Every finding on record at Broken Bow Health and Rehab

Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (#3) of 3 sampled residents reviewed for accidents/hazards. Resident #3 exited the facility and ended up at a fast food restaurant after crossing a busy, four-lane highway. The ADON identified 62 residents resided in the facility and one resident was identified as high risk for wandering. On 05/19/26 at 12:40 p.m., an IJ situation was determined to exist related to the facility's failure to provide adequate supervision for Resident #3, who was determined to have a high risk for wandering, and had prior history of elopement. On 05/19/26 at 5:09 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 05/19/26 at 5:23 p.m., the administrator, DON, and ADON was notified of the IJ situation and was provided the IJ template. On 05/20/26 at 2:01 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Actions Taken to Remove the Immediate Jeopardy: -Resident #3 no longer resides at the facility. -A staff will be placed to monitor the front door starting immediately until alarms and locks are put in place. No one will be able to let themselves in or out. Door will be locked to all people entering or exiting facility unless staff buzzes them in or out. -DON/designee will perform elopement assessments for those residents who have triggered 'high risk to wander' on the wander assessment initiated on 05/19/26. Currently there are no residents that trigger 'high risk to wander.' -All residents currently residing in facility had wander assessment audit and was completed by VP of clinical on 05/19/26 to identify any residents that are considered 'high risk to wander.' -The DON will in-service all staff on the following: elopement policy any resident leaving facility attended or unattended with unsafe exit, 'ex. confusion, physical diagnosis, behaviors, etc. are to notify charge nurse, management/and or administrator. In-services and training will be initiated 05/19/26 and staff will not be allowed to return to work until they have been in-serviced. The VP of clinical will in-service the DON and ADON on assessing residents for risk of elopement until completed by end of day on 05/20/26. On 05/21/26 at 10:38 a.m., the IJ was lifted when all components of the plan of removal had been verified as completed. A staff member was observed to be seated at the nurse's station to buzz people in and out of facility. In-service training regarding elopement and assessments were reviewed. Various members of the staff were interviewed, such as housekeeping, dietary, CNAs, CMAs, LPNs, and registered nurses to ensure in-service training had been completed. Staff were knowledgeable regarding steps to take if a resident exits the facility unattended. Staff stated they were to inform a member of management if a resident began to show a change in behaviors or cognition. The deficient practice remained at an isolated pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings: A care plan for Resident #3, dated 03/22/26, showed the resident had impaired cognition, but showed no interventions for wandering risks. A Wandering Risk Scale for Resident #3, dated 03/23/26, showed the resident was low risk for wandering. The document showed the resident had no history of wandering but did have cognitive impairment. An admission assessment for Resident #3, dated 03/27/26, showed the resident was admitted on [DATE] with diagnoses which included dementia, delirium, and head injury. The assessment showed the resident had a BIMS score of 11 which indicated moderate cognitive impairment. A Wandering Risk Scale for Resident #3, dated 04/22/26, showed the resident was a high risk for wandering. The document showed Resident #3 had a history of wandering and continued to have cognitive impairment. A nurse's progress note for Resident #3, dated 04/26/26 at 8:01 p.m., showed the resident was ambulating, pacing the halls, confused, but easily redirected. A nurse's progress note for Resident #3, dated 05/10/26 at 4:25 p.m., showed a family member was notified the resident had exited the facility and was safely brought inside by CNA #1. A nurse's progress note for Resident #3, dated 05/10/26 at 4:40 p.m., showed the resident had exited the facility and was at a fast food restaurant located four blocks away across a busy four-lane highway. The note showed CMA #2 brought Resident #3 back to the facility. The resident was assessed and determined to have no injuries and was placed on 1:1 care. On 05/13/26, the Oklahoma State Department of Health received an incident report, dated 05/10/26, showed a witness stated Resident #3 had gotten out of the facility earlier, then saw the same resident later in the day at a fast food restaurant. The report showed the witness called the facility to inform a staff member. On 05/19/26 at 11:54 a.m., CMA #1 stated Resident #3 was pleasant, confused, and wandered often. The CMA stated the resident did not exhibit exit seeking behaviors prior to 05/10/26.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was updated after a wandering risk scale increased to high risk for 1 (#3) of 3 sampled residents reviewed for wandering and elopement risk. The ADON identified 62 residents resided in the facility. Findings: A care plan for Resident #3, dated 03/22/26, showed the resident had impaired cognition, but showed no interventions for wandering risks. A Wandering Risk Scale for Resident #3, dated 03/23/26, showed the resident was at low risk for wandering. The document showed the resident had no history of wandering but did have cognitive impairment. An admission assessment for Resident #3, dated 03/27/26, showed the resident was admitted on [DATE] with diagnoses which included dementia, delirium, and head injury. The assessment showed the resident had a BIMS score of 11 which indicated moderate cognitive impairment. A Wandering Risk Scale for Resident #3, dated 04/22/26, showed the resident was a high risk for wandering. The document showed the resident had a history of wandering and continued to have cognitive impairment. A nurse's progress note for Resident #3, dated 04/26/26 at 8:01 p.m., showed the resident was ambulating, pacing the halls, confused, but easily redirected. A nurse's progress note for Resident #3, dated 05/10/26 at 4:25 p.m., showed a family member was notified the resident exited the facility and was safely brought inside by a CNA #1. On 05/19/26 at 11:54 a.m., CMA #1 described Resident #3 as pleasant, confused, and wandered often. CMA#1 stated the resident did not exhibit exit seeking behaviors prior to 05/10/26. On 05/19/26 at 12:12 p.m., the MDS coordinator stated their process for creating and updating comprehensive care plans included the information gathered from assessments, nurse progress notes, and observations. They stated the nurse should inform the MDS coordinator of changes seen when assessments were completed. The MDS coordinator agreed the care plan for Resident #3 should have included interventions for wandering and risk for elopement when a diagnosis of dementia, and documented confusion and disorientation.

Based on record review and interview, the facility failed to obtain hemoglobin A1c lab as ordered for 1 (#5) of 3 sampled residents reviewed for assess, monitor, and intervene.The ADON identified 62 residents resided in the facility. Findings:A facility policy titled Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, read in part, The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.The staff will process test requisitions and arrange for tests.A physician's order Resident #5's , dated 01/02/17, showed hemoglobin A1c (a blood sugar test) due in January, April, July, and October.Laboratory results Resident #5 were reviewed for January and April 2026. There was no documentation the tests were obtained.A physician's progress note for Resident #5, dated 05/18/26, read in part, We need an A1C with this patients labs every 90 days. Has been missed twice in a row now.On 05/21/26 at 8:37 a.m., LPN #1 stated if a resident had an order for lab, they would fill out a requisition form and lab would be collected on Tuesdays and Thursdays.On 05/21/26 at 8:43 a.m., LPN #1 stated the hemoglobin A1c test was not collected in January and April of 2026.On 05/21/26 at 8:44 a.m., LPN #1 stated the physician's order was not followed.On 05/21/26 at 8:46 a.m., LPN #1 stated the hemoglobin A1c test was collected at 8:00 a.m. today.On 05/21/26 at 9:08 a.m., the DON stated the hemoglobin A1c test should have been collected as soon as possible when the physician noticed the tests were missing.

On 08/21/25, an IJ situation was determined to exist related to the facilities failure to provide pharmacy services for Resident #1 in a timely manner.The facility was notified on 08/21/25 at 5:30 p.m., the Oklahoma State Department of Health was notified of the existence of an Immediate Jeopardy situation. On 08/21/25 at 5:38 p.m., the DON and administrator were notified of the existence of an IJ situation related to pharmacy services for Resident #1 . The IJ template was provided to administrator.On 08/23/25 at 9:26 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,Removal of Immediate Jeopardy StatementFacility Name: Broken Bow Health And Rehab Date IJ Identified: August 21, 2025 Resident Affected: Resident #1Actions Taken to Remove the Immediate JeopardyUpon discovery, the facility immediately implemented the following corrective actions to mitigate risk and remove the Immediate Jeopardy:Resident-Centered Interventions-Resident #1 continues on current medication regiment with current cancer treatment.-Resident #1's care plan is updated with the Cancer diagnosis and treatment.-Care Plan meeting is scheduled on 8/22/25 with Resident #1, POA, and Hospice to discuss plan for further follow-up and treatment for the breast cancer.-The Pharmacy Consultant will review Resident #1's chart on 8/22/25 to determine any discrepancy that may need intervention by PCP.Systemic Corrective Measures ImplementedTo prevent recurrence of this type of error, the following systemic interventions were implemented:- Change of Pharmacy was initiated on February 17th, to be electronic and less dependent on fax to reduce opportunity for errors, and if any errors are discovered it will be corrected immediately.-During daily standup and 24 hour report review which contains all new orders; will be reviewed to ensure medications have been ordered and are in the facility. If not, it will be immediately be addressed and corrected.- QA meeting will be held 8/22/25 reviewing system break downs with the missed medication and Diagnosis.Education & Competency- No Registered Nurses, Licensed Nurses, and Certified Medication will work until they are in-serviced. Starting immediately Registered Nurses, Licensed Nurses, and Certified Medication Aides will be in-serviced on the following items:Med Administration policy & procedureTimeliness of implementation of orderNoting orders and transfer to MARAny conflicts of order must contact PCP for clarificationsIf medications are delivered with no orders they are to be reported to DON or ADON asap to ensure appropriate intervention- All Licensed Nursing staff will be in-serviced on responsible party notification and PCP notifications of med changes from outside consultants policy and procedure.- The [NAME] President of Clinical/CEO will in-service DON and ADON will be on clinical morning meeting routine policy; reviewing 24 hour report to catch items that need to be followed up on.All full-time staff will be in-serviced by the end of 8/22/25, and all P.R.N staff will be in-serviced before to being utilized as needed.On 08/26/25 at 11:27 a.m., after interviews with the facility staff, review of in-services, care plans, medication regimen reviews, medication administration records, and pharmacy consultant sheets. The immediacy was lifted and effective 08/26/25 at 12:10 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm.Based on record review and interview, the facility failed to provide pharmacy services in a timely manner for 1 (#1) of 3 resident reviewed for pharmacy services.The DON reported 61 residents resided in the facility.Findings:A minimum date set, dated 03/08/25, read in part, BIMS Score 06.A physician order, dated 03/24/25, read in part, Anastrozole 1 mg tablet, 1mg orally daily.A nursing note, dated 03/26/25, read in part, 03/24/25 Progress notes from doctor at oncology faxed to clinic at this time.A MAR, dated 03/01/25 through 03/31/25, did not show the medication had been administered.A MAR, dated 04/01/25 through 04/30/25, did not show the medication had been administered.A facility policy titled Pharmacy Services Overview, dated 04/2025, read in part, 2. The facility shall contract with a licensed consultant pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.A medication order sheet, dated 04/2025, read in part, date received: 04/28/25 Anastrozole 1 mg rx# 1563586, amount received 30, received by CMA #1.A nursing note, dated 04/30/25, showed, read in part, concerning Resident #1 oncology apt they called and spoke with the POA and they said cancel appointment due to not receiving the medication oncologist was supposed to put Resident #1 on the first time they seen the doctor .The nurse said the oncologist had sent the script to pharmacy back then.A medication order sheet, dated 04/2025, showed, read in part, date received: 04/28/25 Anastrozole 1 mg rx# 1563586, amount received 30, received by CMA #1.A MAR, dated 05/01/25 through 05/31/25, showed the cancer medication was administered daily from 05/26/25 through 05/31/25. Resident #1 did not receive 77 doses of the cancer medication.A fax document, dated 05/20/25, read in part, Anastrozole 1 mg tablet, 1mg orally daily .To be done: 03/24/25. with LPN #1 signature on 05/26/25.On 08/21/25 at 10:50 a.m., the ADON stated the physicians order was written on 03/24/25 for Resident #1. They did not administer the medication for Resident #1 until 05/26/25. On 08/21/25 at 10:51 a.m., the DON stated Resident #1's cancer medication was not administered in March 2025 and April 2025. Resident #1 went 2 months without the cancer medication.On 08/21/25 at 10:01 a.m., the social services personnel stated they scanned the physician orders into their system for Resident #1 on 04/28/25.On 08/21/25 at 10:20 a.m., CMA #1 stated Resident #1's medication was received on 04/28/25 on the medication order and reorder form. The nurses were supposed to put the orders in the system. They did not put the medication in the system until 05/26/25, so they did not know to administer the medication to Resident #1.On 08/21/25 at 10:23 a.m., the DON stated without the administration of the medication the cancer could spread.

Based on observation, record review, and interview, the facility failed to ensure 3 (#1, #2 and #3) of 3 sampled treatment carts were locked.The DON reported 61 residents resided in the facility.Findings:On 08/19/25 at 2:26 p.m., treatment cart #1 was observed to be on the left side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:27 p.m., treatment cart #2 was observed to be on the right side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:28 p.m., treatment cart #3 (wound care cart) was observed to be at the front entrance by the ADON office unlocked.A facility policy titled Security of Medication Cart, revised 04/2007, read in part, 1. The nurse must secure the medication cart during pass to prevent unauthorized entry .4. Medication carts must be securely locked at all times when out of the nurse's view .5. When the medication cart is not being used, it must be locked and parked.On 08/19/25 at 2:25 p.m. LPN #2 was observed walking away from the unlocked treatment cart. They walked into a medication supply closet and closed the door. There were no other staff observed in the area.On 08/19/25 at 2:29 p.m., the ADON was asked about treatment carts being unlocked. They stated, According to policy, all the carts are to be locked and supervised.On 08/19/25 at 3:21 p.m., LPN #2 stated they went to go get medication cups out of the medication room. The treatments carts were supposed to be locked and supervised.On 08/26/25 at 12:31 p.m., the DON stated they had no wanderers in the facility.

Based on record review and interview, the facility failed to ensure a care plan was updated for 1 (#1) of 3 sampled residents reviewed for care plan.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Care Plan, Comprehensive Person-Centered, dated December 2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of resident are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition;A physician consultation note for Resident #1, dated 03/24/25, read in part, Principal Diagnosis: Breast Cancer.A care plan for Resident #1, dated 05/27/25, showed no interventions or diagnosis for cancer was updated on the most recent care plan.On 08/21/25 at 10:51 a.m., the ADON reviewed Resident #1's most recent care plan, dated 05/27/25. They stated Resident #1 had no cancer diagnosis or interventions.On 08/21/25 at 11:16 a.m., the DON stated according to policy Resident #1's care plan should have been updated with interventions and a cancer diagnosis.

Based on record review and interview, the facility failed to ensure a resident who missed 77 cancer medications was included quality assurance and program improvement for 1 (#1) of 3 sampled residents reviewed for medication administration.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Quality Assurance and Performance Improvement, revised 02/2020, read in part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed . Coordination 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessments methodologies and documentation, and in making adjustments to plan.On 08/19/25 at 11:19 a.m., the ADON stated how could they QAPI for the cancer medication we did not know about.On 08/26/25 at 11:40 a.m., the DON stated our last QAPI meetings were 06/10/25 and 08/08/25 and Resident #1's cancer diagnosis or interventions were not included in the meetings.

Based on record review and interview, the facility failed to ensure MDS assessments had been completed accurately for two (#10 and #12) of 15 sampled residents reviewed for MDS accuracy. A daily census, dated 12/09/24, documented 57 residents resided at the facility. Findings: A facility policy titled Certifying Accuracy of the Resident Assessment, dated November 2019, read in part, The information captured on the assessment reflects the status of the resident during the observation period (look back) period for the assessment. 1. An active physician's order, dated 02/09/24, documented Resident #10 was admitted to long term care under the care a contracted hospice provider. A significant change assessment, dated 02/09/24, documented Resident #10 did not receive hospice services. An active physician's order, dated 09/14/24, documented staff were to assess and document the resident's status and collaborate with a contracted hospice provider. A quarterly MDS assessment, dated 11/11/24, documented in Section O that Resident #10 did not receive hospice services. On 12/11/24 at 2:00 p.m., the MDS coordinator stated the significant change and quarterly assessments for Residents #10 were inaccurate because Resident #10 was on hospice services during the time assessments were created. On 12/11/24 at 2:01 p.m., DON stated the significant change assessment was made because Resident #10 had started hospice services. They stated both the assessment were inaccurate. 2. A physician's order, dated 10/08/22, documented the Resident #12 was to be administered Risperdal [an antipsychotic medication] 0.5 mg once daily. The order's discontinue date was 12/11/24. An active physician's order, dated 06/22/23, documented the resident was to be administered Risperdal 1 mg once daily. A MAR, dated 11/01/24 through 11/30/24, documented Resident #12 had been administered Risperdal 0.5 mg once daily and Risperdal 1 mg once daily on each date in that month. A quarterly MDS assessment, dated 11/21/24, documented in Section N that Resident #12 had not been administered an antipsychotic medication during the assessments look back period. On 12/11/24 at 11:45 a.m., the MDS coordinator stated the quarterly assessment for Resident #12 were inaccurate because they thought the question was asking if the resident had started an antipsychotic medication during the assessment look back period and not merely being administered the medication. On 12/11/24 at 11:53 a.m., the DON stated regarding Resident #12 quarterly assessment, the MDS coordinator had answered the questions about antipsychotic medication use incorrectly as they were new to the job and still learning. They stated they were in the process of teaching the MDS coordinator the material.

Based on record review and interview, the facility failed to provide ADL assistance with showers/baths for one (#9) of one sampled resident reviewed for ADL assistance. The administrator identified 55 residents resided in the facility. Findings: A policy titled Bath, Shower/Tub read in part, Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual (s) who assisted the resident with the shower/tub bath .Reporting 1. Notify the supervisor if the resident refused the shower/tub bath. Resident #9 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction and aphasia and dysphagia following a cerebral infarction. The care plan, dated 03/01/22, documented the staff were to assist the resident with a bath at least three times a week and per the resident's request. The care plan documented the resident was a two person assist with shower transfers. A quarterly assessment, dated 09/13/24, documented the resident had modified independent for daily decision making. It was documented the resident required moderate assistance with personal hygiene and supervision with showers/baths. The electronic health record for November 2024 documented the resident received one shower/bath for the month. On 12/10/24 at 10:42 a.m., the resident stated they had not had a shower in five days. They stated they were to get a shower/bath three times a week and did not. The electronic health record for December 2024 documented the resident received one shower/bath for the month. On 12/12/24 at 8:18 a.m., CNA #1 stated there was a paper shower schedule signed by the staff providing the shower and the charge nurse on duty daily. On 12/12/24 at 8:20 a.m., LPN #1 stated at the end of the day the paper shower schedule was given to the DON or ADON for review. On 12/12/24 at 11:14 a.m., the DON stated the form signed by the CNA and charge nurse was for their reference. The DON stated the staff were to chart showers/baths in the electronic heath record. The DON reviewed the resident's electronic health record and stated documentation had not been completed regarding the resident receiving showers/baths.

Based on record review and interview, the facility failed to ensure a resident did not receive an antipsychotic that had been discontinued by a physician for one (#12) of five sampled residents reviewed for unnecessary medications. The DON identified eight residents in the facility were prescribed antipsychotic medications. Findings: A facility policy titled Medication and Treatment Orders, dated July 2016, read in part, Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Resident #12 had diagnoses which included major depressive disorder with psychotic features. A medication order, dated 10/08/22, documented Resident #12 was to have been administered Risperdal [an antipsychotic medication] 0.5 mg once daily. A document titled Pharmaceutical Consultant Report, dated 07/17/24, documented a pharmacist recommendation to reduce the dose of four psychotropic medications which included Risperdal 0.5 mg once daily and Risperdal 1 mg once daily. The report also documented a physician's response which was an order to stop the use of Risperdal 0.5 mg once daily. The report had a signature of the physician and the date 10/22/24. A MAR for November 2024 and December 2024 documented the order for Risperdal 0.5mg tablet once daily remained on the records. The records further documented Resident #12 had been administered Risperdal 0.5 mg tablets once on each date 11/01/24 through 12/11/24. On 12/11/24 at 11:07 a.m., LPN #1 stated the pharmaceutical report for Resident #12, dated 04/17/24, did include a physician's order to discontinue Risperdal 0.5mg once daily. They stated after looking at the electronic health record for Resident #12 the order was still active, and the resident had been getting the medication daily. They stated the pharmaceutical reports go through the DON and they distributed them to the nurses. On 12/11/24 at 11:12 a.m., the DON stated they had confirmed the Risperdal 0.5mg once daily order should have been discontinued. They stated the process for the reports from the pharmacist was that once they receive it, they communicate with the appropriate nurse and make any changes ordered. They stated they were new at the time of this report and must have missed it.

Based on observation, record review and interview, the facility failed to ensure the dish machine temperature and sanitizer concentration was monitored and logged daily, kitchen equipment functioned properly, and food was stored in an appropriate manner. The administrator identified 54 residents received meals from the kitchen. Findings: An initial tour of the kitchen was conducted on 12/09/24 at 2:45 p.m. The following observations were made: a. the paper towel dispenser at the handwashing sink was not functioning; b. the Dish Machine Temperature Log, for December 2024 did not document the temperature or the concentration of sanitizer for 12/05/24, 12/06/24, 12/07/24, 12/08/24, or 12/09/24; c. there were two opened bottles of prune juice with no received on date or opened date; d. there were 10 individual sized cups of ranch dressing with no date of preparation; e. there was an opened 32-ounce carton of whole eggs with no received on or opened date; f. there was an opened uncovered can of pudding with no received on or opened date; g. there was an opened uncovered bulk container of brown sugar sitting on the floor in the storeroom; h. there was an opened uncovered bulk container of flour; e. there was an opened uncovered box of long grain rice; f. there was an undated case of canned pears sitting on the floor; and g. there was an undated case of turnip greens sitting on the floor. On 12/09/24 at 3:06 p.m., the DM stated the temperature of the dish machine and the chemical concentration of the sanitizer should be checked three times a day. They also stated the paper towel machine at the handwashing sink needed to be repaired. The DM further stated dry goods should be stored off the floor in closed containers and all food items should have a received date and should be dated when they were opened.

Based on record review and interview, the facility failed to implement a water management plant to prevent the spread of water borne pathogens. The administrator reported the census was 55. Findings: A facility policy titled Legionella Surveillance and Detection, read in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella .Legionnaire's disease will be included as part of our infection surveillance activities. On 12/12/24 at 7:53 a.m., the administrator reported they were unable to locate any documentation of monitoring for water-borne pathogens.

Based on observation, record review, and interview, the facility failed to assess a resident for self-administration of medication for one (#54) of one sampled resident who was reviewed to self-administer medication. The administrator identified three residents who self-administered medications. Findings: A policy titled Self-Administration of Medication read in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .If it is deemed safe and appropriate for the resident to self-administer medications, this is documented in the medical record and the care plan .Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Resident #54 had diagnoses which included chronic obstructive pulmonary disease, reflux disease, and legal blindness. The care plan, dated 09/23/24, did not document self-administration of medication for the resident. The admission 5 day assessment, dated 09/27/24, documented the resident was cognitively independent and was independent with most ADLs. On 12/10/24 at 12:33 p.m., the resident was sitting on the side of the bed in their room. An inhaler (Spiriva HandiHaler inhaler), an over-the-counter bottle of cold medicine, and a tube of Cortisone 10 cream was on the resident's bedside table. The resident obtained an inhaler from their pocket and stated they had another inhaler for emergencies. On 12/10/24 at 3:52 p.m., LPN #1 reviewed the resident's clinical record and stated they could not locate a medication self-administration assessment record for the resident. The LPN stated if the resident self-administered medication an assessment should have been completed. The LPN stated they were aware of the inhaler at the bedside, but not other medications. On 12/10/24 4:17 p.m., the DON reviewed the resident's clinical record and stated no self-administration of medication assessment had been completed for the resident. The DON stated they were unaware the resident had medications at the bedside. They stated per policy the medication should stored in a safe and secure place, which was not accessible by other residents.

Based on record review and interview, the facility failed to ensure medical records were accurate for one (#34) of two sampled residents reviewed for pressure ulcers. The administrator reported the facility census was 55. Findings: A facility policy titled Charting and Documentation, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Treatments or services performed. Resident #34 had diagnoses which included congestive heart failure and urinary incontinence. An admission assessment, dated 11/13/24, documented Resident #34 had one stage II and two stage III pressure ulcers that were present upon admission. A physician's order, dated 11/09/24, documented Resident #34 was to receive wound care to the left ankle daily. A physicians orders, dated 11/21/24, documented Resident #34 was to receive wound care to the left heel daily and the coccyx daily. A review of Resident #34's TAR did not document wound care had been performed on 12/05/24, 12/07/24, 12/08/24 or 12/09/24. On 12/11/24 at 2:30 p.m., the ADON stated they had performed the wound care on Resident #34 on 12/05/24 and they must have forgotten to document it. They also stated wound care should always be documented on the TAR. On 12/11/24 at 3:02 p.m., LPN #3 stated they had performed the wound care on Resident #34 on 12/09/24 and forgotten to document it. On 12/12/24 at 11:14 a.m., LPN #2 stated wound care should always be documented on the TAR. On 12/12/24 at 11:24 a.m., the DON wound care should always be documented.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for one (#5) of five sampled residents reviewed for medication administration. The administrator identified 56 residents who resided in the facility. Findings: Resident #5 had diagnoses which included epileptic seizures, cerebral infarction, and cognitive communication deficit. The care plan, dated 12/04/19, documented the resident had a history of a seizure disorder. The care plan documented the staff were to administer seizure medication as ordered by the physician. The quarterly assessment, dated 08/20/24, documented the resident was severely impaired for daily decision making and was dependent with activities of daily living. A physician order, dated 09/28/24, documented the resident was to receive phenytoin (an anticonvulsant medication) 125 mg/5 ml and give 5 ml via peg tube daily for seizures. The MAR for November 2024 documented the resident did not receive the phenytoin medication seven out of 25 opportunities. On 11/25/24 at 3:05 p.m., the DON reviewed the resident's MAR and stated they were unsure why the resident's phenytoin medication had not been given. The DON stated if the medication was not given the resident could have seizures.

Based on observation, record review, and interview, the facility failed to provide snacks between meal times for two (#2 and #4) of two sampled residents reviewed for snacks provided between meals. The administrator identified 56 residents resided in the facility. Findings: A facility policy titled Snacks (Between Meal and Bedtime), Serving read in part, purpose of this procedure is to provide the resident with adequate nutrition .Arrange the snack so that it can be easily reached by the resident .Notify the supervisor if the resident refuses the snack and why. 1. Resident #2 had diagnoses which included cerebrovascular disease, dysphagia, and aphasia. The admission assessment, dated 09/02/24, documented the resident was cognitively intact and required setup assistance with eating. The assessment documented it was very important to the resident to have snacks available between meals. On 11/26/24 at 8:32 a.m., Resident #2 stated if they were hungry between meals they would like to have a snack. 2. Resident #4 had diagnoses which included cerebral infarction, muscle weakness, and diabetes. The admission assessment, dated 09/17/24, documented the resident was cognitively intact and required supervision with eating. The assessment documented it was somewhat important to have snacks between meals. On 11/25/24 at 3:28 p.m., the resident stated snacks were only available at night. The resident stated one time they continued to ask the staff for a snack and was provided with a package of crackers. The resident stated they decided to just quit asking for a snack during the day. On 11/21/24 at 10:45 a.m., a tour of the facility was conducted. During tour and throughout the survey no snacks were observed being offered or provided to the residents between meals. On 11/25/24 at 12:37 p.m., the DM stated snacks were only provided for the residents only at night. The DM stated they have had residents request snacks during the day. The DM stated they were unable to provide resident snacks between meals during the day unless it was a medical need, such as the resident was a diabetic.

Based on observation, record review, and interview, the facility failed to ensure a resident was transferred properly to prevent a fall with major injury for one (#2) of three sampled residents who were reviewed for falls. CNA #3 transferred Res #2 without the required assistance of another staff member resulting in a fall with a fracture to Res #2's left tibula/fibula. The Resident Census and Conditions of Residents, dated 08/24/23 documented 44 residents required assistance with transfers. Findings: A Limited Lift Resident Handling Policy, dated January 2017, read in part, .The transfers will be designated into one of the following categories .2 or equivalent = 2-person transfer .Resident transfer status will be tagged in the resident's room to inform the staff of the appropriate transfer to use . Res #2 was admitted with diagnoses which included age-related osteoporosis, intellectual disabilities, dementia, legal blindness, and convulsions. Res #2's ADL care plan, dated 05/23/23, documented Res #2 required extensive assistance with ADL's and transfers required the assistance of two staff members. The annual resident assessment, dated 05/30/23, documented Res #2 had moderately impaired cognition, required extensive assistance with ADLS; and two staff member extensive assistance with transfers; did not walk; and had ROM impairment in both lower extremities. An incident report, dated 07/07/23, documented Res #2 had a fall in the shower room resulting in a left tibula/fibula fracture. The report documented CNA #3 did not follow the facility transfer policy when transferring the resident. The report documented CNA #3 was suspended immediately and an investigation was initiated. A facility in-service was conducted on 07/07/23 at 1:00 p.m. The DON in-serviced all direct care staff regarding the Limited Lift Resident Handling Policy. Upon entrance to the facility on [DATE] and throughout the investigation staff were observed to be following the Limited Lift Resident Handling Policy and transfers were observed to be conducted safely and according to the facility policy. Sampled residents were observed for correct transfer information in their room. Staff were interviewed and reported knowledge of the Limited Lift Resident Handling Policy and demonstrated compliance with the policy. Incident reports were reviewed and there were no other falls related to unsafe transfers. On 08/28/23 at 11:00 a.m., Res #2 was observed in the TV room, sitting up in their wheelchair with their left leg supported by pillows. On 08/30/23 at 3:30 p.m., the DON reported the staff have been in-serviced regarding the Limited Lift Resident Handling Policy and new staff were required to read and sign the policy upon hire.

Based on observation and interview, the facility failed to ensure residents who received meals from the kitchen were served in a timely manner and avoided the daily use of disposable cutlery for 38 residents sampled for respect and dignity. The DON reported 58 residents received meals from the kitchen. Findings: A document, titled Complaints Resident Council, dated 08/10/23, documented in part, .meals served later and later everyday . Resident Council Minutes, dated 06/22/23, documented in part, .certain residents always get real plates no matter what and residents are tired of using plastic silverware . On 08/24/23 at 8:45 a.m., a sign in the dining room, by the kitchen window, documented breakfast at 8:00, lunch at 12:30, and dinner at 4:30. On 08/24/23 at 9:00 a.m., 19 residents were in the dining room, one resident had been served food. Staff were assisting three residents with being seated in the dining room. On 08/24/23 at 9:10 a.m., 19 residents had food and staff were assisting residents entering the dining room. On 08/24/23 at 9:15 a.m., Dietary Aide #1 reported it wasn't possible to feed residents seated at the same table at the same time. On 08/28/23 at 8:28 a.m., 15 residents were observed in the dining room with disposable utensils. On 08/29/23 at 8:33 a.m., Res #43 stated he would like real silverware, not plasticware. On 08/29/23 at 9:30 a.m., hall trays were served with plastic utensils, CNA #2 reported food trays delivered to resident rooms always had plastic utensils, the CNA reported they did not know why the residents were served with plastic utensils. On 08/31/23 at 8:30 a.m., three residents were observed in the dining room being assisted with eating by staff using disposable silverware. The residents' meals were on disposable plates. On 08/31/23 at 10:17 a.m., the certified dietary manager reported there was not enough non-disposable silverware or plates for all of the residents. They reported they didn't know why there weren't enough. The CDM reported they weren't aware serving with disposable utensils and plates was interfering with the homelike environment. They reported they were at the resident council meetings in June and August of 2023 when residents at the meeting reported they didn't want disposable utensils and plates. The CDM reported they didn't know residents seated at the same table should have been served at the same time. The DM reported they didn't think it was going to work. On 08/31/23 at 11:26 a.m., the Corp. Nurse Consultant #1 reported the expectation was to have no disposable utensils or plates unless requested by a resident and care planned. The Corp. Nurse Consultant also reported the residents seated at the same table should have been served food at the same time.

Based on observation, interview, and record review, the facility failed to ensure floors were cleaned in two (#107 and #108) of two resident rooms sampled for a clean, homelike environment. The Resident Census and Conditions of Residents, dated 08/27/23, documented a census of 58 residents. Findings: A document, titled Complaints Resident Council, dated 08/10/23, documented in part, .floors are dirty. Made by all 12 . On 08/29/23 at 7:17 a.m., an unidentified housekeeping staff member was observed mopping room [ROOM NUMBER] and placing a wet floor sign in the doorway of room [ROOM NUMBER]. The floor of room [ROOM NUMBER] was observed to be wet upon entry by the surveyor. Three rolls of toilet tissue, two plastic spoons, and a straw were on the floor between the resident's bed and the wall. A potato chip bag and a pink plastic bottle were under the resident's bed. The DON was summoned to room [ROOM NUMBER] by the surveyor. The DON stated the room did not appear to have been cleaned. The DON stated if the floor had not been wet, they would not have known housekeeping had been in the room. The DON also reported the floor felt sticky. On 08/29/23 at 9:40 a.m., a blue blanket was observed on the floor of room [ROOM NUMBER]. The DON observed the blanket on the floor. On 08/29/23 at 9:45 a.m., Res #10 and Res #34 reported housekeeping had been in room [ROOM NUMBER] earlier and had mopped around the blanket on the floor. The residents reported housekeeping staff did not move items on the floor, the staff mopped around items on a daily basis. On 08/29/23 at 9:50 a.m., the DON reported room [ROOM NUMBER] did not appear to have been cleaned. On 08/31/23 at 2:33 p.m., the housekeeping supervisor reported the uncleanliness of rooms #107 and #108 was not acceptable. The supervisor reported items should have been removed from the floor prior to being swept and mopped.

Based on record review and interview, the facility failed to provide monthly drug regime reviews for three (#7, 15 and #46) of three sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents, dated 08/24/23 documented a census of 58 residents. Findings: 1. Res #7 was admitted with diagnoses which included anxiety and depression. The DON was unable to provide a monthly drug regime review for May and June of 2023. 2. Res #46 was admitted with diagnoses which included schizoaffective disorder, bipolar type brief psychotic disorder and schizophrenia. The DON was unable to provide a monthly drug regime review for March, April and June of 2023. On 08/31/23 at 2:05 p.m., the Corp Nurse Consultant reported the staff could not locate a monthly drug regime review for every month for the past year. The Corp Nurse Consultant reported scanning was backed up and it was difficult to locate the required documents. 29358 3. Res #15 was admitted to the facility on [DATE] and had diagnoses which included vascular dementia with other behavioral disturbance, major depressive disorder, hypertensive heart disease with heart failure, hypothyroidism, DM, COPD, pain, and insomnia. A quarterly assessment, dated 07/10/23, documented the resident was cognitively intact and received insulin, antipsychotic, antianxiety, antidepressant, and diuretic medications. On 08/31/23 at 11:51 a.m., the resident's monthly pharmacy consult medication reviews were not found in the resident's medical record except for the months of January and July 2023. The DON was asked to provide the monthly reviews. On 08/31/23 at 2:57 p.m., the DON was asked about the process for the reviews. They stated when the physician signs off on them they should be scanned in the the medical record. They stated they had a lot of documents that need to be scanned in. They stated they could not provide the medication regimen reviews which had been signed off by the physician.

Based on observation, record review, and interview, it was determined the facility failed to ensure safety during personal care and failed to prevent a fall for one (#1) of three residents sampled for falls and safety. The fall resulted in the resident being hospitalized and diagnosed with [REDACTED]. The facility documented 34 residents who had experienced falls in the last six months. Findings: The facility policy on transfers documented staff would obtain assistance of another individual if necessary for safety. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 04/03/13, documented the resident was severely impaired with decision making ability. The assessment documented the resident required assistance of two persons with transfers and dressing. The assessment documented the resident required human assistance with sitting and balance. A care plan, dated 06/17/14, documented the resident required extensive staff assistance with bed mobility, transfers, incontinent care, dressing, and hygiene. A significant change assessment, dated 06/19/14, documented the resident was severely impaired with decision making ability. The assessment documented the resident required extensive assistance of two persons with personal hygiene needs. A nurse's note, dated 07/29/14 at 4:30 p.m., documented the nurse was summoned to the resident's room. The nurse's note documented the resident was found lying supine on the floor and complained of left hip pain. The note documented the resident's family, physician, and emergency medical system was notified. The note documented the resident was transferred to the hospital for evaluation. The note documented the resident returned to the facility at 11:30 p.m. A facility incident report, dated 07/29/14, documented the nurse-aide positioned the resident on the side of the bed. The incident report documented the nurse-aide turned around to get the resident's shoes and the resident fell off the bed onto the floor. An incident report faxed to the state agency, dated 07/30/14, documented the resident returned to the facility from the hospital on [DATE] with no injuries. A physician's orders [REDACTED]. A nurse's note dated, 07/30/14 at 6:30 a.m., documented the resident continued to complain of pain during repositioning. A nurse's note, dated 07/30/14 at 9:30 a.m., documented the resident complained of left knee pain with redness, and bilateral lower extremity pain that was tender to touch. The note documented an order was received for x-rays to the lower extremities related to severe pain. A nurse's note, dated 07/30/14 at 11:00 a.m., documented the x-ray results showed a fracture to the resident's right knee and femur. The note documented the right knee had warmth to touch. A nurse's note, dated 07/31/14 at 7:30 a.m., documented the resident had increased pain to the leg and warmth and redness to the right knee. A nurse's note, dated 07/31/14 at 9:30 a.m., documented the resident's daughter requested the resident be transferred to the hospital. A hospital assessment, dated 07/31/14, documented the resident had a right femoral fracture, possible sepsis, and leukocytosis. On 08/15/14 at 11:00 a.m., the resident was observed in bed. The resident was observed with a black leg brace on her right leg. On 08/19/14 at 12:30 p.m., the director of nurses was interviewed regarding the resident falling off the bed. The director of nurses (DON) stated the resident always required two nurse-aides for dressing and care needs. The director of nurses stated she interviewed the nurse-aide who was caring for the resident when the resident fell . The director of nurses reported she asked the nurse-aide why she did not get assistance to help with the resident. The nurse aide reported to the director of nurses she knew two nurse-aides were required to care for the resident. The director of nurses asked the aide why did she not follow the protocol. The nurse-aide reported to the director of nurses she knew two people were to care for the resident but that she did not want to wait for any assistance to care for the resident. The director of nurses terminated the nurse-aide on 07/30/14 for not following protocol. On 08/20/14 at 10:15 a.m., the DON was interviewed regarding tracking and trending of falls. The DON was asked if falls were monitored by location and time. The DON stated, "No." The DON was asked if the staff were educated on fall monitoring and possible interventions to decrease falls. The DON reported she had not thought about that.

Based on interview and record review, it was determined the facility failed to ensure care and services were provided for a resident to maintain his/her highest level of functioning for one (#4) of two residents sampled for a change of condition. The facility failed to thoroughly assess, monitor, and track progression/deterioration following a leg injury for resident #4. The injury worsened and the resident required hospitalization . A hospital discharge summary documented the resident had extensive debridement of necrotic tissue after admission to the hospital. The summary documented the resident was admitted with an enlarged progressive abscess and [MEDICAL CONDITION] of the right lateral calf. The facility identified two residents with a change of condition in the last 60 days. Findings: The facility policy on condition change of the resident documented following an injury staff was to assess the resident. The policy documented assessment and monitoring included but were not limited to swelling and discoloration, and if present, document size, site, amount, and color. The policy documented staff was to monitor the resident's condition frequently until stable. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The closed record of resident #4 was reviewed. A quarterly assessment, dated 12/04/13, documented the resident was severely impaired in cognition. The assessment documented the resident required extensive assistance with transfers, dressing, bed mobility, and hygiene and bathing needs. An incident report, dated 02/27/14 at 11:45 a.m., documented, "Summoned to resident by (name deleted) LPN (licensed practical nurse)." The report documented bruising and increased [MEDICAL CONDITION] were noted to the resident's right lower extremity. The incident report documented the area was tender to touch and range of motion was reduced to the right lower extremity. The incident report documented the resident was unable to rate the pain. The incident report documented hospice aide #1 and certified nurse aide (CNA) #1 reported the resident's right lower extremity was "bumped" while putting the resident in the shower. Additional comments on the incident report documented the CNA was informed to monitor extremities during transfers and no cell phone use. A witness statement form, dated 02/27/14, documented CNA #1 was assisting the hospice aide with the resident. The form documented when the hospice aide and CNA got the resident in the shower chair the hospice aide hit the resident's right leg on the metal frame of the lift chair while she was talking on the phone. The form documented the incident occurred at "11:00ish." A witness statement form by the hospice aide, dated 02/27/14, documented while taking the resident to the shower room the "whirlpool chair was pulled out and bumped pts (patient's) R (right) leg on it while putting her in shower." The form documented the incident occurred at 11:45 a.m. A nurse note, dated 02/27/14 at 11:45 a.m., documented a bruise and increased [MEDICAL CONDITION] to the right lower extremity was noted. The note documented the CNA stated the right lower extremity was "bumped" while putting the resident in the shower. The note documented a new order to x-ray the resident's right lower extremity. A witness statement form by licensed practical nurse (LPN) #1, dated 02/27/14, documented the resident was sitting at a table in the dining room and began yelling, "Oww, my leg is burning." The form documented the LPN removed the resident from the dining room and raised her pant leg up. The form documented the resident's right lateral leg above the right ankle was swollen, blue with bruising, firm, and tender. The form documented the area was painful to touch. The form documented the charge nurse was notified of the resident's condition. The form documented the time the incident was discovered was at 12:00 p.m. A skin assessment note, dated 02/27/14 at 12:30 p.m., documented the resident was removed from the dining room to assess the right lower leg and the LPN observed firmness to the lateral right lower leg. The form documented the area was tender to touch with light blue bruising present. The note documented the skin was intact with 2+ [MEDICAL CONDITION] present to bilateral lower extremities. A skin assessment note, dated 02/27/14 at 12:45 p.m., documented the right lower leg was elevated on a pillow. The note documented the resident continued with a firm area to the lateral right lower leg with light blue bruising progressing to darker blue. A skin assessment note, dated 02/27/14 at 1:30 p.m., documented the resident continued to complain of pain to the right leg. The note documented the lateral right lower leg with blue bruising becoming darker in color and progressing towards the ankle and up towards the knee. The note documented an ice pack wrapped in a towel was applied to the right lower leg to aide in minimizing the swelling and bruising and the charge nurse was notified. A nurse note, dated 02/27/14 at 2:30 p.m., documented the x-ray was negative for [MEDICAL CONDITION] lower extremity. A nurse note, dated 02/27/14 at 4:30 p.m., documented the resident was taken to the office of the advanced practice registered nurse (APRN), to be examined for swelling and bruising to the right lower leg. The note documented new orders to wrap the right lower leg with ace wrap, apply ice, and elevate. A nurse note, dated 02/27/14 at 4:35 p.m., documented the right leg was wrapped, ice was applied, and the resident's right leg was elevated. The note documented pedal pulse was present with sensation to toes. The note documented [MEDICATION NAME] was given to the resident for pain. The note documented 2+ [MEDICAL CONDITION] to the resident's right foot. A nurse note, dated 02/27/14 at 6:30 p.m., documented the resident continued with 2+ [MEDICAL CONDITION] to the right foot, pedal pulse present, and foot was elevated. The note documented no increase in swelling or bruising. A nurse note, dated 02/27/14 at 8:30 p.m., documented the resident continued with pedal pulse to the right foot, no increase in swelling or bruising. The note documented pedal pulse was present and sensation continued to toes. A nurse note, dated 02/27/14 at 9:30 p.m., documented pedal pulse continued to the resident's right foot, the right foot was elevated, and an ice pack applied. A nurse note, dated 02/27/14 at 10:30 p.m., documented the resident's right leg was elevated with ice in place. The note documented pedal pulse was present, color within normal limits, [MEDICAL CONDITION] and bruising continue to the right lower leg. The note documented the resident's left leg was starting to bruise on the lateral side and the director of nursing (DON) was notified. An investigative nurse note synopsis was reviewed. The report documented at approximately 11:00 am on 02/27/14 the actual injury occurred and the CNA left the whirlpool room at that point. The report documented the hospice aide assumed that the CNA notified the charge nurse of the incident. The report documented between 11:45 a.m., and 12:00 p.m., the resident was crying in the dining room and complained of burning in her right lower leg. The resident was removed from the dining room and assessed. The report documented the advanced practice registered nurse (APRN), the resident's son, the physician, the director of nursing (DON), and the administrator were notified. The report documented 72 hour charting was initiated. The report documented the area was not defined enough to measure. The nurse note synopsis, at 4:30 p.m., documented the nurses were requested to do a pedal pulse check on the resident every few hours to ensure continued circulation. The note documented the area went from not defined to the size of a fluid filled softball. A nurse note, dated 02/28/14 at 4:00 a.m., documented Ace wrap continued to the right lower leg and bruising continued to bilateral lower extremities. The note documented an ice pack was applied to the right lower extremity and the resident tolerated it satisfactorily. The note documented the right lower extremity was elevated on a pillow, 1+ [MEDICAL CONDITION] was noted to the right lower extremity, and pedal pulses were present to bilateral lower extremities. A nurse note, dated 02/28/14 at 9:00 a.m., documented staff wrapped the right lower extremity with Ace wrap and applied ice packs. The note documented a hematoma continued to the right lower extremity with 1+ [MEDICAL CONDITION] and pedal pulses present to bilateral lower extremities. A nurse note, dated 02/28/14 at 4:30 p.m., documented the resident continued with a large purple bruise to the right lower leg. The note documented the Ace wrap and elevation were continued. The note documented the resident complained of discomfort when the leg was touched. A nurse note, dated 03/01/14 at 3:45 a.m., documented bruising continued to bilateral lower extremities. The note documented the Ace wrap continued on the resident's right leg and an ice pack was applied for 20 minutes. The note documented the resident tolerated satisfactorily and denied pain or discomfort. A nurse note, dated 03/01/14 at 8:00 a.m., documented the resident continued with bruising, a hematoma to the right lower extremity with 1+ [MEDICAL CONDITION] to bilateral lower extremities, and the area was tender to touch. The note documented the resident's feet were elevated on a pillow and no acute distress was noted. A nurse note, dated 03/01/14 at 9:00 a.m., documented the nurse was alerted to the resident's room by a certified medication aide. The note documented the resident had a "c shaped" skin tear to the left lower extremity with a moderate amount of bleeding. The note documented first aid was applied. The note documented the resident's family and the physician were notified and new orders were received. A nurse note, dated 03/01/14 at 4:00 p.m., documented the right leg was swollen, pain to touch, and Ace wrap in place. A nurse note, dated 03/02/14 at 1:30 a.m., documented bruising continued to bilateral lower extremities. The note documented the right leg had an Ace wrap in place and ice pack applied to the bruise. The note documented steri-strips were intact to the left lower extremity and no signs/symptoms of infection were noted. A nurse note, dated 03/02/14 at 9:30 a.m., documented bruising continued to bilateral lower extremities. The note documented the right leg with an Ace wrap and 1+ [MEDICAL CONDITION] noted. The note documented a skin tear with steri-strips intact. The note documented no signs/symptoms of infection, tender to touch, and safety measures continued. A nurse note, dated 03/02/14 at 2:00 p.m., documented another resident rolled up to resident #4 and hit her in the mouth two times. The other resident was redirected by an LPN and the DON. The note documented the resident denied pain, was assessed, and was not injured. The note documented the resident was taken to her room to lay down and watch television. A nurse note, dated 03/02/14 (no time), documented the right leg continued [MEDICAL CONDITION], Ace wrap redone, and a large amount of bruising was noted to the foot. The note documented the resident complained of hurting with movement. A nurse note, dated 03/03/14 at 1:00 a.m., documented the right leg continued with [MEDICAL CONDITION], Ace wrap intact, and bruising to bilateral lower extremities. The note documented the resident moved without complaint. The note documented the skin tear to the left lower extremity had five steri-strips applied and no complaint of acute distress. A nurse note, dated 03/03/14 at 08:00 a.m., documented an assessment of the right lower extremity and the steri-strips on the left lower extremity. A nurse note, dated 03/03/14 at 7:00 p.m., documented an assessment of the steri-strips on the left lower extremity with no signs/symptoms of infection. The note contained no documentation regarding the right lower extremity. An annual assessment, dated 03/04/14, documented the resident was severely impaired in cognition. The assessment documented the resident was totally dependent with transfers, dressing, bed mobility, and hygiene and bathing needs. A nurse note, dated 03/04/14 at 1:00 a.m., documented an assessment of the steri-strips on the left lower extremity. The note contained no documentation regarding the right lower extremity. A nurse note, dated 03/04/14 at 2:00 p.m., documented a new order to obtain a hemoglobin and hematocrit lab due to a hematoma and to obtain an x-ray to the resident's right tibia and ankle. The note documented a new wound care orders to the coccyx and new orders regarding the right lower extremity for a raised hematoma. Nurse notes and skin assessments did not contain documentation of measurements of the bruised area or hematoma on the resident's right lower extremity. The nurse note synopsis, dated 03/04/14 at 2:00 p.m., documented the resident was seen for weekly wound care and to check the hematoma on the right lower extremity. The note documented new orders were received for treatment on the right lower extremity. The note documented a hemoglobin and hematocrit was ordered due to a large hematoma. The note documented another x-ray was ordered. The note documented measurement of the hematoma was 9 centimeters (cm) x 13 cm. The bruised area measured 18 cm x 36 cm. The nurse note synopsis, dated 03/04/14 at 6:00 p.m., documented no fracture was noted and soft tissue was unremarkable. The note documented a new dressing order for an Ace wrap and to elevate and apply ice x 20 minutes two times a day. A nurse note, dated 03/04/14 at 4:00 p.m., documented the resident had no injury to the mouth related to the resident to resident altercation. The note contained no documentation regarding the right lower extremity. A nurse note, dated 03/04/14 at 11:00 p.m., documented the resident had no injury to the mouth and the resident was very confused. The note contained no documentation regarding the right lower extremity. A nurse note, dated 03/05/14 at 10:00 a.m., documented the resident had no injury to the mouth. The note contained no documentation regarding the right lower extremity. A skin assessment note, dated 03/05/14 at 1:30 p.m., documented the right lower lateral leg with a large dark purple hematoma with purplish blue bruising noted from just below the right knee to the lateral right foot and right toes. The note documented the hematoma was covered with oil [MEDICATION NAME] gauze, padded with an abd pad, wrapped with conforming gauze for protection, and wrapped loosely with an Ace wrap from toes up towards heel. The note documented the skin to the right lower leg was intact. The note documented the left lower lateral leg with skin tear 2.5 cm. long with dry brown scab intact. A nurse note, dated 03/05/14 at 4:00 p.m., documented the resident had no injury to the mouth. A nurse note, dated 03/05/14 at 11:00 p.m., documented the resident had no injury to the mouth. The resident's medical records contained documentation the resident's dressing was changed on 03/06/14, 03/07/14, and 03/08/14. The resident's medical records contained no skin assessments of the right lower extremity on those days. A nurse note, dated 03/06/14 at 08:15 a.m., documented the resident had no injury to the mouth. The note contained no documentation regarding the right lower extremity. A nurse note, dated 03/06/14 at 4:00 p.m., documented the resident had no injury to the mouth. The note contained no documentation regarding the right lower extremity. The resident's record contained no nurse note documentation on 03/07/14 or 03/08/14 regarding the right lower extremity. The care plan, updated on 03/09/14, documented the resident required extensive assistance from staff with activities of daily living. The care plan documented staff was to assist the resident to bathe at least three times weekly and as needed. The care plan documented the resident's skin was fragile and the resident was at risk for skin impairments, skin infections, and pressure ulcers. A nurse note, dated 03/09/14 at 2:00 p.m., documented an increase in bruising, redness and heat to the resident's right lower extremity. The note documented the APRN was notified and a new order was received to send the resident to the emergency room for evaluation. A skin assessment note, dated 03/10/14 at 8:00 a.m., documented the resident had been admitted to the hospital. The history and physical from the hospital, dated 03/10/14, was reviewed. The history and physical documented on admission the resident's right lower extremity was swollen [DIAGNOSES REDACTED]tous and very warm to touch from the knee distally. The report documented the resident had large black eschar over the lateral aspect of the right gastronemius muscle. A hospital discharge summary, dated 03/17/14, documented the resident was admitted on [DATE] with an enlarged progressive abscess and [MEDICAL CONDITION] of the right lateral calf. The discharge summary documented surgical consultation was done and the patient was taken to the operative room the next day and extensive debridement needed to be done for the necrotic tissue. On 04/30/14 at 3:55 p.m., the DON was interviewed. The DON reported the hospice aide apparently got a phone call while giving the resident a shower. The DON reported the hospice aide bumped the resident's leg on the shower chair or the resident kicked the shower chair. The DON reported the facility did not have a policy regarding using the cell phone while giving resident care. The DON reported the aide was counseled by the administrator about not using a cell phone while giving resident care. On 04/30/14 at 4:12 p.m., the APRN was interviewed. The APRN reported she had seen the resident's right lower extremity the day of the incident. The APRN reported she looked at it again on 03/04/14 and it looked about the same. The APRN reported she did not see the resident's right lower extremity on the day she was transported to the emergency room . On 04/30/14 at 4:25 p.m., the wound nurse was interviewed. The wound nurse reported she did her weekly skin assessments and the last skin assessment she did for the resident was on 03/05/14. The wound nurse reported the area of bruising and swelling had gotten considerably bigger. The wound nurse reported she did not notify anyone because she thought they had already notified the physician and the resident's family. The wound nurse reported she did not know how often they assess on the acute notes. On 04/30/14 at 7:00 p.m., the administrator was interviewed. The administrator reported she had investigated the incident and found no documentation of assessment of the resident's right lower extremity on 03/06/14, 03/07/14, or 03/08/14. On 05/01/14 at 8:30 a.m., the DON was interviewed. The DON reported if a resident had a change in condition, the resident should have been assessed and documented on every shift for three days. The DON reported if the resident's condition continued to get worse the every shift assessment and documentation should continue. The DON reported resident #4 had a worsening of her condition and assessment and documentation on her right leg should have continued every shift. The DON reported the resident's right leg should have been assessed on 03/06/14, 03/07/14, and 03/08/14.

Based on record review, observation, and interview, it was determined the facility failed to: a) assess and provide interventions to alleviate pain and to decrease pain before daily care and treatments for 1 (#1) of four residents sampled for pain. The resident experienced excruciating pain during daily care and treatments which resulted in actual harm. The facility identified two residents who received pain medication before treatments. b) monitor blood sugar parameters for two (#2 & #5) for four residents who were sampled for blood sugar parameters. The facility identified thirty three diabetic residents in the facility. Findings: The facility policy on pain documented the facility was committed to pain management for all residents. The policy documented residents had the right to expect quick response to reports of pain and receive the best level of pain control. The policy documented the facility recognized pain relief as a resident right. The facility policy documented notification of the physician and family is required when a new pressure ulcer is identified. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility pain evaluation, dated 05/03/23, documented the resident had no pain. A care plan, dated 05/07/12, documented the resident had infected skin tissue, red hot, irritated, and painful to the right ankle and sacrum. A care plan, dated 05/15/12, documented the resident was at risk for pain and discomfort related to pressure ulcers, [MEDICAL CONDITION], impaired mobility, and arthritis. The care plan documented the resident had a risk of decreased movement, irritability, agitation, and a reduced sense of well being. A care plan, with no date, documented the resident would be promptly treated for [REDACTED]. The care plan documented the resident would be able to confirm comfort and experience a sense of well being within 1 hour of receiving pain intervention daily. The care plan documented for staff to anticipate and aggressively treat for pain before, during, and after [MEDICATION NAME] or painful treatments. The care plan documented if pressure ulcer treatments were painful for staff to provide the treatments after the resident was medicated for pain. A quarterly assessment, dated 08/09/12, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident required extensive assistance with bed mobility and transfers. The assessment documented the resident experienced pain occasionally. The assessment documented the resident had one Stage III and one Stage IV pressure ulcer. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No additional pain medication was ordered. A wound clinic note, dated 09/06/12, documented the resident had a Stage III, 3.2 x 1.8 cm x 1.7 x 1.5 pressure ulcer on her coccyx and a Stage IV, 3 x 2.2 cm x 0.2 pressure ulcer on her heel. On 09/11/12 at 7:10 p.m., the resident was observed in bed holding on to a side rail. The DON stated he thought the resident positioned herself in that manner to assist with relieving the pressure off of her pressure ulcers on her heel and coccyx. On 09/11/12 at 7:20 p.m., LPN #1 was observed to adjust the resident's ankle boot and the resident yelled out with pain. LPN #1 stated the resident yelled out with pain frequently. On 09/11/12 at 7:30 p.m., the director of nurses (DON) was interviewed regarding the resident's pain medication. The DON stated the resident was on [MEDICATION NAME] 50 milligram as needed and the [MEDICATION NAME] was increased to 100 milligram as needed. The DON stated he heard the resident yell out with pain earlier in the evening. The DON stated he did not think the [MEDICATION NAME] was sufficient for the type of pain the resident was having. The DON stated the last pain assessment was in May (2012). The DON stated the resident was on [MEDICATION NAME] for pain but the order got lost somewhere in July. On 09/11/12 at 8:15 p.m., LPN #2 was interviewed regarding the resident's pain. LPN #2 stated the resident had pain with pressure ulcer on her coccyx but she was in a lot of pain with the pressure ulcer on her heel. LPN #2 stated with any care or interventions the resident complained with pain. On 09/11/12 at 8:25 p.m., the resident was observed in her bed with a grimaced appearance on her face. The resident was interviewed regarding her pain. The resident stated she hurt all the time. On 09/12/12 at 10:05 a.m., the resident was observed receiving personal care. CNA #3 and CNA #4 cleaned the resident's right arm and abdominal area and the resident screamed out with pain. The resident screamed "Oh, Oh" when CNA #3 and CNA #4 assisted the resident with a clean brief. CNA #4 asked the resident if she was in pain. The resident answered, "Definitely I am." 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 08/31/12, documented the resident's cognition was intact and the resident had a diabetic ulcer. A physician's orders [REDACTED]. Below 200 no insulin, 200-294 = 2 units, 250-299 = 4 units, 300-350 = 6 units, over 350 = 8 units. The care plan, dated 09/04/12, documented to monitor blood sugars three times daily as ordered and as needed for signs or symptoms of hypo/[MEDICAL CONDITION]. The resident's glucose monitoring/insulin form documented the resident's finger stick blood sugars (FSBS) were over 400 eleven times and over 500 four times from 08/22/12 to 09/12/12. The resident's FSBS was rechecked in 2 to 3 hours for the FSBS over 500 and a new physician's orders [REDACTED]. There was no documentation of rechecking the resident's FSBS or of notifying the physician for the eleven FSBS over 400. On 09/12/12 at 1:47 p.m., the resident was observed being provided wound care by facility staff. On 09/12/12 at 4:00 p.m., licensed practical nurse (LPN) #3 was interviewed regarding notification of the physician for FSBS over 400. LPN #3 reported having faxed the physician regarding the resident's FSBS twice. The LPN reported having sent the resident's FSBS information to the physician an hour ago. The LPN reported the facility usually called the physician if a FSBS was over 400. The LPN stated on a couple of residents "We pushed it back to over 500." The LPN reported the resident was not one of those residents. On 09/13/12 at 4:30 p.m., the director of nursing (DON) was interviewed regarding notification of the physician for FSBS over 400. The DON reported the facility usually called the physician if a FSBS was over 400. The DON reported there was no documentation of reporting the BS over 400 to the physician. The DON reported the facility had been trying to get in contact with the physician about the resident's FSBS. The DON reported they could now notify the nurse practitioner. The DON reported the facility used to have to keep trying and trying to report to the physician. On 09/14/12 at 10:35 a.m., the administrator was interviewed regarding notification of the physician for FSBS over 400. The administrator reported the facility should have contacted the physician for those high blood sugars. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order documented if the finger stick blood sugar result (FSBS) was greater than 400 the facility was to administer 12 units of [MEDICATION NAME] R insulin then recheck the FSBS in two hours. The order documented if the FSBS was still greater than 400 the facility was to call the doctor. The care plan, dated 06/20/12, documented the resident was a diabetic and at risk for complications. The annual assessment, dated 06/21/12, documented the resident had short and long term memory problems. The assessment documented the resident was severely impaired with decision making abilities. An injection sheet, dated 08/01/12, documented a fingerstick blood sugar result of 420 on 08/26/12 and a fingerstick blood sugar result of 447 on 08/28/12. There was no documentation a second FSBS was obtained per the physician's orders [REDACTED]. On 09/12/12 at 10:20 a.m., the resident was observed during incontinent care. On 09/13/12 at 2:45 p.m., the assistant director of nurses (ADON) was interviewed regarding the orders for a second FSBS to be obtained two hours after the abnormal FSBS results above 400. The ADON reviewed the injection sheets and reported she did not see documentation a second FSBS result had been obtained on 08/26/12 and 08/28/12.

Based on observations, interviews, and record reviews, it was determined the facility failed to assist with meals and to provide supplements to prevent weight loss for two dependent residents (#1 and #4) of five sampled residents who had experienced a severe/significant weight loss. The facility identified five residents with an unplanned significant weight loss. The facility census and condition identified 30 residents that required assistance with meals. Findings: The facility policy on weight documented the charge nurse and physician would be notified of all weight changes of five pounds or 5% or more in a thirty day period or ten percent in a 180 day period per state requirements. The policy documented the staff would assist with feeding and observe the amount of assistance needed by the resident. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The snack and supplement record dated, July 2011, documented the resident refused a snack eight times and the facility was "out" of snacks one time for the morning snack. The July snack and supplement record documented the resident was not offered a snack for the afternoon snack. The record was blank for any snacks or supplements offered. The July snack and supplement record documented the resident accepted a snack one time during the month for the evening snack. No other snacks or supplements were documented for the evening snack. A quarterly assessment, dated 08/26/11, documented the resident required extensive assistance with all activities of daily living tasks. The assessment documented the resident required extensive assistance with his meals. The assessment documented the resident was moderately impaired in cognition and had short and long term memory problems. The care plan, dated 08/31/11, documented the staff were to sit with the resident and assist with feeding and direct observation. The care plan documented the resident liked a second serving of food at times and the staff were to offer a second serving of food. The snack and supplement record dated, August 2011, was blank for any snacks offered in the morning. The August snack and supplement record documented the resident was not offered any snacks in the afternoon. The record was blank for any snacks or supplements offered. The August snack and supplement record documented the resident refused a snack one time during the month for the evening snack. No other snacks or supplements were documented as being offered for the evening snack. The snack and supplement record dated, September 2011, documented the resident received a snack one time during the month. No additional documentation was available the resident was offered any snacks. A dietary progress note, dated 09/28/11, documented the resident had a significant weight loss of 7.65% in three months. On 10/12/11 at 4:30 p.m., the resident was observed sitting in a wheelchair in the dining room. An unidentified CNA was feeding the resident. The resident consumed all of his food on his plate. No additional food or fluid was offered. On 10/13/11 at 4:30 p.m., the resident was observed in the dining room sitting in a wheelchair. CNA #2 was observed sitting to the left of the resident. An unidentified resident was sitting on the other side of CNA #2. CNA #2 was observed feeding both of the residents. CNA #2 did not face the resident while feeding him. CNA #2 would turn her wrist over and feed the resident to the right of her without facing him. No conversation or interaction was observed during the meal. The resident drank his fluid immediately. The resident was observed eating all of the food on his plate. CNA #2 was observed to scrape the sides of the resident's plate. An unidentified certified medication aide (CMA) walked into the dining room and asked the resident if he was ready to go to his room. The resident did not answer. The resident was transferred out of the dining room. The resident was not offered any additional food or drink. On 10/14/11 at 10:55 a.m., the director of nurses was interviewed regarding who was responsible for offering additional food or fluids for the residents in the dining room. The director of nurses stated there was a charge nurse during every meal in the dining room and she should be making sure that all residents received the ordered diet or additional food if needed. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The meal percentage and fluid intake sheets, dated July 2011, documented the resident consumed less than 50% of meals 11 times for the month. Three blanks were noted on the record. The record documented there were no snacks or supplements offered for the month of July. A dietary progress note, dated 08/03/11, documented the resident weighed 144 pounds and was on a liberal diet. The note documented the resident ate 75-100% of meals and came to the dining room. The meal percentage and fluid intake sheets, dated August 2011, documented the resident consumed less than 50% of meals 13 times for the month. Seven blanks were noted on the record. The record documented there were no snacks or supplements offered for the month of August. The meal percentage and fluid intake sheets, dated September 2011, documented the resident consumed less than 50% of meals 27 times during the month. Five blanks were noted on the record. The record documented there were no snacks or supplements offered for the month of September. A dietary progress note, dated 09/28/11, documented the resident's weight was 128.6 and had a 19.4 pound weight loss in 1 month. The report documented the recommendations of a multivitamin, vitamin C, and zinc. A significant change assessment, dated 09/29/11, documented the resident was severely impaired with cognitive skills. The assessment documented the resident required extensive assistance of staff for all activities of daily living. The assessment documented the resident required total assistance with meals. A care plan, dated 10/10/11, documented the resident needed assistance from the staff with meals. The care plan documented the resident's appetite was fair to poor. The care plan documented the resident had lost weight and was at high risk for [MEDICAL CONDITION]. Approaches documented to offer the resident something different to eat if less than 75% of the meal was consumed. The meal percentage and fluid intake sheets, dated October 2011, documented the resident consumed less than 50 % of meals 10 times for the month. Ten blanks were noted on the record. The record documented there were no snacks or supplements offered for the month of October. On 10/13/11 at 12:30 p.m., an interview was conducted with the director of nursing (DON) regarding the resident's weight loss. The DON stated the resident had declined in one months time. The resident had gone from knowing who the DON was to not knowing the DON at all. The DON stated the resident had lost weight and was now on hospice. The DON stated the resident had just recently required assistance with meals. On 10/13/11 at 3:30 p.m., an interview was conducted with the MDS ( minimum data set) coordinator regarding the interventions put in place when it was discovered the resident had a weight loss. The MDS coordinator stated the facility spoke to the family and physician regarding hospice. When asked about any further documentation since 09/22/11, the MDS coordinator stated, "There isn't any." On 10/14/11 at 4:00 p.m., the resident was observed in a high back wheelchair in the dayroom. On 10/14/11 at 4:35 p.m., the resident was observed transferred to the dining room by a staff member. On 10/14/11 at 4:50 p.m., the resident was observed being fed a meal of Salisbury steak, mashed potatoes and gravy, peas, and chocolate ice cream by CNA #3. Less than 25% of the meal was observed to be eaten by the resident. On 10/14/11 at 5:30 p.m., the resident was observed lying in her bed. A white container was observed on the nightstand with a spoon on top of the container. On 10/14/11 at 5:35 p.m., CNA #1 was asked to check the container on the night stand. The container was observed with Salisbury steak, mashed potatoes, gravy, peas, and chocolate ice cream. CNA #1 was asked if the resident received a supplement. CNA #1 stated she would find out. On 10/14/11 at 5:37 p.m., CNA #1 returned to the resident's room. CNA #1 reported the dietary manager stated the resident did not have a supplement ordered. CNA #1 stated the dietary manager provided a mighty shake and some pudding for the resident. On 10/14/11 at 5:40 p.m., LPN #2 was asked if the resident received a supplement. LPN #2 stated, "No." The LPN was interviewed regarding the white Styrofoam container of food in the resident's room. LPN #2 stated, "I put her food together and took it to her room." LPN #2 stated the staff would try to feed the resident later. On 10/14/11 at 6:05 p.m., the white container of food, mighty shake, and pudding were observed on resident's night stand. The Styrofoam carton of food on the resident's bedside table was the food the resident had not eaten on her dinner tray. On 10/14/11 the resident's weight was documented as 123.8.

Based on observation, record review, and interview, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to ensure resident safety and prevent accidents. The facility failed to ensure supervision was provided: a. during transfers which resulted in falls with an injury for one (#10) of eight residents who were sampled for falls. Resident #10 experienced an acute moderately displaced fracture of the proximal shaft of the humerus. The resident had surgery to repair the fracture. The facility identified 27 residents who were dependent with transfers. b. during bathing in a shower chair which resulted in a fall for one (#9) of two residents sampled for bathing. The facility identified 24 residents who required a shower chair and assistance with bathing. Findings: A facility policy on bath or showers documented equipment needed included a shower chair and a strap to secure the resident if the resident was not independent. The policy documented the staff were to place the resident in the shower chair and strap the resident securely in the chair, if the resident was not independent to prevent falls. A facility policy on the use of the mechanical lift documented the purpose was to ensure a safe and effective method for transferring residents. The policy documented the certified nurse aides (CNAs) were to follow the limited lift policy at all times. The facility's limited lift policy documented the director of nursing (DON) or an appointed nursing staff member would perform an initial screening on all residents to assess transfer and ambulating status. The policy documented the resident transfer status would be tagged at the foot of the bed to inform the staff of the appropriate transfer and fall risk. The policy documented this policy was to be followed at all times. 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive initial assessment, dated 07/09/11, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident required extensive assistance from the staff for all activities of daily living. The assessment documented the resident had not experienced any previous falls. A care plan, dated 07/19/11, documented the resident required the assistance of two people for all ADLs. The care plan documented the resident was a bilateral amputee and required two staff and a lift when transferring. An incident report, dated 10/10/11 at 8:05 p.m., documented CNA #5 and #6 transferred the resident. The incident report documented CNA #5 got her feet tangled in the wheelchair of the resident. The incident report documented CNA #5 fell down and hit her back on the trash can. The incident report documented an uneven distribution of weight was placed on the resident's left shoulder during the fall. The report documented there was no apparent injury noted to the resident after the fall. On 10/11/11 at 10:00 a.m., the resident was observed in bed. The resident reported, "The aides dropped me last night." The resident reported CNA #5 and #6 were transferring her from her wheelchair to her bed. The resident reported she fell and hit her left shoulder. The resident reported her left shoulder was hurting and she was supposed to get an x-ray. The resident was asked if she was able to get out of bed. The resident reported she was not able to walk. On 10/11/11 at 11:20 a.m., the resident was transferred to a local hospital by ambulance for evaluation. A final report submitted to the Oklahoma State Department of Health by the facility for the resident's incident on 10/10/11 documented an x-ray identified an acute moderately displaced fracture of the proximal shaft of the humerus. The report documented the resident had surgery on her left humerus on 10/12/11. A hospital diagnostic imaging report, completed 10/11/11, documented, "...New oblique fracture proximal shaft left humerus..." On 10/11/11 at 3:40 p.m., CNA #6 was interviewed regarding the incident involving the resident. CNA #6 reported she and CNA #5 were changing the resident. CNA #6 stated they grabbed the resident under her arms and by the waistband. CNA #6 reported CNA #5 tripped and fell during the transfer. CNA #6 stated the resident fell on top of CNA #5. CNA #6 stated the resident landed on her left side on top of CNA #5. CNA #6 stated they got the resident up without getting the nurse. CNA #6 stated they lifted the resident under the arms and back of her pants and placed her in the bed. CNA #6 reported the resident stated "If you touch my left shoulder it hurts." CNA #6 reported they didn't use the lift to transfer the resident. CNA #6 reported she had been trained on how to use a lift. CNA #6 reported a lift should have been used on any resident that could not stand on their own. CNA #6 reported she should have used the lift. CNA #6 stated the resident didn't have legs. On 10/11/11 at 6:00 p.m., an interview was conducted with the DON regarding the incident involving the transfer of the resident related to her plan of care. The DON reported the CNAs were not to move any resident after a fall. The DON reported the CNAs had always been told if a resident could not bear weight a lift must be used. The DON reported she would have a meeting with the staff and re-educate the staff on notifying the charge nurse first to ensure there were no injuries before moving the resident. The DON reported any resident with a fall or injury should be documented on every shift for 72 hours. On 10/11/11 at 6:55 p.m., an interview was conducted with CNA #5 regarding the incident involving the transfer of the resident. CNA #5 reported a lift was not used. CNA #5 reported the resident was lifted by her clothes and under each arm. CNA #5 reported she fell back over onto the trash can. CNA #5 reported the resident fell on her left side and on the chest of CNA #5. CNA #5 reported she and CNA #6 eased the resident on the floor. CNA #5 reported she and CNA #6 lifted the resident by her clothes and under each arm onto the electric scooter. CNA #5 reported she was not aware that the resident was to be transferred with a mechanical lift. CNA #5 stated they transferred the resident to a manual wheelchair later that evening and transferred the resident to her bed. CNA #5 stated they transferred the resident under her arms and by the waist band of her clothes during the transfers. The CNA reported the additional transfers were done after the fall earlier in the evening. On 10/11/10 at 7:20 p.m., an interview was conducted with LPN #3 regarding the incident involving the resident. LPN #3 was asked how the resident was transferred back to the bed. LPN #3 reported she didn't know how they got the resident back to bed. LPN #3 reported they were told to use a lift and two people to transfer the resident. On 10/12/11 at 10:10 a.m., the resident's bed was observed. On the end of the bed was a card documenting that a lift and two staff persons were required for all transfers. 2. Resident #9 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's record reviewed was a closed record. The care plan, dated 05/06/11, documented the resident was unable to do daily activities of living without extensive to total staff assistance with bed mobility, transfers, incontinent care, and bathing. A quarterly assessment, dated 07/28/11, documented the resident had short-term memory problems and modified independence in cognitive skills for daily decision making. The assessment documented the resident required two-plus persons physical assist with bed mobility, transfers, bathing, and toilet use. An incident report, dated 09/02/11 at 8:15 p.m., documented licensed practical nurse (LPN) #1 was called to the shower room and found the resident lying in a right lateral position in the shower room floor. A nurse's note, dated 09/02/11 at 8:30 p.m., documented the LPN was called to the shower room where the resident was lying in a right lateral position on the shower room floor. A witness statement, dated 09/02/11 at 5:20 p.m., documented certified nurse aide (CNA) #4 was giving the resident a shower and the resident had a bowel movement (BM) in the shower chair. The statement documented the resident scooted out of the shower chair and landed on his right side (hip). A counseling form, dated 09/03/11, documented CNA #4 was counseled concerning giving a chair or bed bound resident a shower without strapping the resident into the shower chair. The counseling form documented the CNA was informed she was putting the resident at risk for falls and injury without using a safety belt. The employee comment on the counseling form documented, "I now know what to do (the proper way) when bathing a bed patient, always make sure they are safely strapped (buckled) in chair to prevent accidents of any kind." A facility inservice, dated 09/23/11, documented the staff were educated on making sure residents were strapped in shower chairs for whirlpools or showers if the residents were not independent. On 10/12/11 at 4:30 p.m., the DON was interviewed concerning the resident's fall. The DON reported the CNA was instructed to take one of the belts out of a bathing chair and put it around the resident while giving a shower in the future. On 10/13/11 at 5:35 p.m., LPN #2 was interviewed concerning the resident's fall. LPN #2 reported she worked the floor the day following the fall. LPN #2 reported she did a written and verbal counseling with CNA #4 about using a safety belt in the shower. On 10/14/11 at 11:40 a.m., physician #1 was interviewed concerning the resident falling from the shower chair. The physician reported he was told by the facility the resident was having a shower, the resident voided his bowels and scooted out of the shower chair. The physician reported he was told the CNA was with the resident when the accident occurred. The physician reported there was no substantial injury to the resident when the accident occurred.