on: a. 01/28/25 at 8:01 a.m., b. 01/30/25 at 7:52 a.m., and c. 01/31/25 at 8:10 a.m. The January 2025 Medication Admin Audit Report documented the valsartan was initialed as given on: a. 01/28/25 at 8:06 a.m., b. 01/30/25 at 7:52 a.m., and c. 01/31/25 at 8:10 a.m. A Blood Pressure Summary documented the following blood pressures: a. 93/49 mmHg on 01/28/25 at 8:06 a.m., b. 88/46 mmHg on 01/30/25 at 7:54 a.m., and c. 91/41 mmHg on 01/31/25 at 8:12 a.m. The February 2025 Medication Admin Audit Report documented the amlodipine besylate was initialed as given on: a. 02/02/25 at 6:36 a.m., and b. 02/03/25 at 7:33 a.m. The February 2025 Medication Admin Audit Report documented the valsartan was initialed as given on: a. 02/02/25 at 6:36 a.m., and b. 02/03/25 at 7:36 a.m. A Blood Pressure Summary documented the following blood pressures: a. 80/52 mmHg on 02/02/25 at 6:40 a.m., and b. 91/53 mmHg on 02/03/25 at 7:42 a.m. There was no documentation the provider was notified antihypertensives were administered with the abnormal blood pressures above. On 02/05/25 at 2:50 p.m., CMA #1 reviewed Resident #24's blood pressures above. They stated the blood pressures above were considered abnormal. They stated their process was to notify the charge nurse and document in the resident's electronic health record the nurse was notified of low blood pressures. On 02/05/25 at 2:54 p.m., CMA #1 stated they could not locate documentation the nurse was notified of the resident's abnormal blood pressures above. On 02/05/25 at 3:03 p.m., LPN #1 stated the CMAs would report to the nurse abnormal blood pressure readings and the nurse would notify the provider for further guidance. On 02/05/25 at 3:07 p.m., LPN #1 reviewed Resident #24's blood pressures and the medication administration record for January and February 2025. They stated the CMA should have reported the blood pressures to them. They stated they were not notified. On 02/05/25 at 3:10 p.m., LPN #1 stated there was no documentation the provider was notified of the blood pressures above. On 02/06/25 at 11:34 a.m., the DON reviewed Resident #24's blood pressures and the medication administration record for January and February 2025. They stated the resident's antihypertensive medications did not contain parameters for physician notification. They stated their process was to notify the charge nurse and the provider of abnormal blood pressure readings, and to recheck. On 02/06/25 at 11:45 a.m., the DON stated they could not locate documentation the resident's blood pressure was rechecked on the dates above.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed within the required timeframe for one (#170) of 18 sampled residents reviewed for care plans. The administrator identified 81 residents resided in the facility. Findings: Resident #170 admitted to the facility on [DATE]. Resident #170's Admission Resident Assessment was dated 01/22/25. There was no comprehensive care plan located in Resident #170's clinical record. On 02/11/25 at 9:45 a.m., the case manager stated they were responsible for MDS resident assessments and care plans for the skilled residents. On 02/11/25 at 9:48 a.m., the case manager stated they put in basic care plans when residents initially admitted to the facility. They stated they would then complete the admission assessment. They stated the comprehensive care plan should be completed no more than 21 days after admission. On 02/11/25 at 9:50 a.m., the case manager stated Resident #170 admitted on [DATE]. They stated the care plan was not completed and had surpassed the 21 days. On 02/11/25 at 10:27 a.m., the DON stated the facility did not have a care plan policy.

Based on observation, record review and interview, the facility failed to ensure food items were properly sealed, dated, and labeled during one of one kitchen observations. The DON identified 96 residents resided in the facility and received services from the kitchen. Findings: The facility's Dining Services Policies and Procedures - Food Storage policy, revised 04/30/09, read in part, .Food items will be stored, thawed, and prepared in accordance with approved sanitary practices .Fresh Fruits .Rotate so that oldest produce is used first .Fresh vegetables are to be checked and sorted for ripeness . On 11/27/23 at 1:24 p.m., the following items were observed in the walk in the freezer during the initial kitchen tour: a. an opened clear bag of mixed frozen vegetables in a carton not labeled or dated, b. frozen broccoli in a clear bag not properly sealed, and c. cheese pizza in a clear bag not properly sealed. On 11/27/23 at 1:36 p.m., a white bulk storage bin with a clear transparent lid containing a white powder had no label or date. On 11/27/23 at 1:42 p.m., the CDM stated the white powder in the storage was flour and the bin had no label or date. On 11/27/23 at 1:48 p.m., the following items were observed in the walk in refrigerator: a. three bottles of opened cranberry juice with no label or date, b. a carton of mighty shake with mold along the seal, c. orange liquid in a transparent pitcher dated 11/17/23, d. sweet and sour sauce half used with no label or date, e. a carton with nine cantaloupes with a gray and fuzzy substance on all of them, f. a carton with four yellow melons with multiple areas of a black substance on all of them, g. four bags of red grapes in a box dated 10/30/23 with a grey substance present, and not properly sealed, h. lettuce in a transparent bag with no label or date, and not properly sealed. The lettuce was wilted and had multiple dried leaves, and i. shredded cheese in a bag which was not properly sealed. On 11/27/23 at 2:03 p.m., the CDM stated the three bottles of cranberry juice were not labeled or dated. On 11/27/23 at 2:05 p.m., the CDM stated the carton of mighty shake had mold present. They stated the orange soda should be discarded. The CDM stated the sweet and sour sauce was not labeled or dated. On 11/27/23 at 2:10 p.m., the CDM stated there was mold on some of the cantaloupes, melons, and the red grapes. They stated the lettuce had started to go bad. They stated the lettuce and the shredded cheese were not properly secured. On 11/27/23 at 2:15 p.m., the CDM stated all opened food items must be labeled and dated. They stated the refrigerator was checked daily for perishable foods but they had been short staffed.

Based on record review and interview, the facility failed to report a communicable disease to the OSDH for four (#19, 47, 48, and #146) of four residents reviewed for COVID-19. The DON identified 96 residents resided in the facility. Four residents were positive for COVID-19 in the facility. Findings: 1. Resident #146 had diagnoses which included cerebral palsy and diabetes. A nursing note, dated 11/18/23, documented Resident #146 tested positive for COVID-19. 2. Resident #47 had diagnoses which included depression and transient ischemic attack. A nursing note, dated 11/23/23, documented Resident #47 tested positive for COVID-19. 3. Resident #19 had diagnoses which included acute kidney failure and COPD. A nursing note, dated 11/24/23, documented Resident #19 tested positive for COVID-19. 4. Resident #48 had diagnoses which included asthma and diabetes. A nursing note, dated 11/24/23, documented Resident #48 tested positive for COVID-19. On 11/30/23 at 9:53 a.m., state reportable incidents were reviewed and there was no documentation Resident #19, 47, 48, and #146's positive COVID-19 result had been reported to OSDH. On 11/30/23 at 10:10 a.m., the DON stated the administrator was responsible for reporting COVID-19 outbreak to the OSDH. On 11/30/23 at 10:28 a.m., the DON stated the administrator's process was to complete a state reportable after the COVID-19 outbreak was over.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#94) of 20 sampled residents reviewed for resident assessments. The DON identified 96 residents resided in the facility. Findings: Resident #94 had diagnoses which included COPD and hypertension. A Discharge Summary, dated 10/18/23, documented Resident #94 was discharged home with their spouse. It documented Resident #94 was able to walk using a walker and put themselves in a car. Resident #94's discharge resident assessment, dated 10/18/23, documented Resident #94 had a planned discharge to a short-term general hospital (acute hospital). On 11/29/23 at 2:34 p.m., the CM stated Resident #94's discharge resident assessment documented the resident was discharged to an acute hospital. They stated Resident #94's discharge summary documented the resident was discharged home. The CM stated it could have been an error.

Based on observation, record review, and interview, the facility failed to ensure the menu was followed for one of one meal service observed. The Resident Census and Conditions of Residents report, dated 08/21/23, documented 93 residents resided in the facility. The DON identified 93 residents received services from the kitchen. Findings: A Dietary Spreadsheet, dated 03/14/23, documented the lunch service was to contain Dsrt of Day. On 08/21/23 at 12:05 p.m., Resident #14 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:07 p.m., Resident #5 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:22 p.m., Resident #14 was asked how their lunch was. They stated it was good but they did not get any dessert. They stated it was normal not to be served any dessert. On 08/21/23 at 12:29 p.m., Resident #11 stated they weren't offered a dessert at the lunch meal. On 08/21/23 at 12:30 p.m., Resident #5 stated they didn't receive a dessert at the lunch meal. They stated they don't receive a dessert except Every once in a while. On 08/21/23 at 12:33 p.m., Resident #13 was asked if they received any dessert for lunch. They stated they did not get any dessert for lunch. On 08/21/23 at 12:40 p.m., Resident #17 was asked if they got any dessert for lunch. They stated they did not get any dessert for lunch. They stated they got desserts with meals sometimes, but not consistently. On 08/21/23 at 1:16 p.m., CNA #4 stated they checked the meal tickets to ensure the menu for the residents were followed. They stated there wasn't a dessert provided for lunch. On 08/21/23 at 1:31 p.m., the CDM was asked how staff ensured menus were followed. They stated they followed the menu in the kitchen. They were asked what the menu documented the dessert was for today's lunch meal. They stated, Dessert of the day. The CDM was asked if the Dessert of the day had been served to the residents. They stated, No. On 08/21/23 at 1:40 p.m., CNA #1 was asked if they were present in the dining room during today's lunch. They stated they were. CNA #1 was asked if there were any desserts served to the residents during lunch. They stated No. 47827

Based on observation, interview, and record review, the facility failed to ensure medications were administrated as ordered for two (#26 and #134) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Preparation For Medication Administration policy, read in part, .The resident is always observed after administration to ensure that the dose was completely ingested . 1. Resident #26 had diagnosis which included chronic pain syndrome, hypertension, and chronic combined systolic and diastolic heart failure. A Resident Assessment, dated 10/03/22, documented the resident's cognition was intact. On 11/28/22 at 8:22 a.m., Resident #26 was observed laying in bed with a blanket covering them. A large white pill was observed on the resident's upper abdomen area. Five pills were observed on the floor. Resident #26 was observed to sit up on the side of the bed and the large white pill was still in the blanket. On 11/28/22 at 8:30 a.m., LPN #1 was asked how staff ensured residents take their medication. They stated the medication aide watched the resident take them. LPN #1 was asked to observed Resident #26. LPN #1 was observed to go into the resident's room and began to pick up medications off the floor. LPN #1 picked up seven pills off the floor. LPN #1 was alerted to the large white pill in the resident's bed. LPN #1 picked the large white pill off the resident's bed. Resident #26 stated, I knocked them over. LPN #1 stated the large white pill was potassium and one of the other pills was Lyrica. On 11/28/22 at 8:33 a.m., LPN #2 came up to LPN #1 and stated No, I watched both of them this morning. LPN #2 walked away after making the statement. LPN #1 was asked where the pills came from. LPN #1 stated, No telling. LPN #1 stated the medication could have been from the weekend. LPN #1 stated the staff might have walked off when the resident put the medications up to their mouth. On 11/28/22 at 8:56 a.m., ADON stated they spoke with Resident #26 and the resident stated they had spilled them. The ADON stated LPN #2 handed the medication to Resident #26 and the resident tipped them up to their mouth and spilled them. The ADON was notified LPN #2 stated they had watched Resident #26 take their medication. The ADON stated, Apparently not. The ADON was asked how staff ensured the residents took their medications. The ADON stated the staff stand there until the resident takes them. 2. Resident #134 had diagnosis which included allergies, shortness of breath, and hypertension. Resident #134's Hospital Discharge medications, dated 07/01/22, documented to administer Isosorbide Mononitrate CR 30 mg, take 40 mg once daily. Resident #134's physician's orders, dated 07/01/22, documented to administer Isosorbide Mononitrate ER 30 mg once daily, Budesonide-Formoterol Fumarate Aerosol twice a day, and Montelukast Sodium at bedtime. A Pharmacy Manifest, dated 07/01/22, documented Isosorbide Mono 20 mg tablet, Montelukast 10 mg tablet, and Budesonide-Formoterol Aerosol had been delivered for Resident #134. An Orders Administration Note, dated 07/01/22 at 9:16 p.m., documented Montelukast Sodium 10 mg was waiting for pharmacy. An orders Administration Note, dated 07/02/22 at 9:33 p.m., documented Budesonide-Formoterol was not available. An orders Administration note, dated 07/02/22 at 10:59 a.m., documented Budesonide-Formoterol was on order. An orders Administration Note, dated 07/03/22 at 9:18 a.m., documented Budesonide-Formoterol was on order. Resident #134's MAR, dated 07/02/22 and 07/03/22, documented the resident received Isosorbide Mononitrate ER 30 mg. On 11/29/22 at 11:43 a.m., LPN #2 was asked how staff ensured medications arrived and were given as ordered. LPN #2 stated they can order medications stat and received them within a couple of hours. On 11/29/22 at 11:45 a.m., CMA #1 was asked how staff ensured medication arrived and were given as ordered. CMA #1 stated medications were delivered between 9:00 p.m. and 10:00 p.m. at night. CMA #1 stated the staff would sign for the medications and received the medications for their assigned hall. CMA #1 stated new admissions medications were given as ordered the night the resident arrived. On 11/29/22 at 12:25 p.m., the DON stated they were not sure if the Montelukast had been administered. The DON stated if the Budesonide-Formoterol was here, then it should have been given. On 11/29/22 at 3:19 p.m., the DON was asked if the discharge order was for Isosorbide Mononitrate ER 40 mg, the physician's order that had been put into the computer was for Isosorbide Mononitrate ER 30 mg, and the pharmacy sent Isosorbide Mononitrate ER 20 mg, had the medication been administered as ordered. The DON stated they didn't know. The DON stated the Isosorbide Mononitrate ER mg should have been clarified.

41318 Based on record review and interview, the facility failed to ensure allegations related to verbal and physical abuse was reported accurately and thoroughly investigated for two (#12 and #184) of three sampled residents reviewed for abuse. The Residents Census and Conditions, report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Abuse, policy, revised 09/16/16, read in part, .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident . Resident #12 had diagnosis of diabetes mellitus type two, chronic kidney disease, and gout. Resident #12's quarterly assessment, documented the resident's cognition was intact, and they required extensive to total assistance with bed mobility, transfers, hygiene, and toileting. It documented the resident had impaired range of motion to bilateral lower extremities and was always incontinent of bowel and bladder. On 11/27/22 at 11:32 a.m., Resident #12 stated CNA #2 was terrible. Resident #12 stated the CNA screamed at the resident and the CNA refused to help anyone who couldn't help themselves. Resident #12 stated it made them cry for 30 minutes. Resident #12 stated the CNA stated they had worked at the facility for [AGE] years. Resident #12 stated this incident happened about a month ago around 3:30 a.m. Resident #12 stated they had reported it to everyone, including the staffing coordinator and nurses. An initial state report, dated 11/28/22, read in part, .staffing coordinator reported to the Administrator that [Resident #12] .had stated that [CNA #2] was rude to [them] during care last night . An untitled document, dated 11/28/22, read in part, .Interviewed [Staff coordinator] who states [staff coordinator] had told [administrator] a few weeks ago that [Resident #12] had stated that [the resident] had some issues with [CNA #2] .Interviewed [CNA #3] who when asked if [CNA #3] had reported the allegations any time before the 28th, [CNA #3] stated, yes, a few weeks ago, I don't remember the date, I told you that [Resident #12] had made an allegation against [CNA #2]. [CNA #3] stated that I always blow [CNA #3] off and don't listen to [CNA #3], then [CNA #3] walked away . The document was signed by the administrator. On 11/29/22 at 9:24 a.m., Resident #12 stated they peed a lot and needed to be changed every two hours. Resident #12 stated the morning CNA #2 came in and had asked if the resident was wet. Resident #12 stated they were. Resident #12 stated CNA #2 told the resident to roll over. Resident #12 stated CNA #2 yelled the entire time. Resident #12 stated CNA #2 turned the resident and was rough with them when cleaning them up. Resident #12 stated CNA #2 left the room and did not return. Resident #12 stated CNA #3 came in later that morning and Resident #12 reported the incident to CNA #3. Resident #12 stated it was very traumatic for them. Resident #12 recalled it happened on a week day at 3:30 a.m. Resident #12 stated they called their family member the day it happened. On 11/29/22 at 10:01 a.m., CNA #3 stated they were familiar with the hall Resident #12 resided on. CNA #3 stated the resident complained about CNA #2 Friday. CNA #3 stated Resident #12 had complained about CNA #2 three to four times. CNA #3 stated they reported it when it was abuse. CNA #3 stated Resident #12 was worried about retaliation and was terrified. CNA #3 stated Resident #184 complained about CNA #2 yesterday. CNA #3 stated the staffing coordinator was in the room when Resident #12 and #184 made complaints about CNA #2. On 11/29/22 at 10:22 a.m., Resident #184 stated the night before last, CNA #2 came in and asked if the resident was dirty. Resident #184 stated they had diarrhea and the CNA #2 was mad. Resident #184 stated CNA #2 pushed the resident over and left the covers off the resident. Resident #184 stated it was the same routine all night. Resident #184 stated they had been treated in-humane. Resident #184 stated they thought about filing charges and had asked CNA #2 what their name was and CNA #2 refused to give the resident their name. Resident #184 stated CNA #2 would tell the resident to turn over and if the resident didn't do it well enough, CNA would push the resident over. Resident #184 stated they haven't spoke with the administrator or the DON. On 11/29/22 at 10:36 a.m., the staff coordinator stated Resident #12 and #184 reported, yesterday, CNA #2 was rude and rough with them. The staff coordinator stated Resident #12 reported yesterday morning and Resident #184 reported yesterday around lunch time. The staff coordinator stated they had reported Resident #12's allegation to the administrator and CNA #3 reported Resident #184's allegation to the administrator. The staff coordinator stated they had reported to the administrator, in the last two weeks, Resident #12 complained of CNA #2 being rude and rough. The staff coordinator stated the administrator stated Okay, when they had reported it. On 11/29/22 at 11:02 a.m., Resident #12's family member was asked if the resident had reported any incidents to them. The family member stated the resident had called them a couple of weeks ago about CNA #2 being rude, rough, and had yelled at the resident. The family member stated the resident was crying when telling them about the incident. The family member stated they wanted to call the administrator but Resident #12 stated they had already told the staff and nurses. On 11/29/22 at 11:48 a.m., the DON was asked, with corp. nurse consult #1 present, if they were aware of any recent abuse allegations. The DON stated they were aware of Resident #12 and CNA #2 but wasn't aware of any details. On 11/29/22 at 11:55 a.m., the administrator stated the staff coordinator reported an allegation of abuse yesterday morning regarding Resident #12 and CNA #2. The administrator stated they denied having any knowledge regarding CNA #2 prior to this allegation. The administrator stated the DON and administrator went and spoke with Resident #12. The administrator stated Resident #12 stated an overnight shift aide was rude to them while providing care and denied anything physical. The administrator stated it had happened the night of the 27th on the 11:00 p.m. to 7:00 a.m. shift. The administrator stated they have started interviewing residents on the hall. Eight of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel all staff treated them with respect all the time. Two of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel comfortable and safe in the facility all the time. Three of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel comfortable expressing concerns or complaints to some of the staff. An untitled document, dated 11/29/22, read in part, .Interviewed [Resident #184] who states [CNA #2] .exited the room to retrieve supplies and left [the resident] exposed the covers down and the door open when [CNA #2] exited. The resident states that [CNA #2] is not friendly . On 11/29/22 at 12:58 p.m., the corp. nurse consult #1 was asked if they were aware of any abuse allegations currently being investigated. They stated it was against an aide who was rough when changing a resident. The corp. nurse consult was made aware there were allegations of abuse that residents stated they have reported multiple times, and staff members reported notifying management and abuse has not been investigated. The initial state report reported by the administrator, did not identify CNA #2 had been rough with the residents and did not identify Resident #184. On 11/29/22 at 3:18 p.m., corp. nurse consult #1 provided an untitled document, dated 11/29/22, signed by DON with list of staff members interviewed with question regarding [CNA #2] and if there had been any complaints or care issues while CNA #2 was working. The untitled document did not document the staff currently working Resident #12 and #184's hall had been interviewed. The untitled document documented five of six staff who worked on the night shift the alleged abuse happened had not been interviewed. On 11/29/22 at 3:22 p.m., corp. nurse consult #1 accompanied a surveyor to speak with CNA #3. CNA #3 informed corp. nurse consult #1 Resident #12 had complained CNA #2 was rough, yanked the resident around and Resident #12 was terrified. CNA #3 informed corp. nurse consult #1 CNA #3 had notified management several times. CNA #3 stated, I have reported to [DON and Administrator] several times. [Administrator] is the abuse coordinator the person we report to. CNA #3 informed corp. nurse consult #1 Resident #12 had informed their family member. Corp. nurse consult #1 replied there had not mentioned that family had called the facility with a complaint. CNA #3 replied Resident #12's family member knows about the incident. Corp. nurse consult #1 asked CNA #3 if any other residents have complained about CNA #2. CNA #3 reported Resident #184 had also made complaints. CNA #3 stated the staff coordinator was aware of complaints and had reported them to the administrator. Corp. nurse consult #1 went to speak with Resident #12. Resident #12 stated they had talked about it so much, they didn't want to talk about it anymore. Corp. nurse consult #1 asked Resident #12 if the resident was afraid of CNA #2. Resident #12 stated, Yes [CNA #2] should not be taking care of any of the residents. Corp. nurse consult #1 stated, I don't do the hiring and firing. Corp. nurse consult #1 went to Resident #184. Corp. nurse consult #1 did not ask the resident about the Resident's concerns with CNA #2. Corp. nurse consult #1 asked the resident why the resident had called the police on 11/28/22. Resident #184 stated they were not getting help from the staff when the call light was on. Resident #184 stated the staff came to their doorway and told the resident not to call the police. On 11/30/22 at 11:11 a.m., Corp. nurse consult #1 was asked if anyone had spoken to Resident #184 regarding allegations of abuse with CNA #2. Corp. nurse consult #1 stated, the resident [Resident #184] who called the police, I will have to check. On 12/01/22 at 1:41 p.m., corp. nurse consult #1 was asked who was currently being investigated besides Resident #12. They stated they didn't know and they were trying to let the facility handle it. Corp. nurse consult #1 was asked if they received a complaint regarding staff members reporting complaints to administrator staff, and it comes up again, what were the facility doing about it. They stated they knew the incident before was handled as a grievance. The day CNA #3 and staff coordinator reported complaints to administrator and DON, the administrator and DON stated nothing had been reported. Corp. nurse consult #1 was asked what their role was in the facility. They stated they were a consultant and they don't do investigation for the facility. They stated they have not been in the facility, recently, prior to survey. Corp. nurse consult #1 was asked if they had concerns about the abuse coordinator/administrator being aware of abuse allegations and action had not been taken. They stated they had spoke with the administrator and the DON yesterday. They stated the administrator and DON stated they had issues, and it had been taken care of. Corp. nurse consult #1 stated the staff didn't go back to the administrator and ask what had been done with allegations. Corp nurse consult #1 was asked if they were concerned the abuse coordinator/administrator were investigation themselves. They stated noting was reported to them. Corp. nurse consult #1 stated they report to the regional manager and the regional manager has been made aware. Corp. nurse consult #1 was asked who would be interviewed related to allegations. They stated all staff and and cognitive residents. They stated they like to do a percentage of the hall. Corp nurse consult #1 was asked if the abuse happened on a specific shift, would staff on the specified shift be interviewed. They stated yes. Corp. nurse consult #1 was asked to provide all information regarding abuse investigation. On 12/01/22 at 2:03 p.m., the staff coordinator was asked if they had reported any abuse before 11/28/22. They stated they reported Resident #12's complaints to the administrator a couple of weeks ago. The staff coordinator stated they report to the administrator, while they were in there office, during a day shift, and the administrator stated Okay. On 12/01/22 at 2:19 p.m., the regional manager what their role was. They stated they over saw the operations of the whole building. The regional manager was asked what the abuse policy was. They stated every one is to direct report, report to the administrator, and they also have a corporation hotline. They stated if the CNA reported an incident, and it involved an employee, the employee would be suspended and residents and staff who worked with the alleged perpetrator would be interviewed. The regional manager was asked if staff were to follow up with abuse coordinator/administrator regarding abuse allegations that had not been investigated. They stated they would expect the staff to utilize the corporate hotline. The regional manager stated the staff coordinator stated it could have been different situations and the staff reacted to the state surveyors asking questions. The regional manager stated they don't show anything had been reported two weeks ago. The regional manager was asked if the alleged abuse happened on a night shift, would they interview the night shift staff. They stated, Yes, absolutely. We have a more extensive list we will get to you. The regional manager stated they had interviewed the administrator regarding the abuse allegations. The regional manager was asked if they had interviewed anyone else. They stated no. On 12/01/22 at 2:31 p.m., CNA #3 was interviewed with the regional manager. CNA #3 was asked if they had reported any allegations prior to this week to the administrator. They stated they had the week prior. CNA #3 was asked if the administrator was aware of issues prior to Monday of this week. They stated, Should be. CNA #3 stated they had spoke with a quality manager yesterday regarding abuse. On 12/01/22 at 2:34 p.m., the regional manager was asked if allegations of abuse had not been reported and investigated timely what would the facility do. They stated they would suspend the administrator/abuse coordinator. The regional manager was informed there had been a continued allegation of abuse from multiple residents and staff and it had been brought to the administrator/abuse coordinator. They stated, Understood. On 12/01/22 at 2:37 p.m., the negative responses from the safe surveys documentation from the residents were reviewed with the regional manager. They stated they have follow up. The regional manager stated the corp. nurse consult #1 inserviced the administrator on Day 1. On 12/01/22 at 2:42 p.m., the staff coordinator stated, in front of the regional manager, they had reported CNA #2 was rude to the resident to the administrator and the administrator stated they would take care of it. On 12/01/22 at 2:48 p.m., the regional manager was asked to provided all information related to the investigations. On 12/01/22 at 3:19 p.m., the DON stated the administrator had an AIT in their office and the AIT was asked if any abuse had been reported to the administrator and the AIT stated they never saw staff report to the administrator. On 12/01/22 at 3:24 p.m., the DON brought copies of inservices. The DON was asked who interviewed the staff coordinator. They stated the administrator asked the staff coordinator when had the staff coordinator first reports, where were they at, who was in the room when reporting, and the administrator asked the staff coordinator why the staff coordinator didn't ask the administrator if the facility was suspending the staff. On 12/01/22 at 4:00 p.m., the regional manager provided an initial state report with follow up information which read in part, .Follow up info 12/1/22 [staff coordinator] states [they] made [administrator] aware of an allegation of verbal abuse approximately [sic] 2 weeks ago .[staff coordinator] states [AIT] was in the office when report was made .Investigation Cont'd [sic] Part B .[Staff coordinator] states [they] reported the abuse to [administrator] as [CNA #2] being rude to [Resident #12]. [Staff coordinator] was asked if there was any report of physical harm in this instance and [staff coordinator] states not the first time [Staff coordinator] further states that [they] reported on Monday to [administrator] (which is the date of this intial [sic] report) that resident reported that resident reported that [CNA #2] was also rough with .[Resident #12]. Report Amended 12/1/22 to include Physical abuse as well .[Administrator] was suspended pending investigation of failure to investigate allegations of abuse on 12/1/22 [at 3:28 p.m.] .Report amended 12/1/22 to include [Resident #184] with same allegation of rude and rough against [CNA #2] .[CNA #3] reports that [they] reported to DON on Monday that [Resident #184] also had the same complaint for [CNA #2] related to being rude and rough . 42024

Based on record review, observation, and interview, the facility failed to ensure the kitchen was maintained clean and in good repair, and food was stored in accordance with professional standards for food service safety. The DON identified 85 residents who received food from the kitchen. Findings: A Food Storage policy, revised [DATE], read in part, .Label and date all storage containers. Rotate stock. Use the first in, first out method . On [DATE] at 9:41 a.m., a tour of the kitchen was conducted. The following observations were made: a. filters on the back of four ovens, and on one oven motor had visible debris, b. undated and expired bread was observed on a rack in the kitchen, and c. the steam cart's splash guard was soiled and cracked. On [DATE] at 10:29 a.m., the DM was asked how long they kept bread after it had been opened. They stated for three days. They were asked when the bread had been received. They stated last week. The DM was asked how was the bread dated. They stated, the bread was not dated. They stated the bakery would replace the supply of bread weekly. They were shown the undated and expired bread. On [DATE] at 1:39 p.m., the corp. nurse consult #1 stated there was no specific policy for kitchen sanitation. On [DATE] at 2:08 p.m., the downstairs dining room steam table was observed to have a spider-like cracked splash guard with splatter-like substance visible on the guard. On [DATE] at 7:45 a.m., the downstairs steam table was observed with splash guard in same condition as the day before. On [DATE] at 1:20 p.m., the DM was asked how they ensured clean and sanitary kitchen equipment. They stated they came in every other Sunday and cleaned all the steel. They were asked if they cleaned the dust observed on the motor and the filters on the back of the ovens. The DM acknowledged the dust and stated that they believed the maintenance department handled the motor and filters. They stated if it was not the maintenance department then they did not know who cleaned them. The DM was asked how often was the steam tables including the splash guards cleaned. They stated two times a week. They were asked what parts were cleaned. They stated the inside of the steam table was cleaned and the exterior was wiped and shined. The DM stated the splash guards were glass and was cleaned with glass wipes twice a week. The DM was shown the steam table downstairs. The DM described the splash guard as broken and acknowledge it was not clean.

Based on record review, and interview, the facility failed to have an adequate system in place to ensure physician order to receive therapy services were followed for one (#60) of 24 sampled residents reviewed for physician orders. The Resident Census and Conditions report, dated 11/27/22, documented 85 residents resided in the facility. Findings: Resident #60 had diagnosis which included COPD, unilateral osteoarthritis right knee, fibromyalgia, scoliosis, bilateral artificial hips, chronic pain, and bed confinement status. Resident #60's quarterly assessment, dated 10/01/22, documented the resident's cognition was intact, and they required extensive to total assistance of one to two persons for mobility ADLs. It documented the resident had no ROM impairment. On 11/27/22 at 2:21 p.m., Resident #60 stated they want to be able to get therapy and walk. Resident #60's Physician Progress Note, dated 09/07/22, read in part, .Orders .po/Ot [sic] evaluation and treatment for generalized weakness and debility, pt requires strengthening, back exercises . Resident #60's Physician's Order, dated 09/08/22, documented an order for PT/OT evaluation and treatment. On 11/30/22 at 2:30 p.m., the therapy director was asked if they could locate the PT/OT therapy evaluation ordered for Resident #60. They stated they were unable to locate documentation the evaluation had been done. On 11/30/22 at 2:56 p.m., the corp. nurse consult #1 stated medical records was unable to locate PT/OT therapy evaluation.

Based on record review, observation, and interview, the facility failed to provide a clean homelike environment for one (hall 50 shower) of five shower rooms observed for homelike environment. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. The Administrator identified five shower rooms. Findings: Completed Work Orders list, dated 11/01/22 through 11/29/22, contained no documentation regarding the hall 500 shower room. On 11/28/22 at 7:37 a.m., the hall 500 shower room was observed to have brown/black substance covered in a cloudy coating along edge of floor/wall near the whirlpool tub. There were two hoses observed behind the whirlpool tub that are connected to the tub from the wall valve for water source. The hose on the left side was white in color with areas of a black substance covering parts of it. The hose on the right with the yellow handle at the valve was also white in color with the majority of it covered in a black substance. The hose with the yellow handle was observed dripping at the water connecting seal to the valve. On 11/28/22 at 2:30 p.m., the administrator was asked to provide the maintenance logs for January 2022 to current. She stated there were no maintenance logs available before the current month. On 11/29/22 at 8:30 a.m., CNA #1 was asked where the residents who resided on hall 500 received their baths/showers. They stated in the hall 500 shower room. On 11/29/22 at 8:40 a.m., Housekeeper #1 was asked how often the hall 500 shower room was cleaned. They stated twice daily. They were shown the hall 500 shower room and asked what the substance along the corner of the floor/wall was. They stated it was old buildup that doesn't go away. The Housekeeper was asked what was dripping off of the hose covered with black substance connecting the whirlpool tub to the water valve at the wall. They stated it was water because the water was left on, and needed repair. On 11/29/22 at 9:03 a.m., the DON was shown the shower room on hall 500 and was asked what they thought of it's condition. She stated this end of the building was in a re-model and it needed repair. The DON was asked if they would take a bath in that shower room. She stated, I would have to think twice about it. She was asked if residents showered in that shower room. She stated, Yes,

Based on record reviews and interviews, the facility failed to assess, monitor and intervene upon a change of condition with low blood pressure/heart rate for one resident (#1) of three residents reviewed for a change of condition. The administrator identified the facility census was 99. Findings: The American Heart Association blood pressure guidelines for 2021, read in part, a normal blood pressure is 120/80 mm/hg. Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 7/23/21, read in parts, .bowel and bladder incont. [sic] .will remain free from skin breakdown due to incontinence and brief use .Activities: notify nursing if incontinent during activities .unobstructed path to the bathroom .Monitor/document/report to MD .medical causes of incontinence . .Risk for falling .toilet and provide incontinent care frequently .Anticipate and meet the resident's needs . .Risk for impaired skin integrity .incontinence .staff will implement skin interventions to minimize skin breakdown .During daily ADL care, observe skin for redness, open areas, scratches, cuts or bruises and report changes to the nurse . .ADL performance deficit .maintain current level of function .Toilet Use and Personal Hygiene .Toileting .limited x 1 .Monitor/document/report to MD any changes .self-care deficit . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included instructions for the medication to be held if the SBP was less than 110 mm/hg or the heart rate less than 55. A quarterly assessment, dated 10/21/21, documented the resident had severe cognitive impairment with daily decision making; had clear speech, understands and is understood; and required supervision for toileting; limited assistance for bed mobility, dressing, bathing; and extensive assistance for hygiene. The MAR, dated 11/2021, documented the following vital signs: ~ Blood pressure 88/56, and heart rate 49, on 11/21/21 during the 7-11 a.m. medication pass. ~ Blood pressure 89/44 on 11/21/21 during the 6-10 p.m. medication pass. A progress note dated 11/21/21 at 8:45 a.m., documented a medication aide had held the [MEDICATION(S)] due to the parameter of the order. The documentation did not include the VS results or notification to a licensed nurse. A progress note dated 11/21/21 at 6:26 p.m. documented the [MEDICATION(S)] was held due to the parameters. The documentation did not include the VS or notification to a licensed nurse. A progress note dated 11/22/21 at 9:49 a.m., read in parts, .Med aide notified this nurse .observed resident weak and confused .bp 80/6u [sic] .ER . A provider progress note, dated 11/22/21 at 1:37 p.m, read in parts, .Lethargic .Nurse reports patient has low blood pressure and does not seem like himself .send patient to the emergency room .Nurse reports a decline in patient function .requiring assistance for all transfers and toileting help, ongoing assistance for adls . The clinical record did not contain documentation Res #1 had been assessed, monitored or interventions placed 11/21/21 at 8:45 a.m., until 11/22/21 at 1:37 p.m., approximately 29 hours, for the change of condition with low blood pressure and an undetermined time for physical changes for Res #1. A hospital History and Physical, dated 11/22/21 at 2:47, read in parts, .Chief Complaint .Change in mental status .will be admitted to ICU .Severe [CONDITION(S)] . On 12/9/21 at 2:35 p.m., the DON was asked if Res #1 had been identified/monitored and interventions placed when Res #1 presented with an onset of low blood pressure. No information was provided. The DON was asked if the faciity staff should have rechecked Res #1 blood pressure and heart rate when he presented with low results on 11/21/21. She stated, I would have retaken it. The DON was asked what interventions were placed when Res #1 had results of low blood pressure. She stated the physician was notified the following day when Res #1 was transported to the emergency department.

Based on record reviews and interviews, the facility failed to notify the physician of a change in condition for one resident (#1) of three sampled residents reviewed for a change of condition. The administrator identified 99 residents in the facility. Findings: The American Heart Association blood pressure guidelines for 2021, read in part, a normal blood pressure is 120/80 mm/hg. Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included instructions for the medication to be held if the SBP was less than 110 mm/hg or the heart rate less than 55. A quarterly assessment, dated 10/21/21, documented the resident had severe cognitive impairment with daily decision making; had clear speech, understands and is understood; and required supervision for toileting; limited assistance for bed mobility, dressing, bathing; and extensive assistance for hygiene. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ~ Blood pressure 88/56, and heart rate 49, on 11/21/21 during the 7-11 a.m. medication pass. ~ Blood pressure 89/44 on 11/21/21 during the 6-10 p.m. medication pass. A progress note dated 11/21/21 at 8:45 a.m., documented a medication aide had held the [MEDICATION(S)] due to the parameter of the order. The documentation did not include the VS results or notification to a licensed nurse. A progress note dated 11/21/21 at 6:26 documented the [MEDICATION(S)] was held due to the parameters. The documentation did not include the VS or notification to a licensed nurse. A progress note dated 11/22/21 at 9:49 a.m., read in parts, .Med aide notified this nurse .observed resident weak and confused .bp 80/6u [sic] .ER . The clinical record did not contain documentation the physician was notified from 11/21/21 at 8:45 a.m., until 11/22/21 at 1:37 p.m., approximately 29 hours, for the change of condition with low blood pressure for Res #1. On 12/9/21 at 2:35 p.m., the DON was asked if the physician was notified on 11/21/21 when the resident presented with a low blood pressure. She stated the physician was notified the following day.

Based on record reviews and interviews, the facility failed to ensure dependent residents were provided toileting in a timely manner for one resident (#1) of three sampled residents dependent of staff for toileting. The administrator identified 99 residents resided in the facility and 96 residents required assistance and/or were dependent of staff for ADL care. Findings: Resident (Res) #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 7/23/21, read in parts, .bowel and bladder incont. [sic] .will remain free from skin breakdown due to incontinence and brief use .Activities: notify nursing if incontinent during activities .unobstructed path to the bathroom .Monitor/document/report to MD .medical causes of incontinence . .Risk for falling .toilet and provide incontinent care frequently .Anticipate and meet the resident's needs . .Risk for impaired skin integrity .incontinence .staff will implement skin interventions to minimize skin breakdown .During daily ADL care, observe skin for redness, open areas, scratches, cuts or bruises and report changes to the nurse . .ADL performance deficit .maintain current level of function .Toilet Use and Personal Hygiene .Toileting .limited x 1 .Monitor/document/report to MD any changes .self-care deficit . A quarterly assessment, dated 10/21/21, documented the resident to have severe cognitive impairment for daily decision making, had clear speech; required supervision for toileting, and extensive assistance for hygiene. Progress notes, from 09/08/21 through 11/22/21, were reviewed for refusal of care. The clinical record did not have documentation the resident had refused care since 09/28/21. A Weekly Skin Evaluation, dated 11/18/21 at 12:00 p.m., documented a skin assessment was completed but the groin/perineal area including the genitalia were not assessed. A provider progress note, dated 11/22/21, read in parts, .Lethargic .Nurse reports patient has low blood pressure and does not seem like himself .send patient to the emergency room .Nurse reports a decline in patient function .requiring assistance for all transfers and toileting help, ongoing assistance for adls . A hospital ED Provider Report dated, 11/22/21 at 12:06 p.m., read in parts, .Lethargic .unkempt and disheveled .skin break down, saturated diaper w/ stool and feces that appears to have been in place for days frankly and is disintegrating . On 12/09/21 at 3:15 p.m., the DON was asked if Res #1 required assistance for toileting, should he have been provided intrventions to ensure care was provided and skin assessments completed to ensure skin remained intact. No information was provided. The DON was asked if staff should have placed interventions and re-approached to ensure Res #1 was provided toileting/care as indicated on his care plan. She stated they should have at least documented behaviors if Res #1 had refused.

Based on observation and interview, it was determined the facility failed to provide a safe, clean, and homelike environment. The facility identified 83 residents who resided in the facility. Findings: On 09/17/21 at 11:52 a.m., room #801 was observed to have trash and debris under the bed and by the door. The floors on each hall was observed to have a build up of dirt and debris along the walls. At 12:30 p.m., the floor outside of room 808 had a moderate amount of liquid on the floor. There was a yellow sign over the puddle, but it did not cover all of the liquid. There are multiple staff up and down the hall passing the noon meal trays. Residents were observed going up and down the hallway. At 12:38 p.m., a male resident with sock feet was observed to push the yellow sign over and drag through the puddle to the left side. Staff continued to pass meal trays. At 12:44 p.m., a female resident in a wheelchair proceeded to go by the puddle of liquid where the male resident had went. At 12:53 p.m., housekeeping staff was observed to get towels from the closet and clean up the puddle. The geri chair for resident #3 was observed to have dirt and debris on the side and footrest. On 09/21/21 at 10:30 a.m., room #503 was observed to have crumbs, dirt and debris on the floor and on the all mat. Hall 500 floor continued to have dirt and debris along the walls. Room 611 was observed to have a portion of the sheetrock missing behind bed A. Sheetrock dust was observed on the floor under the area. The resident stated the facility had tried to repair in the past. Room 610 A, the privacy curtain at the bottom right had a brown stain along the bottom left corner. The lift on hall 600 was observed to have dirt and debris on the base and bottom of the lift. The handles had a brown wrapping that was falling off. At 10:49 a.m., certified nurse aide (CNA) #2 stated the lifts should be cleaned after use. He was asked if the lift looked like it had been cleaned. He stated no, and the brown wrapping needed to be changed. At 10:53 a.m., licensed practical nurse (LPN) #1 was asked to observe the room 611. She stated she was unaware the wall looked like that and she would put in a maintenance request to repair it. The LPN was also asked to observe the lift on hall 600. The stated it did not look as if it had been cleaned. She stated those brown wrappings should not be there. At 10:35 a.m., housekeeper #1 was shown the geri chair for resident #3. She stated the nurses were responsible for the equipment, but she would take care of it.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with activities of daily living for one (#4) of three residents observed for assistance with activities of daily living (ADL). The facility identified 39 residents who were dependent on staff for ADLs. Findings: Resident #4 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 06/10/21, documented the resident's cognition was intact and required extensive assistance with personal hygiene and had an indwelling catheter. The clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/20/21 at 10:30 a.m., certified nurse aide (CNA) #1 stated the resident was assisted up this morning for a doctors appointment, but the ride did not show up. She just came back to her room. At 12:35 p.m., the resident stated she wanted to stay up for a while. She was asked if the staff had placed a dressing today on her catheter site today. She stated no. At 1:30 p.m., the resident turned on her call light. She stated she was ready to go back to bed. Certified nurse aide (CNA) #1 and #2 brought in a lift and the resident was assisted to bed. Staff were asked to see the catheter site. The CNA pulled the brief down to observe the catheter site and then fastened back up. She stated the brown areas were drainage from the catheter site. The covers were paced up on the resident, call light put in reach. The resident was not provided peri care. On 09/21/21 at 9:28 a.m., the corporate nurse was made aware of the observations of the dark brown substance on the brief and was asked if the resident should have been provided peri care. She stated yes.

Based on observation, record review and interview, it was determined the facility failed to ensure physician's orders were implemented for the application of a dressing for one (#4) of three sampled residents who were reviewed for implementing physicians orders. The facility identified 83 residents who resided in the facility. Findings: Resident #4 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 06/10/21, documented the resident's cognition was intact and required extensive assistance with personal hygiene and had an indwelling catheter. The clinical record documented a physician's order, dated 06/15/21, for a supra-pubic catheter dressing change every day and as needed. On 09/20/21 at 10:30 a.m., certified nurse aide (CNA) #1 stated the resident was assisted up this morning for a doctors appointment, but the ride did not show up. She just came back to her room. At 12:35 p.m., the resident stated she wanted to stay up for a while. She was asked if the staff had placed a dressing today on her catheter site today. She stated no. At 1:30 p.m., the resident turned on her call light. She stated she was ready to go back to bed. Certified nurse aide (CNA) #1 and #2 brought in a lift and the resident was assisted to bed. There was no dressing observed on the supra-pubic catheter site. The front of the brief was observed to have multiple dark brown areas. The CNA stated that was from around the catheter site. She was asked if there was a dressing on the catheter site. She pulled the brief down and stated no. The CNA was asked if there was a dressing on the site this morning when the resident was assisted up and dressed for her doctor appointment. She stated no. At 1:44 p.m., licensed practical nurse (LPN) #1 was asked if there should be a dressing on the supra-pubic catheter site for resident #4. She stated yes. She stated there should have been one on there from last night. The LPN stated it had been a busy morning and she had not gotten to do it yet. She was asked about the doctors appointment the resident missed. She stated it was related to her catheter. The catheter on occasion had been having blood in it and they wanted to get it checked out.

Based on observation and interview, it was determined the facility failed to ensure medications were observed being swallowed and were not left with the resident for one (#8) of three sampled residents. Findings: On 09/21/21 at 9:05 a.m., an empty plastic medication cup was observed sitting on the table in front of resident #8. On the table were two, white pills which were cut in half. The resident was eating breakfast. She was asked if she was going to take her medication. She stated no, the one was a heart pill and she wanted to discuss it with her doctor and the other one was a [MEDICATION(S)] and she was not going to take it but they gave it to her anyway. She was asked if the staff stayed to watch her swallow her medication. She stated no, he gave it to me in the hall as she was coming down to breakfast. She stated she told him it upset her stomach if she took her medication before she had eaten. She just brought the medication with her. At 9:10 a.m., licensed practical nurse (LPN) #1 was asked to observe the medication sitting on the table. She stated the medication should not have been left for the resident to take on her own. She asked the resident if she was going to swallow them. The resident stated no. The LPN stated she would go and destroy them.

Based on observation, record review and interviews, it was determined the facility failed to ensure: ~ residents received care in a dignified manner for one (#15) of three sampled residents reviewed for incontinent care; and ~ catheter bags were covered for two (#12 and #13) of two residents who had an indwelling urinary catheter. The facility identified 80 residents who resided in the facility. Findings: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 05/19/21, documented the resident's cognition was severely impaired, required extensive assistance of two staff for bed mobility, transfers, toilet use and for personal hygiene. The assessment documented the resident was frequently incontinent of bowel and bladder. A care plan, revised on 05/18/21, documented the resident had an activities of daily living (ADL) performance deficit related to decreased mobility and weakness. Interventions documented the resident required extensive assistance of two staff members for toileting hygiene, and transfers. On 06/14/21 at 10:39 a.m., certified nurse aide (CNA) #3 entered the room with linens in her hand. The resident was observed lying sideways across the bed. The resident's roommate was observed laying in his bed. The CNA stated she was going to provide incontinent care as she repositioned the resident in bed and removed the brief. The CNA did not pull the curtain to provide privacy and promote dignity for resident #15 during the provision of incontinent care. At 10:43 a.m., the roommate got up out of bed and left the room. CNA #3 was asked if the privacy curtain should be pulled between residents while providing incontinent care. She stated the resident sometimes yelled at her and did not want the curtain pulled. She stated normally she would pull the curtain for privacy. The resident was not asked about the privacy curtain. At 10:46 a.m., an unknown staff member opened the door to the hallway without knocking while the CNA was providing incontinent care. The staff member observed the care being provided and then shut the door. At 10:49 a.m., CNA #3 was asked if staff should knock on the door prior to entry to maintain dignity of the resident during the provision of incontinent care. She stated yes, they should. On 06/15/21 at 9:45 a.m., the corporate nurse was informed of the observations. She stated she would address the concern. 2. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 06/04/21, documented the resident had an indwelling catheter in place due to urinary retention. On 06/07/21 at 11:15 a.m., the resident was observed sitting in a recliner in her room with the door open with her catheter bag hanging from the side of the recliner with no dignity cover over the catheter bag. The resident was non-verbal and could not state her feelings about having others able to observe her catheter bag with no dignity cover. At 12:00 p.m., the resident was observed to be in her room and assisted by CNA #4 to the dining area with her catheter bag hanging from the bottom of her wheelchair with no dignity cover on the catheter bag. Several residents and staff members joined her in the dining area for lunch. On 06/08/21 at 10:05 a.m., the resident was observed in her room with the door open with her catheter bag hanging from her bed with no dignity cover over the catheter bag. On 06/09/21 at 09:00 a.m., the resident was observed in her room with the door open with her catheter bag hanging from her bed with no dignity cover over the catheter bag. At 12:09 p.m., CNA #4 was asked if the resident had a dignity cover over her catheter bag the last three days. CNA #4 stated she had not. CNA #4 was asked if the resident should have a dignity cover over her catheter bag. CNA #4 stated yes, she should have had a dignity over her catheter bag. 3. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/07/21 at 11:50 a.m., the resident was observed in her room with the door open in bed with her catheter bag hanging from the side of her bed with no dignity cover on the bag. The resident was cognitively impaired and could not state her feelings about having others observe her catheter bag with no dignity cover. At 2:15 p.m., the resident was observed sitting up in bed with the door open to her room and no dignity cover over her catheter bag. On 06/08/21 at 11:36 a.m., the resident was observed in her room with the door open sitting up in her bed with no dignity cover over her catheter bag. On 06/09/21 at 11:15 a.m., licensed practical nurse (LPN) #5 was asked if the residents' catheter bags should have a dignity cover over the bags. LPN #5 stated yes, all of the catheter bags should have a dignity cover over them. She stated the dignity covers for catheter bags are attached to the entire indwelling catheter and nurses have to ensure they change out the indwelling catheter if they do not have dignity covers. She states she will make sure all of the catheter bags have dignity covers applied. On 06/09/21 at 12:15 p.m., CNA #4 was asked if the resident should have a dignity cover over her catheter bag for the last three days. CNA #4 stated yes.

On 09/21/16 at 3:30 p.m., an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to notify the physician of a significant change in condition when resident #1 exhibited signs and symptoms of a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) such as, drooping left side of mouth, visual gaze fixed in one direction, unable to speak, and unable to stand without increased assistance of additional staff. The facility also failed to administer the physician ordered medications, [MEDICATION NAME] and [MEDICATION NAME] (both medications are used to prevent the formation of blood clots), to resident #1. This resident had a history/[DIAGNOSES REDACTED]. The Oklahoma State Department of Health was notified and concurred with the IJ. At 4:00 p.m., the facility administrator and director of nurses (DON) were notified of the IJ. At 7:40 p.m., the plan of removal (POR) was received and documented: .Failure to notify Physician of Significant Change 1. How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? Clinical Manager communicated via telephone at 1800 (6:00 p.m.) to charge nurse that completed SBAR .documentation for the resident in the cited deficiency that she is on leave pending investigation on 9/21/16. Re-education was conducted via the phone by the Clinical Manager to the charge nurse at 1800 on the change (of) condition process on 9/21/16. 2. How will the corrective action be accomplished for other residents? The Director of Clinical and designee reviewed current residents that had a change in condition and SBAR (Situation Background, Assessment/Appearance, Recommendation) from 9/07/16 to current to assist with identification of appropriate documentation. 3. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? Quality improvement Nurse or designee re-educated charge nurses on the change of condition process which includes the SBAR .which includes notification of the health care provider beginning on 9/21/16 and to be completed by 09/21/16 at 11:59 pm. If the associates (staff) are unable to be contacted prior to 9/21/16 at 11:59 pm the associates will be re-educated prior to the return of their next shift. The charge nurses that couldn't be contacted will be re-educated prior to return of their next shift. The Clinical Managers or designee will review the 24 hour summary, orders portal, and order listing report in Point Click Care to assist with review of condition and compliance of documentation. The Clinical Manager or designee will review 3 change of conditions identified each business day to assist with identifying compliance of change of condition process. The interdisciplinary team (May include but not limited to: Executive Director, Health Care Administrator, Director of Clinical Services, Clinical Managers, Social Services, Resident Programs, Dining Services) will review new admissions in the Interdisciplinary team Huddle and change of conditions will be discussed in the Daily Stand up meeting. 4. How will the community monitor its performance to verify that solutions are sustained? Director of Clinical Service or designee will review change of condition documentation compliance in the Quality Assurance Performance Improvement Meeting x (times) 3 month and re-eval . The IJ was lifted on 09/22/16 at 3:00 p.m., after the components of the POR had been carried out. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview it was determined the facility failed to notify the physician of : ~ a significant change in condition when one (#1) sampled resident who exhibited signs and symptoms of a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) such as, drooping left side of mouth, visual gaze fixed in one direction, unable to speak, and unable to stand without increased assistance of additional staff. Six additional residents' clinical records were reviewed for physician notification for changes in condition. The facility identified twenty-eight residents who experienced a change in condition from 09/08/16 to 09/21/16. ~ missed doses of physician ordered [MEDICATION NAME] and [MEDICATION NAME] (both medications are used to prevent the formation of blood clots) for one (#1) of seven sampled residents with physician orders [REDACTED]. The facility identified two additional residents with orders for [MEDICATION NAME] and five additional residents with orders for [MEDICATION NAME]. Findings: 1. Resident #1 was admitted to a local heart hospital on [DATE], prior to his admission to the facility. He had a [DIAGNOSES REDACTED]. During his stay in the hospital he had a thrombectomy (removal of a blood clot) with placement of two drug-eluting stents in the left Circumflex coronary artery. The discharge summary from the local heart hospital, dated 09/06/16, documented the resident had been administered [MEDICATION NAME] and [MEDICATION NAME], at approximately 2:00 p.m., prior to being discharged to the facility. The resident was admitted to the facility on [DATE] at 6:46 p.m., for skilled services. The admission physician's orders [REDACTED]. The orders documented the medications were to be started on 09/07/16. The resident's MARs, dated 09/07/16 and 09/08/16, were reviewed. The MARs contained no documentation of [MEDICATION NAME] and [MEDICATION NAME] having been administered on 09/07/16 or 09/08/16. The resident was discharged to a local hospital on [DATE] at 9:26 a.m. due to exhibiting signs and symptoms of having a stroke. The admission history and physical (H&P), obtained from the receiving hospital, documented the resident arrived at the emergency department on 09/08/16 at 10:03 a.m. The H&P documented the resident's neurological status as: facial asymmetry, eyes deviated to the right, slurred/difficult speech, left side flaccid, and right side weakness. The H&P also documented the resident had an immediate significant threat to life or physiological function and required hospitalization for treatment of [REDACTED]. The resident had [DIAGNOSES REDACTED]. Due to the resident's short stay at the facility no Minimum Data Set Assessment had been completed. On 09/21/16 at 8:50 a.m., the charge/registered nurse (RN) #1 was interviewed. She was asked to provide information about the resident's change in condition and his transfer that had occurred on the morning of 09/08/16. The RN stated certified nurse aide (CNA) #1 notified her about 7:30 to 8:00 a.m., (on 09/08/16), the resident was different. The RN stated as she entered the resident's room he was dressed and sitting in his wheelchair (w/c). His mouth was drooping on the left side and he couldn't speak. The RN stated she had phoned the family about 8:00 a.m. She stated the son didn't answer, so she called the resident's daughter and informed her of the resident's change in condition. The RN stated the daughter told her not to do anything until all the family could be there. The RN stated, per family request, she didn't do anything else (the daughter was not the resident's power of attorney). The RN was asked if she had notified the physician. She stated she had not because she was waiting for the family to arrive, per the daughter's instructions. The RN stated the resident's son arrived about 8:15 a.m. She was asked if the son had requested for his father to be transferred to the hospital. She stated he did not, because he was waiting for the rest of the family to arrive. The RN was asked who placed the 911 call. She stated the family called 911. The RN stated she entered the resident's room and informed the son that was not the way it was to be done. She stated she told him she had to notify the physician, complete the paperwork, and she would then call 911. The RN was asked what time she spoke to the physician. She stated she didn't speak with him, she left a message on his cell phone. The facility's transfer form, which had been filled out by RN #1, documented the ambulance was called at 9:15 a.m., and the resident was transferred at 9:26 a.m., on 09/21/16. At 11:08 a.m., the director of nurses (DON) and the assistant director of nurses (ADON) #1 were interviewed. They were asked to provide documentation of when the physician had been notified of the resident's change in condition. They provided documentation in the form of a Situation Background, Assessment/Appearance, Recommendation (SBAR) for notification to the physician of the resident's change in condition. The SBAR documented the family and physician had been notified at 8:00 a.m., on 09/08/16; however, the time documented on the form was 9:27 a.m., (the discharge time for the resident). The DON and ADON were asked if the form was filled out at 8:00 a.m., or 9:27 a.m. They stated the form documented the physician was notified at 8:00 a.m. They were asked, if the form was supposed to contain current information about the resident's change in condition, why did the form document vital signs that were obtained at 1:19 a.m. Both were unsure why. At 11:55 a.m., a family member was interviewed about his father's change in condition, on 09/08/16. He was asked if he remembered what time he arrived at the facility. He stated he thought it was about 8:15 a.m. The family member stated a few minutes later RN #1 entered the room, and he stated he told the RN his father appeared to be having a stroke. He stated he instructed the nurse to call an ambulance. He stated the RN told him she would have to phone the physician and she left the room. He stated the rest of the family arrived and they waited for someone to help his father or for the ambulance to arrive. He stated about forty-five minutes later the family called 911. He thought that call was placed about 8:45 a.m., but wasn't sure of the time, it could have been a little later. He stated RN #1 came to the room to tell him he couldn't call 911, because that was not the way it was done. He added the RN stated she would contact the physician, do the paper work, and notify the ambulance. The family member was asked if any of the family had instructed the RN not to do anything until all of the family had arrived at the facility. He stated that never happened, none of them told the RN not to do anything. He was asked if he knew when his sister was notified about his father's change in condition. He stated he thought about 7:15 a.m. Medication Errors-MED-10 Applies to Skilled Nursing Communities. Policy Overview A 'medication error' is defined as the preparation or administration of drugs .which is not in accordance with Health Care Provider orders .1. Examples of medications errors include.(a) Omission-a drug is ordered but not administered .The following information should be documented .b .Name of Health Care Provider and time notified.(c) Health Care Provider subsequent orders. On 09/21/16 at 8:50 a.m. RN #1 was interviewed at this same time regarding the administration of [MEDICATION NAME] and [MEDICATION NAME]. She was asked if it would have been her duty to administer the two medications to the resident. She stated she would only have been responsible for administering the [MEDICATION NAME]. She was asked if she administered [MEDICATION NAME] on 09/07/16. She stated it was unavailable. She was asked if she notified the physician and the pharmacy. She stated she probably did, but it was not documented anywhere. At 11:00 a.m., the director of nurses (DON) was asked to provide documentation the drugs had been administered or documentation the physician had been notified of the medications not being administered. She stated the drugs had not been given and she had been unable to find documentation the physician had been notified. At 11:55 a.m., a family member was interviewed. He stated on 09/08/16 about 8:15 a.m., he asked RN #1 if his father received his blood thinners. The RN stated she didn't think the resident was on blood thinners, but she would check on it.

On 09/21/16 at 3:30 p.m., an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to assess, monitor, and intervene during a significant change in condition for one (#1) sampled resident when he had signs and symptoms (s/s) of a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) as exhibited by drooping of the left side of his mouth, visual gaze fixed in one direction, mumbling, change in mental status, and unable to stand without increased assistance of additional staff. The Oklahoma State Department of Health was notified and concurred with the IJ. At 4:00 p.m., the facility administrator and director of nurses (DON) were notified of the IJ. At 7:40 p.m., an acceptable plan of removal (POR) was received. The POR documented: .Significant Change in Condition 1. How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? Clinical Manager communicated via telephone at 1800 to charge nurse that completed SBAR (Situation Background, Assessment/Appearance, Recommendation) documentation for the resident in the cited deficiency that she is on leave pending investigation on 09/21/16. Re-education was conducted via the phone by the Clinical Manager to the charge nurse at 1800 on the change (of) condition process on 09/21/16. 2. How will the corrective action be accomplished for other residents? The Director of Clinical and designee reviewed current residents that had a change of condition and SBAR .from 09/7/16 to current to assist with identification of appropriate documentation. 3. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? Quality Improvement Nurse or designee re-educated charge nurses on the change of condition process which includes the SBAR .began on 9/21/16 and to be completed by 9/21/16 by 11:59 pm. If the associates (staff) are unable to be contacted prior to 9/21/16 at 11:59 pm the associate will be re-educated prior to the return of their next shift. The charge nurses that couldn't be contacted will be re-educated prior to the return of their next shift. The Clinical Manager or designee will review the 24 hour summary, orders portal, and order listing report in Point Click Care to assist with review of condition and compliance of documentation. The Clinical Manager or designee will review 3 change of conditions identified each business day to assist with compliance of change of condition process. The interdisciplinary team (May include but not limited to: Executive Director, Health Care Administrator, Director of Clinical Managers, Clinical Managers, Social Services, Resident Programs, Dining Services) will review new admissions in the Interdisciplinary team Huddle and change of conditions will be discussed in the Daily Stand up meeting. 4. How will the community monitor its performance to verify that solutions are sustained? Director of Clinical Service or designee will review change of condition documentation compliance in the Quality Assurance Performance Improvement Meeting x 3 months and re-eval . The facility provided a copy of their policy and procedures for change in condition with their POR. They stated the policy and procedures would be used as a guide for inservices. Change of Condition for Skilled Nursing . Policy Overview When a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to .the health care provider and other licensed nurses in order to facilitate the appropriate plan of care. Policy Detail .observing a difference in the resident's usual physical, emotional or cognitive patterns the licensed nurse will .Perform a comprehensive evaluation or assessment consulting the Care Paths as indicated will document the current situation, background, assessment (RN) (registered nurse) or appearance (LPN/LVN) (licensed practical/vocational nurse) .SBAR may be filled out later only when the resident's condition is emergent requiring an immediate 911 call Call the appropriate Health Care Provider to communicate the SBAR information . The IJ was lifted on 09/22/16 at 3:00 p.m., after the components of the POR had been carried out. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to assess, monitor, and intervene during a significant change in condition for one (#1) sampled resident when he exhibited signs and symptoms (s/s) of a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) as exhibited by drooping of the left side of his mouth, visual gaze fixed in one direction, mumbling, change in mental status, and unable to stand without increased assistance of additional staff. This lack of monitoring, assessing, and intervening in a timely manner resulted in the resident not being able to be treated with the [MEDICATION NAME] drugs (used to break-up blood clots in the brain) within the three hour time frame. Six additional residents' clinical records were reviewed for changes in condition. No additional discrepancies were identified. The facility identified twenty-eight residents who experienced a change in condition from 09/08/16 to 09/21/16. Findings: Resident #1 was admitted to a local heart hospital on [DATE], prior to his admission to the facility. He had a [DIAGNOSES REDACTED]. During his stay in the hospital he had a thrombectomy (removal of a blood clot) with placement of two drug-eluting stents in the left Circumflex coronary artery. The resident was admitted to the facility on [DATE] at 6:46 p.m., for skilled services. On 09/06/16, a care plan had been developed for fall risks, activities of daily living (ADL) self care deficit, and UTI (urinary tract infection). The resident was discharged to a local hospital on [DATE] at 9:26 a.m. due to exhibiting signs and symptoms of having a stroke. On the day of his discharge on 09/08/16 (time unknown) a care plan was developed for [MEDICAL CONDITION] or acute confusional episode. The admission history and physical (H&P), obtained from the receiving hospital, documented the resident arrived at the emergency department on 09/08/16 at 10:03 a.m. It also documented the ambulance personnel stated the facility staff told them the resident was found with altered mental status at 7:00 a.m., on 09/08/16. The H&P documented the resident's neurological status as: facial asymmetry, eyes deviated to the right, slurred/difficult speech, left side flaccid, and right side weakness. The H&P also documented the resident had an immediate significant threat to life or physiological function and required hospitalization for treatment of [REDACTED]. known well time. The resident had a [DIAGNOSES REDACTED]. Due to the resident's short stay at the facility no Minimum Data Set Assessment had been completed. On 09/21/16 at 8:50 a.m., the registered nurse (RN) #1 was interviewed. She was asked to provide information about the resident's change in condition, which occurred on the morning of 09/08/16. The RN stated certified nurse aide (CNA) #1 notified her about 7:30 to 8:00 a.m., the resident was different. The RN stated as she entered the resident's room, he was dressed and sitting in his wheelchair (w/c). His mouth was drooping on the left side and he couldn't speak. The RN was asked if she had performed an assessment and if so, what were the results. She stated she checked his hand grip strength for both hands and his grips were normal. She was asked if additional assessments had been conducted. She stated she did an assessment; she just couldn't remember exactly what she did. She was asked to provide a narrative documentation of the events. She stated she couldn't remember if she had documented her assessment. The RN was asked what the resident's vital signs were. She stated the CNA had already obtained them and she (CNA) should have documented them. The nurse was asked what she did next. She stated she and the CNA transferred the resident from his w/c to his bed. The RN was asked if the resident had been able to bear weight, stand, and pivot. She stated he was, but he did require more assistance than usual. The RN stated she phoned the family about 8:00 a.m. She stated the son didn't answer, so she called the resident's daughter and informed her of the resident's change in condition. The RN stated the daughter told her not to do anything until all the family could be there. The RN stated per family instructions, she didn't do anything else (the daughter was not the resident's power of attorney). The RN stated the resident's son arrived about 8:15 a.m., and the resident had already been placed in bed. She was asked if the son had requested for his father to be transferred to the hospital. She stated he had not, because he was waiting for the rest of the family to arrive. The RN stated she was unsure what time the rest of the family arrived. The RN was asked if the family had asked her to call 911. She stated they had not. The family had called 911. The RN stated at some point (she was unsure of the time), CNA #1 told her the resident's son had called 911. The RN stated she entered the resident's room and informed him that was not the way it was done. She stated she told him she had to notify the physician, complete the paperwork, and she would then call 911. She was asked if she had the authority to transfer a resident to the hospital prior to notifying the physician, when a resident was exhibiting a serious change in condition. She stated she did not need to wait to speak directly with the physician before transferring the resident. She was asked if a staff member had been assigned to monitor and remain in the room with the resident after he was observed to have had a significant change in condition. She said, No. She was asked if additional assessments had been conducted. She stated she couldn't remember and she couldn't provide any documentation. The facility's transfer form, which had been filled out by RN #1, documented the ambulance was called at 9:15 a.m., and the resident was transferred at 9:26 a.m., on 09/08/16. She was asked why it took so long for the resident to be transferred to the hospital. She stated she was busy doing the paperwork. She was asked if she had requested help with getting assessments, monitoring the resident, documentation, notifications, and doing the paper work, in order to facilitate a speedy transfer. She stated she had not. She was asked how much paper work was required to transfer a resident. She stated the discharge form, communication form, and SBARs. The SBAR (Situation Background, Assessment/Appearance, Recommendation) Communication From and progress note was dated 09/08/16 and timed 9:27 a.m. This form documented, .Situation 1. The change in condition, symptoms, or signs I am calling about is/are Drooping left side of face, mumbling, not as alert .slurred speech .A. Assessment or Appearance (LPN) What do you think is going on with the resident? RN. I think the problem may be (e.g. cardiac, infection, respiratory, dehydration): Definite changes and family request transfer .R. Request I suggest or request (check all that apply) .Monitor vital signs, Lab work and EKG were checked. Transfer to the hospital was not checked. The RN was asked if she was aware there was a short period of time for a resident to receive clot busting medication during a stroke. She stated she was. She was asked what the priority was; assessing, monitoring the resident, and getting him transferred as quickly as possible or doing the paper work. She responded she thought getting the paperwork completed was the priority because the ambulance wouldn't take him without it. She was asked if the resident could have been transferred out quicker. She stated it took that long for the ambulance to arrive. The clinical record of resident #1 was reviewed and contained no documentation the resident had been assessed by nursing staff for his change in condition. There was no documentation a staff member had been assigned to remain with the resident to monitor his change in condition. There was no documentation a staff member had immediately phoned 911 to arrange for a transfer to the hospital. The record documented the family phoned 911. At 11:08 a.m., the director of nurses (DON) and assistant director of nurses (ADON) #1 were interviewed. They were asked if the resident could have been transferred quicker. They stated the paperwork had to be completed before the resident could be transferred. They were asked if it would have been possible for another nurse to help RN #1 facilitate a speedy transfer to the hospital. They both agreed that could have been possible. They were asked if it would have been possible for one nurse to remain with the resident to assess and monitor the resident's change in condition while one nurse completed the paper work and notifications. They both said, Definitely. They were asked if RN #1 had asked for help. They stated they didn't know, but both of them would have been available to help. The DON and ADON were asked to provide documentation of assessments. They stated they were unable to find any documentation of assessments. At 11:55 a.m., a family member was interviewed about his father's change in condition on 09/08/16. He was asked if he remembered what time he arrived at the facility. He stated it was about 8:15 a.m. He was asked if a staff member was in his father's room. He stated there was no one with his father. He stated his father was sitting in his w/c slumped over, he couldn't speak, both of his eyes were looking to the right, and his face was drooping. He stated in a few minutes RN #1 nurse entered the room and told him she had tried to reach him by phone, because the resident wasn't doing well. The family member stated he told the RN his father was having a stroke,Can't you see that? He stated he instructed her to call an ambulance. He stated the RN told him she would have to phone the physician and she left the room. He stated the rest of the family arrived and they waited for someone to help his father or for the ambulance to arrive. The family member stated he later saw RN #1 wheeling another resident down the hall. He stated at that point the family felt no one was going to help his father, so they called 911. He thought the call was placed about 8:45 a.m., but he wasn't sure of the time. The family member stated RN #1 came to the room to tell him he couldn't call 911, because that was not the way it was done. He added the RN stated she would contact the physician, do the paper work, and then notify the ambulance. He was asked if any of the family had instructed the RN not to do anything until all of the family had arrived at the facility. He stated that never happened, none of the family told the RN not to do anything. He was asked if he knew when his sister was notified about his father's change in condition. He stated he thought about 7:15 a.m. On 09/23/16 at 10:52 a.m., CNA #1 was interviewed about the named resident's change in condition on 09/08/16. She was asked to explain what happened. The CNA stated she told RN #1 several times (she was unable to provide a time) the resident was acting different. She stated RN #1 instructed her to wash his face and get him up. The CNA was asked if the RN had completed an assessment of the resident. She stated the RN just looked at the resident and told her to go ahead and get him up. The CNA added that she had taken his vital signs and given them to the nurse. She stated about 8:00 a.m., a certified medication aide (CMA) assisted her with transferring the resident to his wheelchair. The CNA stated a family member showed up later and was upset about his father's condition. On 09/23/16 at 2:30 p.m., CMA #1 was interviewed about the events concerning the named resident's change in condition on the morning of 09/08/16. The CMA stated she was outside the resident's room preparing the resident's medications; she stated she thought it was around 8:00 a.m. She stated CNA #1 was in the resident's room and was urgently requesting her assistance. The CMA stated as she entered the resident's room she could immediately see something was wrong with the resident. She stated the resident was dressed and sitting on the edge of his bed. His face was drooping, he couldn't speak, and he was having trouble balancing. The CMA asked CNA #1 if the nurse had been informed. The CMA stated CNA #1 told her she had informed the nurse earlier and the RN instructed her to wash his face and get him up for breakfast. The CMA stated she asked the CNA if the RN indicated anything was wrong with the resident. She stated the CNA told her the RN just didn't do anything. The CMA stated she left the room to tell RN #1 the resident's face and lip were drooping. She stated the RN followed her back to the resident's room. While in the room the RN instructed the two of them (CMA and CNA) to get him in the wheelchair (w/c) and take him to the dining room, then the RN left the room. The CMA stated the two of them got the resident into his w/c, with a great deal of difficulty because the resident was unable to assist with the transfer. The CMA was asked if RN #1 assessed the resident while she was in the room. She stated the RN did not conduct an assessment prior to leaving the room. The CMA stated she and the CNA transported the resident to the nurses' station. Registered nurse #1 was standing at the desk. The CMA stated she asked RN #1 what to do with the resident's medications because the resident was unable to swallow. She stated the RN instructed her to save them. The RN turned to another nurse who was standing at the nurses' station and asked her if the resident's face looked funny. The other nurse responded that it did. The CMA stated the RN told the CNA to return the resident to his room. The CMA stated the CNA returned the resident to his room and the RN went to the dining room. The CMA stated she returned to her cart to continue with her medication pass. The CMA stated she later saw the resident's son enter the resident's room. She stated no staff member was in the resident's room and the resident was still seated in his w/c when she stepped into the room to check on the resident and to speak to the son. She stated the son was on the phone. She stated when the son hung up, he asked me what was wrong with his father: was he having a stroke? The CMA stated she told him she would find the nurse. She stated as she was looking for RN #1 the nurse was observed walking from the dining room. The CMA stated she thought the RN had been assigned to monitor the dining room during breakfast. The CMA explained to the RN the son was here and was very upset. The CMA stated the RN stated to her that she had already spoken to him and he just needed to calm down. This lack of monitoring, assessing, and intervening in a timely manner resulted in the resident not being able to be treated with the [MEDICATION NAME] drugs (blood clot busting) medication within the three hour time frame.

On 09/21/16 at 3:30 p.m., an IJ (immediate jeopardy) situation was determined to exist due to the facility's failure to administer physician ordered [MEDICATION NAME] and [MEDICATION NAME] (both medications are used to prevent the formation of blood clots) to one (#1) sampled resident with a history/[DIAGNOSES REDACTED]. M I, [MEDICAL CONDITION]), removal of a thrombus (blood clot), and [MEDICAL CONDITION]. The Oklahoma State Department of Health was notified and concurred with the IJ. At 4:00 p.m., the facility administrator and director of nurses (DON) were notified of the IJ. At 7:40 p.m., an acceptable plan of removal (POR) was received. The facility plan of removal documented; Plan of Removal 09/21/16 Med Error 1. How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? Clinical Manager communicated via telephone at 1800 (6:00 p.m.) to charge nurse that completed SBAR (Situation Background, Assessment/Appearance, Recommendation) for the resident in the cited deficiency that she is on leave pending investigation on 09/21/16, Re-education was conducted via phone by the Clinical Manager at 1800 on the change of condition process on 09/21/16. 2. How will the corrective action be accomplished for other residents? Director of Clinical Services reviewed current residents on anticoagulants for missed doses on 09/21/16. No other residents were noted to be effected. 3. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? The Quality improvement Nurse or designee re-educated current charge nurses and Certified Medication Aides on Medication Errors, pharmacy notification if medication not delivered, and notification of health care provider if medication isn't available will began on 9/21/16 and to be completed by 11:59 pm. If the associates (staff) are unable to be contacted prior to 9/21/16 at 11:59 pm the associate will be re-educated prior to return of their next shift. The Clinical Managers or designee will review the orders portal for medications waiting to be received daily for one month and then on business days thereafter. If medications are not delivered timely the charge nurse will notify the pharmacy, health care provider, and clinical on call designee of medication not being delivered timely for further direction. 4. How will the community monitor its performance to verify that solutions are sustained? Director of Clinical Services or designee will review errors and timely delivery of medications in the Quality Assurance Performance Improvement Meeting x (times) 3 months and then re-eval . The facility provided a copy of their polices for pharmacy services and procedures with their POR. They stated the policy and procedures would be used as a guide for inservices. The Pharmacy and Procedures documented: .5. If the medication is needed before the next scheduled delivery and is not available .facility staff should Fax or transmit the order to the Pharmacy Notify the Pharmacy and include the exact time by which the medication is needed Facility staff should ask the pharmacists to read the order back to assure accuracy Document the information The facility polices documented: Medication Procedures for medication not in the Facility If medication is not in the facility the MD (medical doctor) is to be notified for further orders. The Clinical on call person is to be notified of the medications not available. (Phone number provided). Medication Errors-MED-10 Applies to Skilled Nursing Communities. Policy Overview A medication error is defined as the preparation or administration of drugs .which is not in accordance with Health Care Provider orders . 1. Examples of medications errors include. (a) Omission- a drug is ordered but not administered 7. In the event of a significant medication-related error .immediate action is taken, as necessary, to protect the resident's safety and welfare Significance is defined as: .requiring hospitalization , .Life threatening; and/or .resulting in death The following information should be documented .in the resident's clinical record:(a) Factual description of the error(b) Name of Health Care Provider and time notified.(c) Health Care Provider subsequent orders . The IJ was lifted on 09/22/16 at 3:00 p.m., after the components of the POR had been carried out. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to ensure one (#1) of seven sampled residents was administered physician ordered [MEDICATION NAME] and [MEDICATION NAME] (both medications are used to prevent the formation of blood clots). The resident was transferred to the hospital after he showed signs and symptoms of a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke) as exhibited by drooping of the left side of his mouth, visual gaze fixed in one direction, mumbling, change in mental status, and required increased assistance to stand. The resident was diagnosed with [REDACTED]. There were no additional residents with orders for [MEDICATION NAME] or [MEDICATION NAME]. Findings: Resident #1 was admitted to a local heart hospital on [DATE], prior to his admission to the facility. He had a [DIAGNOSES REDACTED]. During his stay in the hospital he had a thrombectomy (removal of a blood clot) with placement of two drug-eluting stents in the left Circumflex coronary artery. The discharge summary, dated 09/06/16, from a local heart hospital, documented the resident had been administered [MEDICATION NAME] and [MEDICATION NAME] at approximately 2:00 p.m., before his discharge to the facility. The resident was admitted to the facility on [DATE] at 6:46 p.m., for skilled services. On 09/06/16, a care plan had been developed for fall risks, activities of daily living (ADL) self care deficit, and UTI (urinary tract infection). The admission physician orders, dated 09/06/16, documented the resident was to be administered one [MEDICATION NAME] 75 mg (milligram) tablet one time a day and [MEDICATION NAME] 40 mg/0.4 ml (milliliters) subcutaneously one time a day. The orders documented the medications were to be started on 09/07/16. The resident's Medication Administration Records (MARs), dated 09/07/16 and 09/08/16, were reviewed. The MARs contained no documentation of [MEDICATION NAME] and/or [MEDICATION NAME] having been administered. The MARs also documented both drugs were to be administered at 9:00 a.m., every morning. The resident was discharged to a local hospital on [DATE] at 9:26 a.m. due to exhibiting signs and symptoms of having a stroke. On the day of his discharge on 09/08/16 (time unknown) a care plan was developed for [MEDICAL CONDITION] or acute confusional episode. The admission history and physical (H&P) form, dated 09/08/16, obtained from the receiving hospital, documented the resident arrived at the emergency department on 09/08/16 at 10:03 a.m. The H&P documented the resident's neurological status as: facial asymmetry, eyes deviated to the right, slurred/difficult speech, left side flaccid, and right side weakness. The H&P also documented the resident had an immediate significant threat to life or physiological function and required hospitalization for treatment of [REDACTED]. The H&P documented the resident had suffered an acute right MCA (middle cerebral artery) stroke. Due to the resident's short stay at the facility no Minimum Data Set Assessment had been completed. On 09/21/16 at 8:50 a. m., RN #1 was interviewed regarding the administration of [MEDICATION NAME] and [MEDICATION NAME]. She was asked if it would have been her duty to administer the two medications to the resident. She stated she would only have been responsible for administering the [MEDICATION NAME]. She was asked if she had administered [MEDICATION NAME] on 09/07/16. She stated it was unavailable. She was asked if she had notified the physician and the pharmacy. She stated she probably did but it was not documented anywhere. She was asked what she did document. She stated she thought she documented somewhere the drug had not arrived. At 11:00 a.m., the director of nurses (DON) was asked to provide documentation the drugs had been administered or documentation the physician had been notified of the medications not being administered. She stated the drugs had not been given and she had been unable to find documentation the physician had been notified. She stated they found a nurse's note, dated on 09/07/16 at 10:19 a.m., that documented the drugs were not available. The DON was asked to provide a pharmacy invoice sheet to document when the orders were placed. She stated the physician orders [REDACTED]. She was asked if the pharmacy provided confirmation of receipt of the physician orders. The DON stated not that she was aware of. The DON provided a delivery sheet from the pharmacy which documented both drugs had been delivered on 09/07/16 at 9:51 p.m. The [MEDICATION NAME] and/or the [MEDICATION NAME] was never administered after delivery. The DON was asked if a stat (at once) order had been placed for the [MEDICATION NAME] and [MEDICATION NAME] on 09/06/16 and/or 09/07/16. The DON and ADON both stated they could not find documentation that a stat order had been placed.

On 09/21/16 at 3:30 p.m., an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to acquire (in a timely manner) and administer physician ordered Lovenox and Plavix (both medications are used to prevent the formation of blood clots) to one (#1) sampled resident with a history/[DIAGNOSES REDACTED]. The Oklahoma State Department of Health was notified and concurred with the IJ. At 4:00 p.m., the facility administrator and director of nurses (DON) were notified of the IJ. At 7:40 p.m., an acceptable plan of removal (POR) was received. The facility POR documented; Plan of Removal 9/21/16 . Failure to acquire medication and administer 1. How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? Clinical Manager communicated via telephone at 1800 (6:00 p.m.) to charge nurse that completed SBAR (Situation Background, Assessment/Appearance, Recommendation) for the resident in the cited deficiency that she is on leave pending investigation on 9/21/16. Re-education was conducted via phone by the Clinical Manager at 1800 on the change condition process on 9/21/16. 2. How will the corrective action be accomplished for other residents? The Director of Clinical Services reviewed current residents on anticoagulants for missed doses on 9/21/16. No other residents were noted to be affected. 3. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? The Quality improvement Nurse or designee re-educated current charge nurses and Certified Medication Aides on Medication Errors, pharmacy notification if medication not delivered, and notification of health care provider if medication isn't available will began on 9/21/16 and to be completed by 11:59 pm. If the associates (staff) are unable to be contacted prior to 9/21/16 at 11:59 pm the associate will be re-educated prior to return of their shift. The Clinical Managers or designee will review the orders portal for medications waiting to be received daily for one month and then on business days thereafter. If medications are not delivered timely the charge nurse will notify the pharmacy, health care provider, and clinical on call designee of medication not being delivered timely for further direction. 4. How will the community monitor its performance to verify that solutions are sustained? Director of Clinical Service or designee will review Medication errors and timely delivery of medications in the Quality Assurance Performance Improvement Meeting x (times) 3 months and then re-eval. The facility provided a copy of their polices for pharmacy services and procedures with their POR. They stated the policy and procedures would be used as a guide for inservices. The Pharmacy and Procedures documented: .5. If the medication is needed before the next scheduled delivery and is not available .facility staff should Fax or transmit the order to the Pharmacy Notify the Pharmacy and include the exact time by which the medication is needed Facility staff should ask the pharmacists to read the order back to assure accuracy Document the information Medication Procedures for medication not in the Facility If medication is not in the facility the MD (medical doctor) is to be notified for further orders. The Clinical on call person is to be notified of the medications not available. (Phone number provided). Medication Errors-MED-10 Applies to Skilled Nursing Communities. Policy Overview A medication error is defined as the preparation or administration of drugs .which is not in accordance with Health Care Provider orders . 1. Examples of medications errors include. (a) Omission- a drug is ordered but not administered .The following information should be documented .in the resident's clinical record: .(b) Name of Health Care Provider and time notified.(c) Health Care Provider subsequent orders. The Role of the Provider Pharmacy policy documented: Policy Interpretation and Implementation .3.The provider policy shall agree to provide services that comply with applicable facility policies and procedures .e. Provide routine pharmacy services seven days a week and emergency pharmacy service 24 hours per day, seven days a week; .h. Establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medications and prescriptions; The IJ was lifted on 09/22/16 at 3:00 p.m., after the components of the POR had been carried out. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to ensure one (#1) of seven sampled residents was administered physician ordered Lovenox and Plavix (both medications are used to prevent the formation of blood clots). The medications were not readily available. The resident was transferred to the hospital after he showed signs and symptoms of a cerebrovascular accident (CVA/stroke) as exhibited by drooping of the left side of his mouth, visual gaze fixed in one direction, mumbling, change in mental status, and required increased assistance to stand. There were no other residents that had Lovenox or Plavix ordered. Findings: Resident #1 was admitted to a local heart hospital on [DATE], prior to his admission to the facility. He had a [DIAGNOSES REDACTED]. During his stay in the hospital he had a thrombectomy (removal of a blood clot) with placement of two drug-eluting stents in the left Circumflex coronary artery. The discharge summary, dated 09/06/16, from a local heart hospital, documented the resident had been administered Lovenox and Plavix at approximately 2:00 p.m., before his discharge to the facility. The resident was admitted to the facility on [DATE] at 6:46 p.m., for skilled services. On 09/06/16, a care plan had been developed for fall risks, activities of daily living (ADL) self care deficit, and UTI (urinary tract infection). The admission physician orders, dated 09/06/16, documented the resident was to be administered one Plavix 75 mg (milligram) tablet one time a day and Lovenox 40 mg/0.4 ml (milliliters) subcutaneously one time a day. The orders documented the medications were to be started on 09/07/16. The resident's Medication Administration Records (MARs), dated 09/07/16 and 09/08/16, were reviewed. The MARs contained no documentation of Lovenox and/or Plavix having been administered. The MARs also documented both drugs were to be administered at 9:00 a.m., every morning. The resident was discharged to a local hospital on [DATE] at 9:26 a.m. due to exhibiting signs and symptoms of having a stroke. On the day of his discharge on 09/08/16 (time unknown) a care plan was developed for delirium or acute confusional episode. The admission history and physical (H&P) form, dated 09/08/16, obtained from the receiving hospital, documented the resident arrived at the emergency department on 09/08/16 at 10:03 a.m. The H&P documented the resident's neurological status as: facial asymmetry, eyes deviated to the right, slurred/difficult speech, left side flaccid, and right side weakness. The H&P also documented the resident had an immediate significant threat to life or physiological function and required hospitalization for treatment of [REDACTED]. The H&P documented the resident had suffered an acute right MCA (middle cerebral artery) CVA/stroke. A nurse's entry by registered nurse (RN) #1, dated 09/07/16 at 10:19 a.m., documented Lovenox was not available. The note did not contain documentation for the unavailability of Plavix. The note did not document the pharmacy and/or physician had been notified of the need for a stat (at once) delivery of the medications. On 09/21/16 at 8:50 a.m., RN #1 was interviewed regarding the administration of Lovenox and Plavix. She was asked if it would have been her responsibility to administer the two medications to the resident. She stated she would only have been responsible for administering the Lovenox. She was asked if she had administered Lovenox on 09/07/16. She stated it was unavailable. She was asked if she had notified the physician and the pharmacy. She stated she probably did, but it was not documented anywhere. She was asked what she did document. She stated she thought she documented somewhere the drug had not arrived. At 11:00 a.m., the director of nurses (DON) was asked to provide documentation the drugs had been administered or documentation the physician had been notified of the medications not being administered. She stated the drugs had not been given and she had been unable to find documentation the physician had been notified. She stated they found a nurse's note, dated on 09/07/16 at 10:19 a.m., that documented the drugs were not available. The DON was asked to provide a pharmacy invoice sheet to document when the orders were placed. She stated the physician orders [REDACTED]. She was asked if the pharmacy provided confirmation of receipt of the physician orders. The DON stated not that she was aware of. The DON provided a delivery sheet from the pharmacy which documented both drugs had been delivered on 09/07/16 at 9:51 p.m. The Lovenox and/or the Plavix was never administered after delivery. The DON was asked if a stat (at once) order had been placed for the Lovenox and Plavix on 09/06/16 and/or 09/07/16. The DON and ADON both stated they could not find documentation that a stat order had been placed.

On 06/10/14 at 11:40 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for allegations of mistreatment, failure to report allegations of mistreatment, and failure to ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 12:10 p.m., the Administrator and the Director of Nursing were notified of the IJ situation. On 06/10/14 at 3:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Removal for Deficient Practice Identified on 6/10/2014 Immediate Actions Taken to ensure the Safety of the Residents: Reports identified by the State will be submitted along with all information on the incident. By Midnight 6/10/2014 All Staff will be in-serviced on: State Reporting Requirements as they relate to Abuse and Neglect Brookdale Policy and Procedure for Identifying and Reporting Abuse and Neglect Elder Abuse and Neglect The appropriate person(s) in our community to contact with concerns or suspicions of abuse In-Services will be complete by Midnight on 6/10/2014 All associates we are unable to In-service by the stated deadline will be notified via phone and certified letter that they will not be permitted to clock in for their next shift until the above in-services have been completed. Leadership and Nursing Management will review all Brookdale Policies regarding Abuse and Neglect. Additionally, leadership and nurse management staff will be inserviced on the investigative process. By 12 Midnight on Tuesday 6/10/2014 Use of a Brookdale Procedure for Conducting and Internal Investigation will be implemented to verify that all appropriate documentation occurs in the event of any allegation of abuse, neglect or misappropriation. By Midnight on Tuesday 6/10/2014." On 06/11/14 at 7:20 a.m., thru 1:00 p.m., facility staff members from all shifts who attended the inservices were interviewed. They were knowledgeable in regard to abuse policy and procedures for investigating, reporting and protecting the residents. The Immediate Jeopardy was removed on 06/11/14 at 1:00 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interviews and review of clinical records, policies and procedures, personnel records, and staff schedules, it was determined the facility failed to: ~ensure a thorough investigation was completed of allegations of mistreatment for one (#1) of two sampled residents with allegations of mistreatment, and ~ensure allegations of mistreatment were reported to the Oklahoma State Department of Health (OSDH) for two (#1 and #6) of two sampled residents with allegations of mistreatment by staff. This had the potential to affect all 92 residents who resided in the facility. Findings: A facility policy, titled 'Abuse Investigations', documented, "...All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by community management... 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The individual conducting the investigation will, as a minimum: a. Review the resident's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident (as medically appropriate); e. Notify the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors; h. Interview other residents to whom the accused employee provides care or services; and i. Review all events leading up to the alleged incident... 7...Associates of this community who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator... 9. The results of the investigation will be recorded... 12. As required, the Administrator will provide a written report of the results of abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident..." 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. An admission assessment, dated 05/05/14, documented the following. The resident was severely impaired in cognitive skills for daily decision making. He required extensive two person assistance with bed mobility, dressing and toileting. He required extensive one person assistance with transfers, locomotion, eating, and personal hygiene. He was totally dependent and required two person assistance with bathing. He was occasionally incontinent of bowel and had a suprapubic catheter. A nurse note, dated 04/29/14 at 12:00 a.m., documented, "...Resident stayed in bed for 30 min then he started screaming Help me, get me out of here then tried to climb out of bed. We brought him to the nurses station for one on one..." On 06/10/14 at 9:20 a.m., a confidential interview with a former employee was conducted. The interviewee stated on 04/29/14 during the 11:00 p.m. to 7:00 a.m. shift, resident #1 was at the nurses' station with several other staff members present. He/she stated that the resident attempted to get out of the chair and LPN #1 threw the resident back into his chair causing him to yell out. The interviewee was asked if they reported the occurrence to their supervisor. They stated that it was reported to the DON. On 06/10/14 at 10:00 a.m., the Administrator was asked when and how an allegation of abuse was reported and investigated. She stated, "Anytime we have an allegation of abuse or neglect. When we become aware we report it." She was asked if any incidents or allegations of abuse were reported recently regarding resident #1. She stated, "Oh I know what you are talking about. Neither of those employees work here anymore. APS was out here last week investigating that and another occurrence." She was asked what employees she was referring to and she replied, "(named LPN #1) and (named CNA #1)." She was asked when LPN #1 was terminated. She stated on 05/21/14 for another allegation. She stated there was no physical findings of abuse but the LPN had several instances of reported misconduct. She was asked if an allegation of abuse involving LPN #1 and resident #1 which occurred on 04/29/14 was reported to her. She stated, "I would have to look back but I don't believe we were aware until APS came in and investigated." She was asked if the allegation was reported to all applicable agencies and she stated, "Should I have reported that. I thought that since APS was here investigating that it was enough." On 06/10/14 at 10:19 a.m., the Administrator stated, "We investigated the 04/29/14 incident." On 06/10/14 at 10:48 a.m., the ADON was interviewed and asked if an allegation of abuse on 04/29/14 was ever reported to her. She stated, "No but it was reported to someone else." She was asked who it was reported to. She stated "To the DON by a letter under her door." She was asked when it was reported. She stated she could not remember exactly. A statement, date unknown, by the ADON documented, "...On the overnight shift of 4/29/14 it was reported that (named LPN #1) was slamming a resident's wheelchair around in the hallway and yelling at the cna's. Upon investigation these allegation were found to be untrue. (named RN #1) was orientating with the nurse (named LPN #1)..." At 10:55 a.m., the DON was asked if she was notified regarding the allegation on 04/29/14. She stated no, but it was rumored a former employee put a note under my door. She stated I found out when the former employee was terminated and reported the allegation to the Administrator on 05/20/14. On 06/11/14 at 8:09 a.m., RN #1 was asked if she had ever worked with LPN #1. She stated, "Yes." She was asked if she had ever observed the LPN abuse, neglect, or mistreat any residents. She stated, "Yes, (named resident #1) was trying to get up and (named LPN #1) made him sit back down." She was asked how the LPN made him sit down. She stated the LPN used her hands to pull his shoulders down to the chair. She stated she pushed his shoulders back and then sat him down pushing down on him. She was asked if the LPN made any attempt to explain what she was doing to the resident. RN #1 stated, "No." She was asked if the resident said anything about what was being done. She stated, "No not really. He makes jibberish." She was asked if anyone else ever talked to her about the incident. She stated, "Yes, (named ADON) a couple of days after the incident." At 8:33 a.m., the ADON was asked if she spoke to RN#1 regarding the incident on 04/29/14 with resident #1. She stated she texted and called her and that RN #1 said the LPN was a strong nurse. The allegation on 04/29/14 was not thoroughly investigated, reported, or were the residents protected during the investigation. 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A 14 day assessment, dated 05/15/14, documented the following. The resident was alert and oriented and was cognitive with skills for daily decision making. She required supervision assistance of one person for walking and eating. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She was continent of bowel and bladder. A facility document titled, Occurrence/Allegation Investigation, documented, "...Resident/Patient Name: (named resident #6)... Date of Occurrence: 5/20/14...Associate(s) Involved (named LPN #1)... Summary of Initial Report: (named CNA #2) alleges that LPNS (sic) was rough w/(with) (resident #6) during the 11-7 (11:00 p.m. - 7:00 a.m.) shift..." A staff statement, dated 05/20/14, "(named director of human resources), I am writing this statement as a result of what I witnessed. What I witnessed on 5/20/14 at about 2:15 a.m. I went to answer a call light and as I got there the nurse, (named LPN #1) was already in there changing out oxygen tubes. (named LPN#1) grabbed (named resident #6) wrist and pulled her out of bed. The resident was upset of how she was helped up. I feel like this is something that needed to be addressed. If you have any questions please feel free to call me ...(signed by CNA#2) A facility document titled, Personnel Action Form/Termination, documented LPN #1 was terminated on 05/21/14 for misconduct. On 6/10/14 at 10:00 a.m., the Administrator was asked if the allegation was reported to the OSDH. She stated,"No, but we terminated her because of her attitude. I didn't find any physical evidence of abuse." She stated the nurse had multiple reports of a bad attitude. At 11:45 a.m., the resident was asked if any staff had ever mistreated her. She stated, "Yes, my little aide was in the door and she reported it. I didn't have the nerve. I didn't want any retaliation. I was so glad she was standing there. The nurse came in and I asked her to help me to the bathroom. The nurse shoved me back down on the bed and then jerked my left wrist." She was asked the name of the nurse. The resident named LPN#1. The resident was asked if she thought if the nurse shoved her intentionally. She stated, "Yes I do but I didn't want to say anything at the time. She was mad when she came in and acted like she didn't like her job. I was afraid to take any medicine that she would have given me. If she was that mad she could have done something to me to get back at me." There was no state reportable or report to the Oklahoma State Board of Nursing for the allegation.

On 06/10/14 at 11:40 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to complete a thorough investigation for allegations of mistreatment, failure to report allegations of mistreatment, and failure to ensure residents were protected until a thorough investigation was completed. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy Situation. At 12:10 p.m., the Administrator and the Director of Nursing were notified of the IJ situation. On 06/10/14 at 3:00 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "Plan of Removal for Deficient Practice Identified on 6/10/2014 Immediate Actions Taken to ensure the Safety of the Residents: Reports identified by the State will be submitted along with all information on the incident. By Midnight 6/10/2014 All Staff will be in-serviced on: State Reporting Requirements as they relate to Abuse and Neglect Brookdale Policy and Procedure for Identifying and Reporting Abuse and Neglect Elder Abuse and Neglect The appropriate person(s) in our community to contact with concerns or suspicions of abuse In-Services will be complete by Midnight on 6/10/2014 All associates we are unable to In-service by the stated deadline will be notified via phone and certified letter that they will not be permitted to clock in for their next shift until the above in-services have been completed. Leadership and Nursing Management will review all Brookdale Policies regarding Abuse and Neglect. Additionally, leadership and nurse management staff will be inserviced on the investigative process. By 12 Midnight on Tuesday 6/10/2014 Use of a Brookdale Procedure for Conducting and Internal Investigation will be implemented to verify that all appropriate documentation occurs in the event of any allegation of abuse, neglect or misappropriation. By Midnight on Tuesday 6/10/2014." On 06/11/14 at 7:20 a.m., thru 1:00 p.m., facility staff members from all shifts who attended the inservices were interviewed. They were knowledgeable in regard to abuse policy and procedures for investigating, reporting and protecting the residents. The Immediate Jeopardy was removed on 06/11/14 at 1:00 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level with a potential for more than minimal harm. Based on interviews and review of clinical records, policies and procedures, personnel records, and staff schedules, it was determined the facility failed to implement their abuse policies to ensure: ~ a thorough investigation was completed of allegations of mistreatment for one (#1) of two sampled residents with allegations of mistreatment, ~ residents were protected until a thorough investigation was completed, and ~ allegations of mistreatment were reported to the Oklahoma State Department of Health (OSDH) for two (#1 and #6) of two sampled residents with allegations of msitreatment by staff. This had the potential to affect all 92 residents who resided in the facility. Findings: A facility policy, titled 'Abuse Investigations', documented, "...All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by community management... 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2. The individual conducting the investigation will, as a minimum: a. Review the resident's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident (as medically appropriate); e. Notify the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; f. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; g. Interview the resident's roommate, family members, and visitors; h. Interview other residents to whom the accused employee provides care or services; and i. Review all events leading up to the alleged incident... 7...Associates of this community who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator... 9. The results of the investigation will be recorded... 12. As required, the Administrator will provide a written report of the results of abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident..." 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. An admission assessment, dated 05/05/14, documented the following. The resident was severely impaired in cognitive skills for daily decision making. He required extensive two person assistance with bed mobility, dressing and toileting. He required extensive one person assistance with transfers, locomotion, eating, and personal hygiene. He was totally dependent and required two person assistance with bathing. He was occasionally incontinent of bowel and had a suprapubic catheter. A nurse note, dated 04/29/14 at 12:00 a.m., documented, "...Resident stayed in bed for 30 min then he started screaming Help me, get me out of here then tried to climb out of bed. We brought him to the nurses station for one on one..." On 06/10/14 at 9:20 a.m., a confidential interview with a former employee was conducted. The interviewee stated on 04/29/14 during the 11:00 p.m. to 7:00 a.m. shift, resident #1 was at the nurses' station with several other staff members present. He/she stated that the resident attempted to get out of the chair and LPN #1 threw the resident back into his chair causing him to yell out. The interviewee was asked if they reported the occurrence to their supervisor. They stated that it was reported to the DON. On 06/10/14 at 10:00 a.m., the Administrator was asked when and how an allegation of abuse was reported and investigated. She stated, "Anytime we have an allegation of abuse or neglect. When we become aware we report it." She was asked if any incidents or allegations of abuse were reported recently regarding resident #1. She stated, "Oh I know what you are talking about. Neither of those employees work here anymore. APS was out here last week investigating that and another occurrence." She was asked what employees she was referring to and she replied, "(named LPN #1) and (named CNA #1)." She was asked when LPN #1 was terminated. She stated on 05/21/14 for another allegation. She stated there was no physical findings of abuse but the LPN had several instances of reported misconduct. She was asked if an allegation of abuse involving LPN #1 and resident #1 which occurred on 04/29/14 was reported to her. She stated, "I would have to look back but I don't believe we were aware until APS came in and investigated." She was asked if the allegation was reported to all applicable agencies and she stated, "Should I have reported that. I thought that since APS was here investigating that it was enough." On 06/10/14 at 10:19 a.m., the Administrator stated, "We investigated the 04/29/14 incident." On 06/10/14 at 10:48 a.m., the ADON was interviewed and asked if an allegation of abuse on 04/29/14 was ever reported to her. She stated, "No but it was reported to someone else." She was asked who it was reported to. She stated "To the DON by a letter under her door." She was asked when it was reported. She stated she could not remember exactly. A statement, date unknown, by the ADON documented, "...On the overnight shift of 4/29/14 it was reported that (named LPN #1) was slamming a resident's wheelchair around in the hallway and yelling at the cna's. Upon investigation these allegation were found to be untrue. (named RN #1) was orientating with the nurse (named LPN #1)..." At 10:55 a.m., the DON was asked if she was notified regarding the allegation on 04/29/14. She stated no, but it was rumored a former employee put a note under my door. She stated I found out when the former employee was terminated and reported the allegation to the Administrator on 05/20/14. On 06/11/14 at 8:09 a.m., RN #1 was asked if she had ever worked with LPN #1. She stated, "Yes." She was asked if she had ever observed the LPN abuse, neglect, or mistreat any residents. She stated, "Yes, (named resident #1) was trying to get up and (named LPN #1) made him sit back down." She was asked how the LPN made him sit down. She stated the LPN used her hands to pull his shoulders down to the chair. She stated she pushed his shoulders back and then sat him down pushing down on him. She was asked if the LPN made any attempt to explain what she was doing to the resident. RN #1 stated, "No." She was asked if the resident said anything about what was being done. She stated, "No not really. He makes jibberish." She was asked if anyone else ever talked to her about the incident. She stated, "Yes, (named ADON) a couple of days after the incident." At 8:33 a.m., the ADON was asked if she spoke to RN#1 regarding the incident on 04/29/14 with resident #1. She stated she texted and called her and that RN #1 said the LPN was a strong nurse. The allegation on 04/29/14 was not thoroughly investigated, reported, or were the residents protected during the investigation. 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A 14 day assessment, dated 05/15/14, documented the following. The resident was alert and oriented and was cognitive with skills for daily decision making. She required supervision assistance of one person for walking and eating. She required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. She was continent of bowel and bladder. A facility document titled, Occurrence/Allegation Investigation, documented, "...Resident/Patient Name: (named resident #6)... Date of Occurrence: 5/20/14...Associate(s) Involved (named LPN #1)... Summary of Initial Report: (named CNA #2) alleges that LPNS (sic) was rough w/(with) (resident #6) during the 11-7 (11:00 p.m. - 7:00 a.m.) shift..." A staff statement, dated 05/20/14, "(named director of human resources), I am writing this statement as a result of what I witnessed. What I witnessed on 5/20/14 at about 2:15 a.m. I went to answer a call light and as I got there the nurse, (named LPN #1) was already in there changing out oxygen tubes. (named LPN#1) grabbed (named resident #6) wrist and pulled her out of bed. The resident was upset of how she was helped up. I feel like this is something that needed to be addressed. If you have any questions please feel free to call me ...(signed by CNA#2) A facility document titled, Personnel Action Form/Termination, documented LPN #1 was terminated on 05/21/14 for misconduct. On 6/10/14 at 10:00 a.m., the Administrator was asked if the allegation was reported to the OSDH. She stated,"No, but we terminated her because of her attitude. I didn't find any physical evidence of abuse." She stated the nurse had multiple reports of a bad attitude. At 11:45 a.m., the resident was asked if any staff had ever mistreated her. She stated, "Yes, my little aide was in the door and she reported it. I didn't have the nerve. I didn't want any retaliation. I was so glad she was standing there. The nurse came in and I asked her to help me to the bathroom. The nurse shoved me back down on the bed and then jerked my left wrist." She was asked the name of the nurse. The resident named LPN#1. The resident was asked if she thought if the nurse shoved her intentionally. She stated, "Yes I do but I didn't want to say anything at the time. She was mad when she came in and acted like she didn't like her job. I was afraid to take any medicine that she would have given me. If she was that mad she could have done something to me to get back at me." There was no state reportable or report to the Oklahoma State Board of Nursing for the allegation.

Based on observation, record review, and interview, it was determined the facility failed to identify residents at risk for pressure ulcers and provide interventions to prevent the development of pressure ulcers and to promote healing of pressure ulcers for two (#2 and #7) of four sampled residents reviewed for pressure sores. The facility failed to: ~ identify the resident(s) was at risk for pressure ulcers and put measures in place to prevent the development of pressure ulcers; ~ provide pressure relieving devices in a timely manner; ~ develop a temporary care plan to identify the resident's needs related to the development of pressure ulcers; ~ complete timely, thorough skin assessments which included measurements and descriptions of the wounds; ~ obtain wound care consults as ordered by the physician; and/or ~ develop a comprehensive care plan in a timely manner for residents #2 and #7. Resident #2 was readmitted to the facility with reddened areas to his heels and buttocks and developed two unstageable pressure ulcers and one Stage III pressure ulcer. This had the potential to affect five residents identified by the facility with pressure ulcers. Findings: A policy, titled, "Pressure Ulcers/Skin breakdown - Clinical Protocol", documented, "... 2. In addition, the nurse shall document the following: Full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue ...The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage 1 pressure area that has not yet ulcerated at the surface. The physician will help the staff define the type...and characteristics...of an ulceration..." 1. Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The admission evaluation data sheet, completed by the licensed nurse, did not identify skin integrity issues. The full body skin evaluation did not indicate reddened areas on the resident's body. The resident was admitted to the hospital on [DATE], and returned to the facility on [DATE]. The admission evaluation data form, signed by the licensed nurse on 06/10/12, documented the resident had red heels and redness to the coccyx and right buttock. An admission skin data form documented the resident did not have deep tissue injury. A nurse's note, dated 06/10/12, documented, "...Resident bilateral heels are red. There is also redness to resident (right) buttocks and to the middle of her coccyx..." The admission/start-up physician's orders [REDACTED]. was dated 06/11/12. The risk for pressure ulcers was not addressed at the time of admission from the hospital. An admission assessment, dated 06/18/12, documented the resident was severely impaired in cognitive skills for daily decision making, but understood others and was understood by others. She required extensive assistance with transfers, did not ambulate in the room but moved about the facility with the use of a wheelchair, and required limited assistance in locomotion. She was incontinent of bowel and bladder, and had no pressure ulcers. The temporary care plan, dated 06/20/12, was blank. No other care plan in relation to condition of the resident's skin on the date of admission, was provided to the surveyor. A nurse's note, dated 06/21/12 at 7:25 a.m., documented, "(Resident name deleted) noted to have red soft heel. Black area (approximately) 1.5 by .5 (0.5) noted. (No) open areas notified (physician) new order received to skin prep (and) apply Spenco boots..." The clinical record contained no prior entries with measurements of the wound. A physician's orders [REDACTED]. "Bactrim DS 1 Tab PO Twice daily - 7 days [MEDICATION NAME] 500mg 1 Tab PO Twice daily - 5 - days [MEDICATION NAME] 1 Tab PO Twice daily - 10 days DTI Buttock." The treatment record for June 2012, contained one entry, dated 06/27/12, for documentation of weekly skin evaluations on shower day. A nurse's note, dated 06/27/12 at 10:00 p.m., documented, "Resident noted to have redness on both bone prominences on her buttocks. Dr. informed and ordered Bactrim DS 1 tab po BID for 7 days, [MEDICATION NAME] 500mg 1 tab po BID - 5 days. [MEDICATION NAME] 1 tab PO BID for 10 days. Apply skin prep to affected area on both buttocks q shift and prn till healed and she's for skin counsel as per facility..." A physician's orders [REDACTED]. "Consult skin counsel Apply skin prep to affected area on both buttocks Q shift and prn, till healed. Indication - Dx Redness on both sides buttock (DTI)" The short-term problems need list, dated 06/27/12, documented redness on both buttocks. The approaches listed were the administration of antibiotics as ordered by the physician and skin prep to the affected areas. A weekly skin integrity review sheet, dated 06/28/12, which documented both buttocks were red on the bony prominences, with a dark spot at the middle. The entry also documented a dark spot to the right heel. The facility provided a home medical equipment and supplies delivery ticket which documented the delivery of a specialized low air loss mattress for the resident on 06/28/12. A care plan, dated 06/28/12, 18 days after the identification of reddened heels and 7 days after the identification of a blackened area to the heel, documented, "(Resident's name) is at risk of pressure ulcer R/T requiring assistance of 2 staff for some ADL's, incontinent of bowel and bladder, and has a pacemaker placed." The care plan documented as the goal that the resident would remain free of skin breakdown over the next 90 days. The interventions of the care plan for the risk of pressure ulcer included to: ~ check for incontinence and change if wet or soiled, ~ check for skin redness, skin tears, swelling, or pressure areas and report any signs of breakdown, ~ perform Braden scale quarterly and PRN with the development of skin breakdown, and ~ monitor the skin during ADL care for redness, breakdown, or skin tears. A nurse's note, dated 06/29/12 at 9:00 p.m., documented, "...The redness on her bottom still persists and area hardened and elevated. For close monitoring..." A nurse's note, dated 07/02/12 at 8:10 p.m., documented, "...Redness on her buttocks, the Rt side is healing well, the left side is dark and hard..." A nurse's note, dated 07/05/12 at 2:00 p.m., documented, "...Skin prep applied as ordered. Resident needs wound review..." The treatment record for July 2012, contained one entry, dated 07/06/12, for documentation of the weekly skin assessment on bath day. An undated weekly skin integrity review sheet, located in the treatment book for the month of July 2012, contained one entry that documented redness to both buttock bony prominences and an old open area to the heel. The clinical record contained no further documentation of weekly skin assessments. A nurse's note, dated 07/06/12 at 11:00 p.m., documented, "Wound on the resident's bottom one noted to be getting worse c a dark (black) spot in the middle. Called Dr. (name deleted) and he ordered review by wound counsel tomorrow. Called N O call and she said a nurse will review the wound tomorrow..." A physician's orders [REDACTED]." A nurse's note, dated 07/07/12 at 10:00 p.m., documented, "...the nurse did the assessment and noted on bilateral below buttock is having unstageable wound, the nurse called Dr. (name deleted) who ordered for wound consult on Monday 7/9/12 Santyl w/ [MEDICATION NAME] chg Q D & PRN w/ covrsite (sic)...Vitamin C...Zinc Oxide...Arganaid..." A physician's orders [REDACTED]. "Wound consult on Monday 7/9/12 Santyl w/ [MEDICATION NAME] chg QD & PRN w/ coversite... Vitamin C 250mg qd po x 10 days Zinc oxide 220mg...po x 10 days [MEDICATION NAME] day." There was no documentation that a wound consult was obtained. On 07/11/12 at 10:50 a.m., the resident's wounds were observed. LPN #9 removed the dressing to the resident' right heel. The right heel was noted to have a blackened area at the back of the heel approximately 2 inches in length by 0.5 inches in width. The skin was intact and no drainage was noted. The left heel had no reddened areas. An open area was noted to the right buttock, on the bony prominence, which measured approximately 1 inch by 0.25 inches. The center of the wound was at an unknown and unmeasured depth. An open area was noted on the bony prominence of the left buttock. The wound measured approximately 1 inch in length by 1 inch in width. The surface of the wound had gray moist tissue that covered the upper one-third of the wound and a black substance that appeared solid that covered the lower two-thirds of the wound. The skin at the edges of the wound was dark in color. On 07/11/12, the resident was seen at a wound care center. An Initial Examination report from the wound care center documented: "...The unstageable pressure ulcer located on the right heel has been present for approximately 1 month...The pressure ulcer measures 1.6cm x 3.8cm x 0.1cm...the pressure ulcer bed has exposed subcutaneous tissue..." A Physician's Procedure Note, from the wound care center, documented: "Procedure Date: 7/11/2012 Procedure: Debridement; Subcutaneous Tissue Location: Ulcer, right ischium Ulcer, left ischium... 1. The Stage III pressure ulcer located on the right ischium. The pressure ulcer measures 2cm x 1cm x 0.1cm...There is a minimum amount of serous and serosanguinous exudate draining from the pressure ulcer. Necrotic or devitalized tissue is estimated to be present in approximately 100% of the pressure ulcer bed. The pressure ulcer bed has exposed subcutaneous tissue. The pressure ulcer shows signs or symptoms of infection. 2. The unstageable pressure ulcer located on the left ischium. The pressure ulcer measures 3.4cm x 3.4cm x 0.1cm...There is a moderate amount of serosanguinous exudate draining from the pressure ulcer. Necrotic or devitalized tissue is estimated to be present in approximately 100% of the pressure ulcer bed. the pressure ulcer bed has exposed subcutaneous tissue. The pressure ulcer shows signs or symptoms of infection..." At 11:00 a.m., LPN #9 was asked the proper procedure when reddened areas were noted on a resident. She stated she was to contact the physician for new orders, contact the wound nurse and DON, and document the information in the clinical record. She was asked if a wound nurse was present in the facility. She stated the ADON had been responsible for wound assessments and documentation. She also stated the ADON was no longer at the facility and she guessed no one else was assigned to do it. She was asked when she had received training in wound care, which included staging and measuring wounds. She stated she had been taught about wound care in nursing school, but had no training since that time. She acknowledged she did not measure and stage the wounds. The LPN was asked if the resident's wounds were being documented. She stated there was a page in the treatment book where the condition of the wound, as well as the size and stage were documented. The surveyor asked her to locate the documentation for resident #2. She searched in the treatment book and could not find the documentation. The surveyor was shown another resident's wound documentation sheet which included measurements and descriptions of the wound. The surveyor asked the LPN if resident #2 had a similar sheet. She stated, "No." At 2:25 p.m., RN #1 was asked if the resident's wounds had been assessed weekly as ordered by the physician. She stated she would need to review the clinical record. She was asked if the reddened heels had been addressed between the time of admission from the hospital on [DATE], until 06/21/12, and if the redness to the heels and buttocks had been addressed in a care plan. She was shown the admission care plan, dated 06/20/12, that contained no documentation and the care plan, dated 06/28/12. She stated again she would need to review the clinical record before answering. No further documentation was provided. At 5:15 p.m., LPN #10, was shown the orders for antibiotics for the wound to the buttocks on 06/26/12, and asked if she was aware of the reason for the order of antibiotics. She stated the buttocks had been very red and she was concerned of an infection. When asked if she had noted open areas to the buttocks she stated she had not. "I would not put skin prep on open wounds." When asked when the reddened areas to the buttocks became open wounds, she stated she called the physician on July 6, 2012 when she noted the wounds were open around the edges. On 07/11/12, the resident was seen at a wound care center. Documentation from the center revealed the resident had an unstageable pressure ulcer to the right heel, a stage 3 pressure ulcer to the right schism, and an unstageable pressure ulcer to the left schism. 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/11/12, documented the resident was moderately impaired in her cognitive skills for daily decision making. She required extensive assistance for bed mobility and transfer. She had limitation in ROM in both upper and lower extremities. She was at risk for developing pressure ulcers. A Weekly Skin Integrity Review, dated 07/02/12, documented, "Skin Condition Dry (checked) ...S/P (suprapubic) cath (catheter) site... Open Area (checked)..." A CNA Weekly Shower Skin Check, dated 07/04/12, documented, "...B. No suspicious areas- (checked), ...Comments: 'Bed Bath." A care plan, dated 10/04/11 and last updated 07/06/12, documented, "Problems Resident is at risk for skin breakdown due to [DIAGNOSES REDACTED]. 7/6/12 wound to R (right) scapular area. Goals (Resident) will remain free of skin breakdown over the next 90 days. Interventions Check for incontinence of bowel; change if wet or soiled. Clean skin with mild soap and water. Apply moisture barrier. Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown... Use pillows, pads, or wedges to reduce pressure on heals and pressure points. Turn/reposition... DO NOT MASSAGE SKIN over pressure areas... 7/6/12 Cleanse wound to R (right) scapular area c NS, pat dry, apply santyl Q day. Wound consult on Monday (07/09/12)... Braden scale to be performed quarterly and PRN with the development of skin breakdown. Complete pressure area checklist if score is 12 or less... Monitor skin during ADL care for redness, breakdown or skin tears. Inform LN (licensed nurse) promptly if noted..." A nurse's note, dated 07/06/12 at 9:00 p.m., documented, "@ 2100 (9:00 p.m.) res was found with wound 1 cm to 0.5 cm wide. (Physician) was notified and he order (sic) for us to cleanse wound to R scapular area with NS (normal saline). Pat dry and apply Santyl Q day. See wound consult on Monday (07/09/12)." A physician's telephone order, dated 07/06/12 at 9:00 p.m., documented, "Cleanse wound to R scapular area with NS Pat dry and apply Santyl Q day. See wound consult on Monday (07/09/12). There was no documentation which indicated a wound consultant was contacted from 07/06/12 to 07/11/12. A nurse's note, dated 07/11/12 at 7:45 a.m., documented, "Late Entry this nurse talked with (physician) regarding open area on residents right shoulder received new order to change tx to Solosite new order cleanse open area R scapular area c NSS pat dry apply Solosite Q Day and PRN (and) cover c opsite until healed." A physician's telephone order, dated 07/11/12 at 8:00 a.m., documented, "DC current wound tx to R scapular New order Cleanse wound to R scapular open area c NSS pat dry apply solosite cover c opsite Q - Day and PRN." On 07/11/12 at 1:20 p.m., the DON was asked who was responsible for charting weekly skin assessments. She stated, "The nurses." She stated it depends on which shift the resident gets their bath. At 1:50 p.m., LPN #8 was asked when the wound opened up. She stated, "That's how the wound looked Monday. She stated she did not know how the wound looked in the first place. She further stated, "I just followed the treatment orders." At 3:30 p.m., Observations were made of the resident's wound by LPN #3 and the surveyor. the LPN was asked to assess the wound. She stated, "It looks like a pressure ulcer." The wound was circular in shape and approximately 1.1 cm x 1.5 cm. The wound bed was covered by yellow slough. Serosanguinous drainage was present on the dressing. At 3:35 p.m., LPN #4 stated, "She used to be in an electric wheelchair. There was a pad on it for her shoulders." She stated she leans to the right so she was switched to a regular wheelchair about one to two weeks ago. She further stated there was a screw in the new chair where the resident usually leans. At 4:40 p.m., LPN #5 was asked about his entry on 07/06/12 with regards to the resident's wound. He was asked who discovered the wound. He stated, "The aide, when they gave her a shower, found the wound." He was asked to describe the wound. He was asked the stage of the wound upon discovery. He stated, "It was like a blister, like a stage I." He stated it looked like a blister that had broken. The skin was still there. At 5:17 p.m., LPN #6 was asked asked if the wound consultant had been called in. She stated, "I am not really sure. I am really new here. I don't know." At 5:25 p.m., LPN #7 was asked about the facility's policy for scheduling wound consults. He stated, "Most importantly the nurse should call." He was asked who documents the wound assessments. He stated, The ADON does the measurements. He was asked who the ADON was now. He stated, "I don't know. They called someone in to do that." He stated, "The ADON that used to do this has left." At 5:29 p.m., LPN #3 was asked who would normally be setting up a wound care consult. He stated, "It will be done by the charge nurse." A nurse's note, dated 07/11/12 at 7:10 p.m., documented, "Open area noted to R shoulder/scapula area 1.1 x 1.5 cm, wound bed noted with yellow slough surrounding skin slightly macerated. (No) odor noted scant serous drainage, unstageable @ this time cont c current tx. Wound consult c wound clinic @ (hospital)..." The clinical record documented an enlargement of the wound by 0.1 cm x 1.0 cm. from 07/06/12 to 07/11/12. There was a change in the wound bed from broken skin to yellow slough with drainage from 07/06/12 to 07/11/12.

Based on record review and staff interview, it was determined the facility failed to provide supervision and assistance as documented in the resident's care plan for three (#1 #5 and #12 ) of eight sampled residents who had sustained a fall with injury. This resulted in an actual harm for residents #1, 5 and #12. The DON identified an additional 65 residents at risk for falls. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A fall risk evaluation dated 10/25/11, documented a total score of 12. (a score > 10 indicated high risk for falls). A Fall Prevention Checklist for 10/25/11, documented the following interventions: falling star participants, routine room monitoring, hi-low bed, mat on floor, chair/bed alarm. A quarterly assessment dated [DATE], documented the resident was severely impaired in cognition, exhibited clear speech and was able to make her needs known. The assessment further documented the resident required supervision with transfers, locomotion on the unit and required limited assistance with locomotion off the unit. A "Falls Risk Evaluation" dated 12/14/11, documented a total score of 17. A "Fall Prevention Checklist" dated for the same time period, documented as an intervention: staff training. A facility incident report dated 12/14/11, documented: "Res found on bathroom floor, water noted on floor, resident unaware of what happened. Staff informed to check restroom every shift to make sure the floor is clean and dry." A facility incident report dated 01/12/12, documented: "Res was found on floor by another res in rm 806, who observed res on floor in room 805. Res examined by LPN and taken to own rm, family + MD notified, follow up information; specific rest periods." A "Short-Term Problems Needs" list dated 1/12/12, documented "Needs/Problems: Falls. Short-term objective/goal: prevent future falls. Approach/Action Plan: routine room monitoring & assist res to rm p meals, specific rest periods." A "Fall Risk Evaluation dated 1/12/12, documented the resident's total fall risk score of 19. A facility "ADL Flow Sheet" dated February 2012, documented the resident required extensive assistance with one person assist for bed mobility and transfers 22 of the 28 days during the month of February. A nurse's note dated 02/26/12, documented, "1415 (2:15 p.m.) CNA summoned this nurse to resident. She was found in an empty room sitting on her bottom. Resident stated; 'I thought this was my room and I was trying to get in bed' c/o pain to L arm with grimacing and guarding." A hand written note signed by LPN #5 documented, "On 2-26-12, I was called to room 808 by CNA. (resident) was sitting on her bottom guarding her L arm saying, 'my wrist and arm hurts.' Assessment completed head to toe. nurse supervisor notified. Resident said she rolled herself to this room (it was after dinner) and tried to put herself in bed. The bed was in a high position, She stated, "I fell trying to get in this bed." A physician's telephone order dated 02/26/12, documented, "X-ray to L humerus, elbow, forearm wrist dx: pain." A radiology report dated 2/26/12, documented, "Exam: Humerus Left -2 V, Left. Results: ..transverse fracture through the surgical neck of the proximal humerus with approximately 1.5 cm displacement on the single view. Conclusion: Humerus fracture." On 04/05/12 at 1:45 p.m., CNA #4 was interviewed and asked if she had cared for the resident during her stay in the facility. She stated she had. She was asked if she was aware the resident required specific rest periods after meals and frequent room checks. She stated she was not made aware of any special care the resident required after meals. The surveyor then asked the CNA if any of her current residents were on frequent room checks or specific rest periods as fall precautions. She stated, "No." On 04/06/12 at 11:45 a.m., LPN #5 was interviewed and asked if she had cared for resident #1 during her stay within the facility. She stated she had. When asked about resident #1's care plan interventions, she stated she wasn't aware of any special interventions. When asked if she was aware the resident had a fall the previous month, she stated, she was not. The surveyor asked her to explain what 'specific rest periods' and 'frequent room monitoring' meant. She stated, "It means to check on the residents every time you go by their rooms, and encourage rest periods." On 04/09/12 at 12:55 p.m., an interview was conducted with the DON. She was asked what interventions were put into place for the resident after the first incident, in which she was found in an unoccupied room. She stated, "She was put on routine room monitoring which meant every time they past her room, if she wasn't there, go find her. Ms (Name withheld) could get around this facility very quickly in her chair." The surveyor then asked how interventions from updated care plans were relayed to the direct care staff. She stated, "The charge nurse for each area reports it to the oncoming shift and it's passed on." The DON identified six residents presently with fall interventions of "frequent room checks and specific rest periods" The DON was advised of the staff's lack of knowledge regarding the terms of 'specific rest periods' and 'frequent room monitoring' when questioned by the surveyor. She stated, "I know. We have inserviced and re-educated everyone last night about this." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A bladder assessment dated [DATE], documented a score of 13. The assessment tool indicated a score of 7-14 identified the resident to be a candidate for a toileting program (timed voiding). A "Post-Fall Or Incident Assessment" dated 09/14/11, documented the resident had fallen when attempting to go to the bathroom. A "Post-Fall Or Incident Assessment" dated 09/19/11, documented the resident had fallen when attempting to transfer herself from the bed to the recliner. A "Post-Fall Or Incident Assessment" dated 09/27/11, documented the resident had fallen. Documentation on the Incident Report Summary indicated the fall occurred when the resident attempted to get up out of her recliner by herself. No injury was sustained. Documentation on the Incident Report Summary indicated the resident had a fall in the bathroom on 09/28/11, sustaining a bruise to the forehead. A "Short-Term Problems Need List" dated 11/12/11, documented, "Needs/Problems: Fall-toileting. Short-term objective/goal: Free from falls. Approach/action plan: toilet after meals and HS. Needs/Problems: Fall. Short-term objective/action plan: to be offered for bathroom q 2 hours." A "Post-Fall Or Incident Assessment" dated 11/12/11, documented the resident had fallen when attempting to go to the bathroom. Documentation on the Incident Report Summary indicated the resident c/o coccyx pain and an x-ray was obtained. The x-ray was negative for fracture. The fall was not documented on the Incident Report Summary. The "Fall Risk" assessment dated [DATE], documented a fall risk score of 16. A score of 10 or more indicated the resident was a high risk for falls secondary to physical limitations, disease processes and use of medications that increased the resident's risk for falls. A "Fall Prevention Checklist" dated 11/25/11, documented the facility was going to implement the following intervention to help prevent the resident from falling: Specific rest periods for resident. A "Short-Term Problems Need List" dated 12/15/11, documented, "Needs/Problems: Fall. Short-term objective/goal: No more falls. Approach/action plan: Frequent room monitoring/ER." A nurse's note dated 12/15/11 at 5:00 a.m., documented, "Res found on bathroom floor, lying on Rt side, c/o Rt hip and knee pain scale 5/10 (10 being the highest and 0 the lowest), Dr. (Name withheld) notified and ordered xray. Will cont to monitor." A nurse's note dated 12/15/11 at 8:15 p.m., documented, "Res x-ray results came in et showed that res has a L hip fracture. Dr. (Name) was notified and he ordered for resident to be sent to the ER. (Name) DON (Name) and family members (Name) daughter were all notified." A "Post-Fall Or Incident Assessment" dated 12/15/11, documented the resident had fallen when attempting to go to the bathroom. Documentation on the Incident Report Summary indicated the resident c/o right hip pain and an x-ray was obtained. The x-ray report was positive for fracture of the right hip and the resident was sent to the hospital. A "Fall Prevention Checklist" dated 12/15/11, documented the facility was going to implement the following interventions to help prevent the resident from falling: Specific rest periods for resident. A bladder assessment dated [DATE], documented a score of 9. The assessment tool indicated a score of 7-14 identified the resident as being a candidate for a toileting program (times voiding). A "Monthly Summary" completed 01/05/12, documented in the section for urinary continence that the resident was always incontinent and that she was not on a toileting program. A "Post-Fall Or Incident Assessment" dated 01/18/12, documented the resident had fallen when attempting to go to her closet. Documentation on the Incident Report Summary indicated the resident had no injury. A "Fall Prevention Checklist" dated 01/18/12, documented the facility was going to implement the following intervention to help prevent the resident from falling: Toileting schedule. The resident's care plan dated 01/23/12, documented, "Problems: At risk for decline in physical functioning. Enrolled in restorative program. Goals: Will maintain or improve physical functioning during the next 90 day review. Interventions: Perform restorative exercises 3 to 5 x weekly as ordered. ... Toilet per restorative schedule Q2 hours WA x 30 d and re-eval." A "Monthly Summary" completed 02/03/12, documented in the section for urinary continence that the resident was occasionally incontinent. There was nothing documented about the resident's urinary patterns or whether she was on a toileting program or not. Restorative services were ordered 02/20/12, to prevent the resident from declining in physical functioning and for toileting. These services were D/c'd on 03/24/12. The restorative notes for 02/12, started on 02/21/12, documented in the plan of care, "Goals: ... Restoration for self toileting. ... Approaches: Toileting Q 2 hr. ... Monthly review: Pt has reached max quality of life due to Parkinson's. Pt will do standing with certain ADLs c SBA, however she is continent." Documentation on the approaches indicated the restorative toileting was only being provided 5 days a week with the resident being independent with toileting. A quarterly assessment dated [DATE], with an ARD of 02/14/12, documented the resident had moderate cognitive impairment, required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit and toilet use. The assessment documented the resident had decreased ROM to one lower extremity, had unsteady balance moving on and off the toilet, with surface to surface transfers and had not fallen since the completion of the prior assessment. The restorative notes for 03/12, documented in the plan of care, "Goals: ... Will be toileted q 2 hr, PRN c SBA. Approaches: ... ADLs toileting. ... " Documentation on the approaches indicated the restorative toileting was only being provided 5 days a week with the resident being independent sometimes and requiring assistance with toileting at other times. A "Monthly Summary" completed 03/12/12, documented the resident was occasionally incontinent. There was nothing documented about the resident's urinary patterns or whether she was on a toileting program. The restorative services ordered to prevent the resident from declining in physical functioning and for toileting were D/c'd on 03/24/12. A nurse's note dated 04/01/12 at 4:30 p.m., documented, "Pt alert oriented, pt noted on the floor. the resident stated that she was going to her closet, and went down to the floor. the nurse did the assessment and no physical injury at the moment ... " A "Fall Prevention Checklist" dated 04/01/12, documented the facility was going to implement the following interventions to help prevent the resident from falling: Routine room monitoring and staff training. On 04/06/12 at 2:35 p.m., CNA #1 was interviewed regarding the meaning of specific rest periods and routine room monitoring. She stated, "Take them to room put to bed if high risk for falls. Write on book where we chart and let nurse know." She stated they were to check on the residents routinely every 1-2 hours. LPNs #3 and #4 were interviewed regarding what the term "lie resident down at specific times" meant. They stated the "Fall Prevention Check List" had multiple interventions on it the nurses could choose to help prevent falls. They stated if the nurse chose the intervention of laying the resident down at specific times, they were to document on the form the specific times the resident was to be laid down, such as, after meals. 3. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan dated 08/18/11, documented, "Problem: (Resident) has vision impairment due to [DIAGNOSES REDACTED]. Goals: will maintain current level of function/activity without injury...interventions: ensure adequate lighting for all activities. Keep areas free of obstructions to reduce the risk of falls with injury... Problem: self care deficit-limited assistance required with bathing, hygiene, dressing, and grooming R/T poor vision. Goal: (Resident) will bathe and dress self with supervision and cues...Interventions...assist with ADLs (bathing, grooming, toileting)...footwear will fit properly and have non-skid soles while (Resident) is out of bed.... Problem: At risk for falls R/T poor vision. Goals: (Resident) will demonstrate the ability to ambulate/transfer without fall related to injuries over the next 90 days. Interventions: Implement safety measures (keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bell quickly). Keep areas free of obstructions to reduce the risk of falls or injurys. Place call bell/light within easy reach. Remind (Resident) to call for assistance before moving from bed to chair and from chair to bed. Respond promptly to calls for assist to the toilet. Footwear will fit properly and have non-skid soles while Lois is out of bed. Provide reminders to use ambulation and transfer assist devices. Fall risk assessment performed quarterly. Place on falling star program if score is 10 or above... Problem: Walking in room & corridors- (Resident) requires limited assistance. Goal: (Resident) will walk in room with the assistance of 1 person...interventions: Remind (Resident) to call for assistance before getting out of bed to walk. Walk in room with the assistance of 1..." A quarterly assessment dated [DATE], documented the resident's cognition was intact, required extensive assistance with transferring, walking in room and corridor, locomotion on and off the unit, dressing, toilet use and was not able to stabilize self when completing surface to surface transfers. The assessment also documented the resident had one fall without injury since the last assessment. The assessment did not document the resident was on a toileting program and/or receiving restorative services. An incident report documented, "...General incident information: date of incident 10/19/11...approx. time of incident 9:50 p.m....location of incident resident room...type of injury: no apparent injury...additional facts: was reported by charge nurse D.C. that resident fell while going to b/Rm. She stated, 'that her walker tipped over'...follow up information: res. had c/o pain all over @ 8 p (8:00 p.m.) pain med given." A "Fall Prevention Checklist" dated 10/19/11, documented, "Fall risk score 8: possible interventions, routine room monitoring." The form did not indicate how often the resident's room should be monitored. A "Fall Prevention Checklist" dated 01/03/12, documented, "Possible interventions: falling star participant, routine room monitoring; lab monitoring- ua, H&H, lytes, med levels; pain management; activities involvement; mobility pole in room (walker)." The form did not indicate how often the resident's room was to be checked on. An incident report dated 01/05/12, documented, "...General incident information: date of incident 01/05/12...approx. time of incident 6:00 a.m....location of incident resident room/not bedside...type of injury: no apparent injury...additional facts: Res was going to turn on call light and stated she slipped on cath tubing and sat on floor denies hitting head...follow up information: Resident teaching, specific rest periods, encourage to rest after meals." A "Fall Prevention Checklist" dated 01/05/12, documented, "Possible interventions: specific rest periods for resident and resident teaching." The form did not indicate when and how often the resident was to have rest periods. No new interventions were added. A "Fall Risk Evaluation" dated 02/07/12, documented the resident was a high risk for falls with a score of 19. A score of ten or higher indicated the resident was a high risk for falls. An incident report dated 02/11/12, documented, "...General incident information: date of incident 02/11/12...approx. time of incident 9:00 a.m....location of incident resident bathroom...type of injury: c/o of back pain (L) hip and (L) finger...additional facts: Pt went to bathroom...type of injury: no apparent injury...additional facts: Res stated she went to the bathroom and on the process she fell down, slide on the floor...follow up information: Pt states that she is ok, 0 discomfort noted." A second incident report dated 02/11/12, documented, "...General incident information: date of incident 02/11/12...approx. time of incident 4:10 p.m....location of incident resident bathroom...type of injury: c/o back pain (L) hip and (L) finger...severity: harm/injury without outside treatment...additional facts: Pt went to bathroom to use and on the process slide out of walker and fell on the floor...follow up information: pt c/o pain and discomfort prn pain medication administered, x-ray, call for assistance." No new interventions were addressed. A nurse's note dated 02/11/12 at 8:00 p.m., documented, "Pt alert oriented X 4. The staff noted pt on floor in the bathroom on sitting position. states that she was trying to use the bathroom pot but she felt weak & went down to the floor...resident states that she is feeling discomfort on her left hip and (L) femur..." A "Fall Prevention Checklist" dated 02/11/12, documented, "Possible interventions: falling star participant, pain management; staff training." There was no indication as to what the staff was trained on to prevent further occurrences of falls. An incident report dated 02/26/12, documented, "...General incident information: date of incident 02/26/12...approx. time of incident 8:10 p.m....location of incident resident room...type of injury: cut/laceration, swelling...severity code: harm/injury with outside treatment (e.g. urgent care, doctors office, EMT...additional facts: pt states she was on her bed and she does not know how she fell ...follow up: pt sent to the hospital, med review, toilet schedule, staff training...." A signed note with the incident report documented, "On 02/26/12 I heard a loud bang went to (Resident) room and she was on the floor. She hit her head and it was bleeding. charge nurse was notified. Resident sent out to hospital." A "Fall Risk Evaluation" dated 02/26/12, documented the resident was a high risk for falls with a score of 21. A "Fall Prevention Checklist" dated 02/26/12, documented, "Possible interventions: medication reviews, toileting schedule, staff training, and resident training on call lights." The form did not indicate the resident's toileting schedule and/or the results of the medication review. There was no documentation to indicate what training the staff received to prevent a recurrence of falls. The resident's care plan was not updated to address the resident's toileting plan or schedule and/or the results of the medication review. A "History and Physical" dated 02/27/12, documented, "Date of admission: 02/27/12. Chief complaint: Fall. History of present illness..brought to the emergency room status [REDACTED]. The patient was reportedly found in her room after falling..." There was no documentation in the resident's clinical record to indicate how or why the resident sustained [REDACTED]. A "Bowel and Bladder Review Tool" dated 03/07/12, 03/14/12 and 03/21/12, documented the resident was a good candidate for an individualized toileting retraining program with a score of 18. A score between 15 and 21 indicated the resident was a good candidate. An incident report dated 03/26/12, documented, "...General incident information: date of incident 03/26/12...approx. time of incident: 11:45 a.m....location of incident: resident bathroom...type of injury: no apparent injury...additional facts: Resident said she walked to the bathroom toilet with the aide of walker, while she tried to sit on toilet in the bathroom she missed it. She was able hang on to something till help arrived. No injury noted...Follow up: She was told to always call for assist to use the bathroom at anytime..." A "Fall Prevention Checklist" dated 03/26/12, documented, "Possible interventions: falling star participant, specific rest periods." The form did not indicate when the resident's specific rest periods were to occur. The care plan was not updated and/or revised to address the resident's individualized rest periods. An incident report dated 03/30/12, documented, "...General incident information: date of incident 03/30/12...approx. time of incident: 11:00 p.m....location of incident: resident room...type of injury: no apparent injury...additional facts: Res was coming from BR went to sit on bed and missed bed. Denies hitting head 0 injury noted...follow up information: Encourage resident to use call light when she needs to get ^..." A "Post-Fall or Incident Assessment" dated 03/31/12, documented, "What was resident doing immediately preceding the incident coming from BR(bathroom)...before incident pertinent conditions: dizziness...unsteady gait...post incident pertinent conditions: dizziness...unsteady gait...POC updated post incident: yes...Treatment intervention rendered: none....Devices, interventions is use before incident: falling star...devices, interventions put in place post incident: footwear review..." An incident report dated 03/31/12, documented, "...General incident information: date of incident 03/31/12...approx time of incident 12:10 p.m....location of incident: dining room...type of injury: cut/laceration...body part involved: other part of head...initial actions; called 911...severity codes: harm/injury with outside treatment, harm/injury with ER treatment...follow up returned from hospital..." The facility did not list any additional facts under the section titled "additional facts." A final report sent to OSDH documented, "Resident was in dining room and had a fall. Res was observed by cna as she was falling and can was unable to get to her in time. Resident with laceration noted to back of head with blood visible. CNA states she was unable to reach resident in time but witnessed fall, resident hit back of head causing laceration to back of head. Resident sent to ER for evaluation and sent back same day with staples to back of head. Intervention to continue with include toileting schedule, resident to use w/c for locomotion instead of ambulating with walker as needed, resident to use call light for assistance and staff to assist resident with adls and dining services as needed..." A signed statement with the incident report documented, "On 03/31/12 @ lunch time...cna was running down 700 hall saying they need help in dining room, there is a resident who fell and it sounded like she hit the floor hard. I ran into the dining room and found (Resident) lying on her back holding her back part of head /c her (R) hand...back of head was bleeding..." A nurse's note dated 03/31/12 at 1:00 p.m., documented, "Resident alert oriented, resident was in d/room the staff noted the resident on the floor in supine position, the nurse did assessment and noted blood coming from the back of resident her hear/ hematoma & laceration unmeasurable, pt denied pain/ discomfort...the nurse called Dr...who ordered pt to be transferred to hospital..the weekend supervisor notified..." A physician's telephone order dated 03/31/12, documented, "Tr resident to (Name withheld) medical center ER for TX & Evals." A general instructions sheet dated 03/31/12, from the hospital documented, "...you have been evaluated today...for the following conditions: laceration to scalp, fall, minor head injury without loss of consciousness..." A physician's telephone order dated 03/31/12 at 6:00 p.m., documented, "Wound care to scalp daily...staples removed in 5 days...head injury precautions...follow up with Dr. (Name withheld)..." A "Post-Fall or incident Assessment" dated 04/01/12, documented, "What was resident doing immediately preceding the incident: pt was ambulating ...before incident pertinent conditions: impaired vision...safety ...hearing...balance...unsteady gait...post incident pertinent conditions: impaired vision...safety...hearing...balance...unsteady gait...POC updated post incident: yes...Treatment intervention rendered: oxygen sat., cold pack....Devices, interventions is use before incident: falling star...devices, interventions put in place post incident w/c for locomotion..." A "Fall Prevention Checklist" dated 03/31/12, documented, "Possible interventions: footwear review." There was no documentation to indicate the facility assessed the resident's footwear and the results of the assessment. There were no further incident reports or documentation for the fall that occurred on 04/01/12. A "Fall Prevention Checklist" dated 04/01/12, documented, "Possible interventions: wheel chair for locomotion." The care plan did not address a toileting schedule which was to be implemented as part of the fall prevention. The care plan did not address how often the resident should be checked on while in her room, "frequent room monitoring." An interview was conducted on 04/06/12 at 12:10 p.m., with LPN #5, regarding the resident's falls. She was asked if the resident was able to ambulate on her own without assistance. She stated, "She isn't ambulating. She use to used a walker but doesn't anymore." She was asked how the resident got around. She stated the resident propelled herself around the facility in a wheelchair. She was asked why the walker was no longer utilized. She stated the resident had falls due to her weakness and dementia, which resulted in two head injuries. An interview was conducted on 04/06/12 at 12:30 p.m., with LPN #3 and #4, regarding the resident's falls and lack of interventions. They were asked where the resident's care plan interventions for falls were updated. They both indicated fall updates would be on the resident's intervention sheet. They were asked if the resident's care plan included the interventions of specific timed rest periods, frequent monitoring and a toileting plan. They both indicated, "If it's not specified, it would be after meals." A request was made for documentation to indicate the resident had specific rest periods, a toileting schedule and frequent monitoring. No further documentation was provided. An interview was conducted on 04/06/12 at 3:30 p.m., with the DON and LPN #4. LPN #4 was asked if the resident was receiving restorative services and was on a toileting schedule. She stated, "She is not on a formal restorative program." The LPN was asked about the individualized toileting schedule for the resident and where the bladder assessment was located to determine the program. She stated it would be in the restorative notes. She was asked what interventions were implemented to prevent a recurrence of falls. She stated, "Falling stars, mat on floor next to the low bed, specific rest periods and labs monitored." She was asked where the documented rest periods were located and if the care plan addressed the specific rest periods. She stated, "I'll check for that." The DON was asked about the resident being sent out on 03/03/12. She stated, "It was a result of the fall with a hematoma to the head on 02/26/12." She stated the resident had a very bad headache and was complaining of vision problems. She stated the resident was admitted to the hospital after the fall on 02/26/12. They were asked if the interventions were the same for all residents or if they were individualized. No comment was made. A request was made for documentation of the resident's toileting schedule and of received restorative services. At 4:15 p.m., LPN #4 stated, "(DON) said there is nothing in the restorative program that the resident had a scheduled toileting plan." She was asked if the care plan addressed all other interventions such as frequent room monitoring. She made no comment. An interview was conducted on 04/06/12 at 4:20 p.m., with the restorative aide. She was asked if the resident was receiving range of motion for strengthening and a scheduled toileting program. She stated the resident did not receive restorative services. She was asked if there was a resident specific toileting program implemented for the resident. She stated, "She is a high risk for falls so the resident is toileted after meals and every two hours." She was asked if this was the same intervention for all residents. She then stated, "She is not currently on a scheduled toileting program." She was asked if the resident had been assessed for the toileting program and schedule. She stated, "I don't have any documentation one has been completed." The facility provided no further documentation to indicate the resident's fall interventions had been implemented. On 04/06/12, interviews were conducted with several CNAs regarding the care plan approaches of, "Specific rest times and routine room monitoring" for residents #1, 5 and #12: CNA #1 was asked on 04/06/12 at 2:35 p.m., about her understanding of the instruction for specific rest time. She replied, "I am to take them to the room, put them to bed if a high risk for falls, then write it on the book where we chart and let the nurse know." She responded that routine room monitoring in her understanding was every 1-2 hours. CNA #2 was interviewed on 04/06/12 at 2:40 p.m. and asked about her understanding of instructions on care plans regarding 'specific rest times.' She responded "Take the resident from the dining room back to the bedroom and get them ready for bed." She responded routine room monitoring was every 30 minutes. CNA #3 was interviewed on 04/06/12 at 2:45 p.m. On the first question, she responded "Take resident to room, to bathroom, brush teeth and get ready for bed." CNA #3 responded monitoring was every 2 hours. CNA #4 was interviewed on 04/06/12 at 2:50 p.m.. She was asked the first question regarding rest times. She stated her knowledge of this was to take residents to their rooms and lay them down. She responded that routine room monitoring was every 2 hours. CNA #5 was interviewed on 04/06/12 at 3:00 p.m. regarding the understanding of care plan instructions. She replied,

Based on observation, record review and interviews, it was determined the facility failed to ensure there was sufficient staff to implement and follow residents' care plans for three (#1, 5 and #12) of eight sampled residents who had recurring falls. This deficient practiced resulted in an actual harm and had the potential to affect all residents in the facility. Findings: 1. The "24 HR Assignment Sheet" dated 02/26/12, documented the following staff on each shift: 7:00 a.m. through 11:00 p.m. shift: One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 100/200 500/600 700/800 One charge nurse on the following halls: 100/200 300 400 500/600 700/800 3:00 p.m. through 11:00 p.m. shift: One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 500/600 700/800 One charge nurse on the following halls: 100 200 300 400 500/600 700/800 11:00 p.m. through 7:00 a.m. One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 500/600/700/800 One charge nurse on the following halls: 100/200 300/400 500/600/700/800 A review of the "Daily Staff Posting" for 02/26/12, confirmed the staffing above. The "24 HR Assignment Sheet" dated 03/26/12, documented the following staff on each shift: 7:00 a.m. through 11:00 p.m. shift: One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 500/600 700/800 One charge nurse on the following halls: 100 200 300 400 500/600 700/800 3:00 p.m. through 11:00 p.m. shift: One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 500/600 700/800 One charge nurse on the following halls: 100 200 300 400 500/600 700/800 11:00 p.m. through 7:00 a.m. One certified nurse aide on each of the following halls: 100 200 300/400 500 600 700 800 One certified medication aide on the following halls: 500/600 700/800 One charge nurse on the following halls: 100/200 300/400 500/600/700/800 A review of the "Daily Staff Posting" for 03/26/12, confirmed the staffing above. During the initial tour of the facility on 04/05/12 from 1:10 p.m. through 2:00 p.m., the following staff was confirmed working with their assigned halls: One certified nurse aide on each of the following halls: 100 200 300 400 500 600 700 800 One certified medication aide on the following halls: 500/600 700/800 One charge nurse on the following halls: 100/200 300 400 500/600 700/800 2. A review of the clinical records for residents #1and #12 documented the residents sustained falls with injuries on 02/26/12 and/or 03/26/12. The facility failed to implement resident care plans to prevent accident hazards prior to and after the falls with injuries. The facility failed to develop and implement a care plan for a scheduled toileting plan for resident #5 and #12, both who sustained falls while attempting to self toilet and failed to implement restorative programs to assist with strengthening and safe ambulation to aide in the prevention of falls. See F-323 for supervision to prevent accident hazards and F-315 for failure to assess and implement a toileting plan for individuals who had recurring falls while self toileting. 3. A confidential family interview was conducted on 04/05/12 at 1:05 p.m., regarding availability of staff in response to residents needs. The family member expressed concern about staff responses to resident call lights, "Because they're not connected to anything." The family member explained the residents' lights would come on but unless someone was in the hall, the lights were not answered. When staff was not available, the lights would not ring anywhere to let the staff know a resident needed assistance. The absence of any sound or ring prevented the staff from knowing how long the resident had to wait for help. The family member also stated the resident had fall alarms on and had fallen twice with the appropriate alarm sounding. The family member stated the staff had been slow in responding because they were busy in another resident's room. 4. A confidential resident interview was conducted on 04/05/06 at 2:15 p.m., with a resident on hall 800. He was asked about staff available to ensure he received the care he needed. The resident stated there was not enough help and the resident was always waiting for assistance. The resident also stated there had always been problems with having enough staff to get the care that was needed. 5. On 04/05/12 at 3:10 p.m., CNA #14 was interviewed regarding the residents she cared for. She was asked how many residents she was responsible for during her shift. She stated "all residents on Hall 600." She was asked if she was able to provide the residents with the care they needed. She stated, "I do the best I can in between the baths and the meals we have to provide." 6. On 04/09/12 at 10:55 a.m., CNA #6 was interviewed regarding her specific duties and about the number of staff available to take care of the residents. She stated there was one CNA to a hall and they worked together when needed. When asked what she did when the other CNA was on break, she stated she just did the best she could, but the nurses helped out. She stated at certain times it was busier, when they were getting residents up, and it would be nice to have an extra CNA to float between halls 100 and 200. 7. A confidential resident interview was conducted on 04/09/12 at 11:12 a.m., regarding availability of staff in response to resident needs. The resident reported most of the staff was slow to respond to his needs. He was asked if they answered promptly. He did not answer. 8. A confidential resident interview was conducted on 04/09/12 at 11:15 a.m., regarding availability of staff in response to resident needs. The resident reported most of the staff was slow to respond to residents needs. She also stated that even when they had enough staff available, not all of them knew what they were doing. 9. On 04/09/12 at 11:35 a.m. a confidential resident interview was conducted on hall 600. The resident was asked if they felt the staff on hand was able to take care of their needs. The resident stated the staff was very slow to respond to the call lights. 10. On 04/09/12 at 11:40 a.m. a confidential resident interview was conducted on hall 600. The resident was asked if they felt the staff on hand was able to take care of their needs in a timely manner. The resident quickly responded, "No.' 11. On 04/09/12 at 11:45 a.m., a confidential resident interview was conducted on hall 600. The resident was asked about the number of staff provided to take care of the residents. The two residents both agreed there was not enough staff to provide them with timely care. One resident stated she called out last evening but could not get any help. She further stated her bed was, "wet from head to toe before any help arrived." 12. On 04/09/12 at 11:50 a.m., a confidential resident interview was conducted on hall 500. The resident was asked if they felt the staff on hand was able to provide care in a timely manner. The resident stated, "It seems like they need help. One on the hall isn't enough." 13. On 04/09/12 at 11:55 a.m., a confidential resident interview was conducted on hall 700. The resident was asked about the number of staff available to take care of their needs. The resident stated, "It's the weekends I dread. They are bad or the help is different." 14. An interview was conducted on 04/09/12 at 12:05 p.m., with the facility scheduler. She was asked how she determined how much staff were assigned on each hall. She stated, "With the PPD (per patient day) calculator provided by corporate." She then stated, "It gives's the legal minimum." She was asked if she every staffed greater then the minimum. She stated, "No, just the minimum."

Based on review of clinical records and staff interviews, it was determined the facility failed to provide supervision to prevent falls for one (#8) of nine sampled residents identified with falls. This had the potential to affect 90 residents identified by the facility as having falls in the past three months. Findings: Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 02/14/11, documented the resident was severely impaired in cognitive skills for daily decision making. The resident's balance was not steady and required the assistance of others for stabilization. The resident had falls in the previous two to six months before admission and also had a fracture within six months of admission to the facility. A care plan, dated 02/14/11, documented, "Problems: (Resident) has a history of multiple falls during the past few months and one fall with humerus fracture approx. one month ago. In (resident's) most recent fall (which led to her admission here) she sustained a head injury, contusions to knee and buttocks and a thoracic sprain. She is at very high risk to fall again with fracture or serious injury. (Resident) also has a seizure disorder and takes anti-seizure and anti-depressant medications daily, along with narcotics for pain control. Goals: (Resident) will be free from falls with serious injury/fracture during the next 90 day review. Interventions: -Observe (resident) for s/s of seizure activity, a change in LOC or s/s of sedation r/t narcotic medication used for pain control. Report to nurse/MD if noted. -Keep personal items within easy reach; bed to be in lowest position with wheels locked. -Fall risk assessment performed quarterly. Place on falling star program if score is 10 or above. -Assist (resident) to wear non-slick footwear that fits. -Complete fall risk assessment quarterly and prn. Place on fall program as indicated. Keep bed in low position when in use, and assist (resident) with ADL's daily to promote safety. Add safety interventions such as personal alarms, floor mats and other measures as indicated. -Instruct (resident) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Encg (Encourage) (resident) to ask for ADL assist with transfers, toileting and locomotion. -Keep areas free of obstructions to reduce the risk of falls or injury." An OSDH (Oklahoma State Department of Health) incident report form, dated 02/19/11, documented, "CNA notified nurse that she assisted pt to use the rest room, she left pt on the toilet to look for help. CNA said pt tried to get herself up from the toilet to her bed and apparently fell . CNA said she did not witness the fall, but visitor found pt on the floor and call for help. When nurse went to patients room pt was on the floor. Pt was bleeding from back of the head. VS were taken. Pt was alert with some confusion. (Ambulance service) was called and pt was transferred to (hospital name deleted)... A hospital history and physical, dated 02/19/11, documented, "This [AGE] year-old white female from Bradford Village was admitted to my service with skull fracture..." The resident was admitted to the hospital for three days and was readmitted to the facility on [DATE]. Admission/Start-Up orders, dated 02/22/11, documented, "...PT/OT/ST eval + treat if indicated..." The care plan did not document any new interventions initiated to prevent further falls for this resident. A OSDH incident report form, dated 03/24/11, documented, "Resident (name deleted) was in the dining room walking towards her table in the south dining area. Witnesses state resident fell straight backward hitting her head on the floor. There was noted blood coming from residents left ear. Due to the impact of the fall and residents history resident was not moved and left in supine position until (ambulance service) arrived to transport resident to the hospital. Resident was alert and oriented to person, place and time. Resident was able to answer questions appropriately...Resident has a recent history of a skull fracture..." A hospital history and physical, dated 03/25/11, documented, "Patient is a 83 y.o. female presenting after a fall...After the fall, she complained of occipital headache with left ear bleeding... Assessment: Subdural hematoma (3/25/11) Skull fracture (2/19/11) Fall (3/25/11)..." The resident was admitted to the hospital on [DATE] for four days and was readmitted to the facility on [DATE]. A Fall Risk assessment, dated 03/27/11, documented the resident scored a "16", which indicated the resident was at high risk for falls. The care plan did not document any new interventions initiated to prevent further falls for this resident. On 04/20/11 at 3:25 p.m., CNA #1 was asked if she was familiar with the resident. She stated she was. She was asked if the resident had declined since her second fall. She stated the resident was more confused and would yell out a lot. She stated the resident had a hematoma from her fall and that the resident was unsteady on her feet. She stated the resident had been left alone in the dining room when she had fallen and the resident would try and get up on her own. She stated the resident had definitely declined since her fall and the resident was more anxious and more easily upset. At 4:20 p.m., LPN #2 was asked if the resident had a change in cognition since her last fall. She stated the resident was more confused, more impatient and would yell out sometimes. She stated the resident was always trying to put herself into the bed. She stated this occurred every day. She was asked what she did differently for the resident to prevent falls since her most recent fall. She stated the bed was in low position, alarm in place and that she kept a close watch on her. She was asked if these interventions were new. She stated, "No." On 04/21/11 at 9:15 a.m., MDS coordinator #1 was asked if any interventions for falls had been put in place after the resident's fall on 02/19/11. She stated the resident had a serious fall on hall 200. She stated when the resident returned from the hospital, she was placed on the skilled unit to keep an eye on her better. At 5:30 p.m., the DON was informed there were no new interventions put into place after the resident's second fall on 03/25/11. No further information was provided by the facility.