Every finding on record at Brookside Nursing Center

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the refrigerator was labeled and dated per the facility policy. This deficient practice had the potential to affect all 46 residents who currently resided in the facility.Findings included: A facility policy titled, Food Storage, revised 06/01/2019, revealed Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. During an observation of the stand-alone refrigerator in the kitchen on 06/09/2026 at 9:24 AM, the surveyor noted there were two clear, opened plastic bags that contained sausage links with no label or discard date; one clear, opened bag with four breaded chicken strips with no label or discard date; and one clear, opened bag of tater tots with no label or discard date. During an interview on 06/09/2026 at 9:25 AM, the Dietary Manager (DM) stated all food items in the refrigerator should be labeled and dated. The DM stated the sausage links, chicken strips and tater tots should have been labeled with an opened date and discard date. During an interview on 06/10/2026 at 9:05 AM, the Administrator stated all 46 residents who resided in the facility received their meals from the kitchen. During an interview on 06/10/2026 at 11:35 AM, the Registered Dietician stated all opened food items should be stored in a sealed container with label to identify its opened date. During an interview on 06/10/2026 at 11:51 AM, the Administrator stated she expected all food items to be stored, labeled and marked when the item package was opened. The Administrator stated the sausage links, chicken strips, and tater tots should have been labeled with opened date per the facility food storage policy. During an interview on 06/11/2026 at 1:00 PM, the Director of Nursing stated the expectation was for all stored food to be labeled and dated appropriately.

On 04/10/25 at 11:40 a.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to update Resident #1's care plan related to sexually inappropriate behaviors. Resident #1 was observed to place their hand under Resident #2's shirt and rub the resident's breast area. Resident #1 had a history of a similar incident involving another resident of the opposite sex. Resident #1 was sent to a behavioral health hospital after the first and second incident with no updated interventions to the resident's care plan to prevent recurrence. On 04/10/25 at 12:03 p.m., the administrator and DON were notified of the immediate jeopardy and provided the immediate jeopardy template. On 04/11/25 at 9:04 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan Of Removal 4/10/2025: 1. Care plan has been updated to include behavior and interventions to prevent reoccurrence and will be revised upon residents return from hospitalization . 2. All residents could be affected 3. MDS Nurse to be in-serviced regarding updated resident care plans to match resident preferences, behaviors of sexual nature, and interventions that are put in place for behaviors. 4. Audit conducted on all residents to determine sexual behaviors identified. Care plans immediately updated to match resident preferences, behaviors of sexual nature, and interventions that are put in place for behaviors. 5. Date of compliance: 4/10/2025 at 2000pm On 04/11/25 after interviews with facility staff, review of in-services, and resident sexual behavior audits, the immediacy was lifted, effective 04/10/25 at 8:00 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 update a resident's care plan following sexually inappropriate behavior for 1 (#1) of 1 sampled residents reviewed for care plans. Resident #1 had a known history of sexually inappropriate behaviors. Resident #1 was observed to place their hand under Resident #2's shirt and rub the resident's breast area. The care plan did not document interventions to prevent recurrence. The administrator reported one resident with a history of sexually inappropriate behaviors. Findings: An OSDH Incident Report Form, dated 04/05/25, showed CNA #1 witnessed Resident #1 with a resident of the opposite sex in the facility dining room, where Resident #1 was observed to place their hand under the resident's shirt and rub their breast area. The form showed an investigation was conducted and video documentation was reviewed. The video showed Resident #1 rubbing the other resident's back and then putting their hand down the front of their shirt. The report showed the administrator interviewed Resident #1 and the resident initially denied the incident. The report showed when informed of the video documentation, the resident stated, Well [they] like it. A Resident to Resident Altercations policy, dated September 2022, read in part, Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents .Behaviors that may provoke a reaction by residents or others include .sexually aggressive behavior .inappropriate touching/grabbing .make any changes in the care plan approaches to any or all of the involved individuals .document in the resident's clinical record all interventions and their effectiveness. A care plan for Resident #1, with a problem start date of 05/18/21, showed the resident had behaviors of being sexually inappropriate. The care plan showed a resident to resident incident on 05/29/24. The care plan showed a resident to resident incident on 04/07/25. The care plan showed no interventions following either incident to prevent further behaviors. A progress note for Resident #1, dated 05/29/24 at 12:38 p.m., showed it was reported to the nurse Resident #1 was touching a resident of the opposite sex inappropriately in the dining room. A progress note for Resident #1, dated 05/29/24 at 2:15 p.m., showed the resident would be admitted to a hospital behavioral health unit. A physician order for Resident #1, dated 06/12/24, showed to give medroxyprogesterone (a hormone medication) 2.5 mg, 3 tablets to equal 7.5 mg daily, for sexual dysfunction not due to a substance or known physiological condition. The order showed the medication was discontinued on 12/04/24. A progress note for Resident #1, dated 06/22/24 at 1:39 p.m., showed the resident was observed exiting the dining room when they stopped and started tickling the feet of a resident of the opposite sex. The note showed the other resident asked multiple times for Resident #1 to stop and Resident #1 had to be redirected away from the resident. An MDS assessment for Resident #1, dated 02/18/25, showed a brief interview for mental status score of 9, which indicated the resident was moderately impaired with cognitive function. The assessment showed the resident required substantial to maximal assistance with most activities of daily living. A progress note for Resident #1, dated 04/05/25 at 7:32 p.m., showed CNA #1 witnessed the resident place their hand under the shirt of a resident of the opposite sex and rub their breast area. A progress note for Resident #1, dated 04/06/25 at 10:44 a.m., showed the resident was observed to wheel self to an unidentified resident of the opposite sex. The note showed staff removed Resident #1 from the other resident before Resident #1 could touch them. A care plan for Resident #1, dated 04/07/25, showed diagnoses which included history of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, chronic obstructive pulmonary disease, bipolar disorder, anxiety, sexual dysfunction, unspecified psychosis, and depression. On 04/10/25 at 8:40 a.m., LPN #2 reported they did not know of any resident they needed to watch for sexual behaviors. LPN #2 reported they did not witness the incident between Resident #1 and the resident of the opposite sex, but had noticed Resident #1 showing the resident more attention, touching their hair, bringing them coffee, and sitting close in the dining room. LPN #2 reported they did not think the behaviors were anything to be concerned about. On 04/10/25 at 10:00 a.m., the DON was asked what interventions were implemented to protect residents before Resident #1 was sent out. The DON reported staff watched Resident #1 closely when they were out of their room following the incident. The DON was asked if there was any documentation to show this monitoring. The DON provided a form, with no name or date, and reported it showed one on one monitoring. The form showed every one hour checks from 8:00 p.m. until 10:00 a.m., but did not document one on one monitoring. The DON then wrote Resident #1's name on the form and the date of the incident (04/05/25). On 04/10/25 at 10:10 a.m., the DON provided an updated care plan for Resident #1, revised during the survey, which showed the resident to resident incident. The care plan showed the residents were separated immediately and an investigation initiated. The care plan showed a psychiatric referral was obtained. The care plan showed no interventions to prevent recurrence of sexually inappropriate behaviors. The DON was asked if there were interventions in place for when Resident #1 returned to the facility. The DON stated, Obviously we'll need to do something to make sure it doesn't happen again.

On 04/10/25 at 11:40 a.m., the Oklahoma State Department of Health was notified and verified the existence of an immediate jeopardy situation related to the facility's failure to protect a resident from sexual abuse from another resident with a known history of sexually inappropriate behaviors. Resident #1 was observed to place their hand under Resident #2's shirt and rub the resident's breast area. On 04/10/25 at 12:03 p.m., the administrator and DON were notified of the immediate jeopardy and provided the immediate jeopardy template. On 04/11/25 at 9:04 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, Plan Of Removal 4/10/2025: 1. Facility staff observed the incident reported. Staff intervened and stopped the incident from occurring and made sure resident #2 was safe. Staff separated residents and reported incident to charge nurse immediately. On 4/5/2025, the administrator sent referral to [hospital name withheld] for acceptance due to incident. Resident #1 was observed by staff when out of his room. Resident #1 left with family on 4/6/2025 at 10:58 a.m. to admit to [hospital name withheld] in Ardmore, OK [Oklahoma] due to incident. 2. All residents could be affected. Resident did attempt to contact another resident on 4/6/2025 and staff intervened. 3. All staff to be in-serviced regarding facility abuse policy and reporting 4. Complete audit on all residents to determine sexual behaviors identified. Safe surveys were completed on 4/7/2025 and no further allegations were made. Facility staff utilize target behavior monitoring daily on all residents. 5. Date of compliance: 4/10/2025 at 2000pm On 04/11/25 after interviews with facility staff, review of in-services, and resident sexual behavior audits, the immediacy was lifted, effective 04/10/25 at 8:00 p.m. The deficient practice remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to prevent resident to resident sexual abuse between 2 (#1 and #2) of 2 sampled residents reviewed for sexual abuse. Resident #1 had a known history of sexually inappropriate behaviors. Resident #1 was observed to place their hand under Resident #2's shirt and rub the resident's breast area. The administrator reported one resident with a history of sexually inappropriate behaviors. Findings: An OSDH Incident Report Form, dated 04/05/25, showed CNA #1 witnessed Resident #1 and Resident #2 in the facility dining room, where Resident #1 was observed to place their hand under Resident #2's shirt and rub their breast area. The form showed an investigation was conducted and video documentation was reviewed. The video showed Resident #1 rubbing Resident #2's back and then putting their hand down the front of Resident #2's shirt. The report showed the administrator interviewed Resident #1 and the resident initially denied the incident. The report showed when informed of the video documentation, Resident #1 stated, Well [they] like it. The report showed when the administrator interviewed Resident #2, the resident stated Resident #1 was rubbing their back and breast area and it made them feel uncomfortable. An Abuse Prevention Program policy, dated December 2016, read in part, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents. 1. A care plan for Resident #1, with a problem start date of 05/18/21, showed the resident had behaviors of being sexually inappropriate. The care plan showed a resident to resident incident on 05/29/24. The care plan showed a resident to resident incident on 04/07/25. The care plan showed no interventions following either incident to prevent further behaviors. A progress note for Resident #1, dated 05/29/24 at 12:38 p.m., showed it was reported to the nurse Resident #1 was touching a resident of the opposite sex inappropriately in the dining room. A progress note for Resident #1, dated 05/29/24 at 2:15 p.m., showed the resident would be admitted to a hospital behavioral health unit. A physician order for Resident #1, dated 06/12/24, showed to give medroxyprogesterone (a hormone medication) 2.5 mg, 3 tablets to equal 7.5 mg daily, for sexual dysfunction not due to a substance or known physiological condition. The order showed the medication was discontinued on 12/04/24. A progress note for Resident #1, dated 06/22/24 at 1:39 p.m., showed the resident was observed exiting the dining room when they stopped and started tickling the feet of a resident of the opposite sex. The note showed the resident asked multiple times for Resident #1 to stop and the resident had to be redirected away from the other resident. A MDS assessment for Resident #1, dated 02/18/25, showed a brief interview for mental status score of 9, which indicated the resident was moderately impaired with cognitive function. The assessment showed the resident required substantial to maximal assistance with most activities of daily living. A progress note for Resident #1, dated 04/05/25 at 7:32 p.m., showed CNA #1 witnessed the resident place their hand under Resident #2's shirt and rub their breast area. A progress note for Resident #1, dated 04/06/25 at 10:44 a.m., showed the resident was observed to wheel self to an unidentified resident of the opposite sex. The note showed staff removed Resident #1 from the other resident before Resident #1 could touch them. A care plan for Resident #1, dated 04/07/25, showed diagnoses which included history of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, chronic obstructive pulmonary disease, bipolar disorder, anxiety, sexual dysfunction, unspecified psychosis, and depression. 2. A MDS assessment for Resident #2, dated 02/17/25, showed the resident had a memory problem and was severely impaired with cognitive skills for daily decision making. The assessment showed the resident was dependent on staff for assistance with activities of daily living. A progress note, dated 04/05/25 at 7:27 p.m., showed CNA #1 witnessed Resident #1 place their hand under Resident #2's shirt and rub their breast area. The note showed a skin assessment was completed and no visible signs of injury were noted. A care plan for Resident #2, dated 04/07/25, showed a resident to resident incident. The care plan showed psychiatric referrals were made and a trauma informed care observation completed. The care plan showed Resident #2 had diagnoses which included dementia, atrial fibrillation, pseudobulbar affect, depression, insomnia, and muscle weakness. A progress note, dated 04/08/25 at 12:11 p.m., showed a new order for Resident #2, Nuedexta (a central nervous system agent), one tablet by mouth daily for impulsive crying, and Melatonin (an acetamide) 10 mg one by mouth at bedtime as needed for insomnia. On 04/09/25 at 2:15 p.m., CNA #1 reported Resident #1 initially started bringing Resident #2 coffee and sitting near them. CNA #1 reported they had seen Resident #1 touch Resident #2's hair, but had not witnessed anything inappropriate until they saw Resident #1 with their hand inside Resident #2's shirt. CNA #1 reported they separated the residents immediately and told Resident #1 it was not appropriate to touch Resident #2 like that. CNA #1 reported Resident #1 stated, [They] like it. CNA #1 reported Resident #2 did not say anything at the time the incident happened. On 04/09/25 at 3:00 p.m., LPN #1 reported they had noticed Resident #1 sitting closer to Resident #2, bringing them coffee, but had not witnessed anything inappropriate. LPN #1 reported they would occasionally have Resident #1 move a little further away from Resident #2 if they were getting too close. On 04/09/25 at 5:03 p.m., Resident #2's family member was interviewed by phone. They reported the facility had notified them when the incident happened with Resident #1. The family member reported they asked facility staff how their loved one responded, if they swatted the resident's hand or slapped at the other resident, because that was how they would have responded in the past. The family member reported staff stated they thought the resident was shocked by the incident and did not do anything. On 04/10/25 at 8:35 a.m., this surveyor attempted to interview Resident #2 in their room. The resident did not acknowledge any incident and was only able to answer simple yes or no questions. On 04/10/25 at 8:40 a.m., LPN #2 reported they did not know of any resident they needed to watch for sexual behaviors. LPN #2 reported they did not witness the incident between Resident #1 and Resident #2, but had noticed Resident #1 showing Resident #2 more attention, touching their hair, bringing them coffee, and sitting close in the dining room. LPN #2 reported they did not think the behaviors were anything to be concerned about. On 04/10/25 at 10:00 a.m., the DON was asked what interventions were implemented to protect Resident #2 and other residents before Resident #1 was sent out. The DON reported staff watched Resident #1 closely when they were out of their room following the incident with Resident #2. The DON was asked if there was any documentation to show this monitoring. The DON provided a form, with no name or date, and reported it showed one on one monitoring. The form showed every one hour checks from 8:00 p.m. until 10:00 a.m. The DON then wrote Resident #1's name on the form and the date of the incident (04/05/25). The DON was asked if there were interventions in place for when Resident #1 returned to the facility. The DON stated, Obviously we'll need to do something to make sure it doesn't happen again.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a level II PASARR evaluation for two (#12 and #18) of three sampled residents reviewed for PASRR's. The Administrator reported 56 residents resided in the facility. Findings: 1. Resident #12 was admitted to the facility on [DATE]. Resident #12 had diagnoses which included recurrent major depressive disorder, date diagnosed [DATE], and schizoaffective disorder date diagnosed [DATE]. The Level I PASRR screen, dated 07/21/11, documented no mental illness. On 08/13/24 at 4:03 p.m., the MDS coordinator reported the Level I PASRR screen should have been reassessed and submitted to OHCA when resident #12 was diagnosed with a new mental illness diagnoses of recurrent major depressive disorder and the schizoaffective disorder. 2. Resident #18 was admitted to the facility on [DATE]. Resident #18 had diagnoses which included bi-polar disorder, date diagnosed [DATE], anxiety disorder, date diagnosed [DATE], and schizoaffective disorder, date diagnosed [DATE]. The Level I PASRR screen, dated 10/22/19, documented no mental illness. On 08/13/24 at 4:03 p.m., the MDS coordinator reported resident #18's Level I PASRR screen should have documented the bi-polar disorder and schizoaffective disorder. The MDS coordinator reported the Level I PASRR was filled out correctly. On 08/13/24 at 4:11 p.m., RN#2 reported the facility had no PASRR policy.

Based on observation, record review, and interview, the facility failed to develop and implement fall interventions to include supervision to decrease or lessen the risk for injury for one (#40) of four sampled residents reviewed for falls. The facility failed to ensure fall interventions were implemented after three of six documented falls. The last fall resulted in a fractured right humerus. The Resident Census and Conditions of Residents form, dated 07/25/23, documented 53 residents resided in the facility. Findings: The Assessing Falls and Their Causes policy, revision date March 2018, read in part, . Performing a Post-Fall Evaluation .After a fall, a nurse will complete the Post-Fall Evaluation to determine the root cause of fall .An intervention to prevent re-occurrence of the fall will be implemented immediately and documented on the Incident Report .The Incident Report and Post-Fall Evaluation will be reviewed by the IDT the following business day to determine root cause and review the intervention .The intervention to prevent reoccurrence will be placed on the care plan . The Falls Prevention Program not dated, read in parts, .FALLING STAR - symbol will be placed on a. door name tag (small Star), b. CNA assignment sheet or pocket care plan (Star symbol), c. Wheelchair/walker if applicable (Large Star) .All employees in all departments will be in-serviced on the fall prevention program. The employees are expected to recognize the star symbol and understand what they are to do when seeing a star symbol on a door name tag, CNA assignment sheet or on a resident's wheelchair or walker . The care plan, dated 08/22/22, for Resident #40, read in part, .Resident is at risk for falls AEB: weakness, unsteadiness and extensive assistance required for transfers R/T neuropathy, incontinence, and dementia .Long Term Goal Target Date: 09/06/2023 .Resident will be free of falls and injury through next review . The care plan, dated 08/22/22, read in part, .Approach [Interventions], for the following falls: a. 11/17/22 - fall with no injuries - resident encouraged to call for help when needing to get up. verbal reminders will be given frequently. b. 12/28/22 - fall with no injury - keep chair lift unplugged unless staff is in room to assist resident up out of chair. c. 06/16/23 - fall- fracture R humerus-move resident to room closer to nurse's station . The facility's care plan related to the falls that had occurred on 01/05/23, 02/20/23, and 05/31/23 were not listed on the plan of care and the facility did not implement fall interventions to prevent or decrease the risk for falls or injury. The fall dated 06/16/23 was documented in the care plan as no injury and was updated on 08/01/23 on the day of survey to a fracture of the right humerus. An event report, dated 01/05/23, documented CNA reported that resident was lying on the floor in her room. Resident stated they were trying to transfer from the bed to chair and slipped landing on the floor. No injuries documented. No intervention was documented to prevent recurrence and no care plan update. An event report, dated 02/20/23, documented CNA came to get this nurse and inform of resident fall with head injury. Upon entering room this nurse observed resident wrapped up in blankets laying on right side next to bed on floor. Assessment completed and noticed an extremely large knot forming at right eyebrow and eye area. There was no intervention added to prevent recurrence and no plan of care update. An event report, dated 05/31/23, documented, resident sitting upright on the floor with their back against the bed. The report documented the resident stated, Getting out of the recliner to go to bed, my leg gave out, so I sat down. No injuries noted. There was no intervention added to prevent recurrence and no care plan update. The facility submitted event reports dated for 11/17/22, 12/28/22, 01/05/23, 02/20/23, 05/31/23, and 06/16/23 for Resident #40. An OSDH Final Incident Report Form, dated 06/16/23, read in part, .resident informed staff she was trying to go to bed from recliner, Resident is unable to transfer on her own and doesn't always remember this and forgets to use call light. Resident has been moved closer to nurses' station and has a bed alarm and chair alarm in place to monitor when she is attempting to get up. Right arm has been placed in sling and to f/u with ortho . A quarterly assessment dated [DATE], for Resident #40, documented the resident's cognition was severely impaired, required extensive assistance with ADL's, and no falls. A Radiology Test Information dated 06/16/23, for Resident #40, read in part, .Right Shoulder .Indication: Injury with right shoulder pain .Findings: There is an impacted fracture of the right proximal humeral neck . A Fall Risk assessment, dated 06/23/23, for Resident #40, read in part, .Total Fall Risk Score 21.0, Level: High Fall Risk, >13 total points=High Fall Risk . A significant change assessment, dated 06/29/23, for Resident #40, documented the resident had a fall in the last month prior to admission/entry or reentry and had a fall in the last 2-6 months prior to admission/entry or reentry. The assessment documented the resident had a fracture related to falls in the 6 months prior to admission/entry or reentry. The assessment documented the resident did not have an alarm. The assessment documented the resident's cognition was severely impaired, required extensive assistance with ADL's. Resident #40 had diagnoses which included hypertension, non-Alzheimer's dementia, anxiety, and depression. On 08/01/23 at 02:02 p.m., no bed or chair alarm was observed in Resident #40's room. Resident #40 was asked if their lift chair worked. They were able to activate the chair up and down. The lift chair was not unplugged and there was no staff in the room as outlined as one of the interventions for a fall that had occurred on 12/28/22. On 08/01/23 at 02:05 p.m., CMA #2 was asked if Resident #40 had a bed/chair alarm. They stated the resident did not have a bed or chair alarm and did not know of them having one. On 08/01/23 at 02:10 p.m., LPN #2 was asked if Resident #40 had a bed/chair alarm. They stated, No. They were asked if they ever had a bed/chair alarm. They stated maybe last year. They were asked if resident #40 was moved closer to the nurse's station. They stated after their fall they were moved closer to the nurse's station. On 08/01/23 at 02:25 p.m., the assessment coordinator was asked about the significant change assessment, dated 06/29/23. They were asked about the section related to falls. They stated it documented a fall history in the last month and in the last 2-6 months. They were asked about a chair/bed alarm section on the assessment. They stated just a wheelchair was documented. They stated, I don't have an alarm for the resident. On 08/01/23 at 02:49 p.m., LPN #2 was asked if Resident #40's lift chair was functional. They stated, Yes, is it plugged in? They used the remote to lift Resident #40's legs in the chair. They stated it was care planned for the chair to be unplugged, but they have new staff, so they will need to in-service them. On 08/01/23 at 4:33 p.m., the regional LPN was asked about the post fall evaluations completed after Resident #40's falls on 11/17/22, 12/28/22, 01/06/23, 02/20/23, 05/31/23, and 06/16/23. They agreed nothing was added to the plan of care for the falls on 01/06/23, 02/20/23, and 05/31/23. They were asked if Resident #40 had a bed/chair alarm as documented on the State reportable for the fall that occurred on 06/16/23. They stated, No, she did not. On 08/02/23 at 08:51 a.m., LPN #1 and LPN #2 were asked if the facility had indicators on the door to alert staff of a resident with high risk for falls. They stated they did not know of a fall program like that at this facility. LPN #1 stated they were aware of others places they had worked that had leaves on the door to indicate a resident at risk for falls. CNA #9 reported she had been back to work for about a week and was not aware of indicators on the resident doors to indicate they were at risk for falls.

Based on record review and interview the facility failed to obtain routine laboratory values per physician orders for two (#13 and #26) of five sampled residents reviewed for laboratory results. The Resident Census and Conditions of Residents, dated 07/25/23, documented 53 residents residing in the facility. Findings: A facility policy and procedure, Obtaining Blood Specimens ., read in part .A physician order is required to obtain blood samples .Documentation .laboratory results and notification of physician of results .notify .of any problems or inability to get blood samples. 1. Resident #13 was admitted with diagnoses which included chronic obstructive pulmonary disease, heart failure, and DM. A physician order, dated 10/04/22, documented to obtain labs once a day on the 12th of every 3rd month for ammonia level, CBC, and CMP. The resident's clinical record documented lab results received on 03/30/23. No other labs had been obtained for June and no results were documented. On 07/31/23 at 2:48 p.m., the corporate V.P. of clinicals nurse reported the labs ordered for June had not been obtained. 2. Resident #26 was admitted with diagnoses which included congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease. A physician order, dated 02/17/23, documented labs to be drawn once a day on the 1st Thursday of January, April, August, and November, draw CBC, CMP, hemoglobin A1c, lipid profile and liver profile. A laboratory form, dated 4/11/23, documented the resident refused the lab draw and handwritten at the top of the form, T.O. try to get at night as he is not a morning person, 04/11/23. On 07/31/23 at 4:14 p.m., the RN survey consultant, reported the labs were refused in April, the physician was notified and a T.O. to try obtaining labs at night as the resident was not a morning person. She reported no documentation of another attempt was made and no labs since that time.

Based on record review and interview, the facility failed to ensure discharge planning was completed information for one (#203) of two sampled residents whose discharge records were reviewed. The Resident Census and Conditions of Residents form, dated 07/25/23, documented 53 residents resided in the facility. Findings: The facility's Discharge Summary and Plan policy, dated December 2016, read in part, 1.a discharge summary and a post-discharge plan will be developed . 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented . Res #203's quarterly assessment, dated 03/29/22, documented the resident's cognition was intact, and he was independent with his ADL's. His diagnoses included heart failure and DM. A physician order, dated 06/23/22, read in part, dc to home with medication and personal belongings. A nurse note, dated 06/23/22 at 3:29 p.m., read in part, Resident discharging, per orders from Dr. Medication and instructions given and explained, leaving facility due to failure to pay at his request, clothing and all items belonging to him taken with him . A nurse note, dated 06/23/22 at 6:34 p.m., read in part, Resident discharged of his own accord, resident gave [address withheld] for d/c. informed us that it was his home. resident left voluntarily, packed himself, given medications and instruction on how to take them. Resident driven to address that he stated was his home via facility van. Facility received calls that the residence was not his and that we needed to get him. APS notified. The clinical record contained no documentation of a discharge summary or a post-discharge plan, and no documentation of the residents medication reconciliation. On 08/02/23, at 10:25 a.m., the corporate nurse reported she could not find a discharge summary, a post-discharge plan, or a medication reconciliation in the residents record.

Based on observation, record review, and interview, the facility failed to individualize and implement fall interventions in the plan of care for one (#40) of one sampled resident reviewed for care plans. The Resident Census and Conditions of Residents form, dated 07/25/23, documented 53 residents resided in the facility. Findings: The Assessing Falls and Their Causes policy, revision date March 2018, read in part, .The Incident Report and Post-Fall Evaluation will be reviewed by the IDT the following business day to determine root cause and review the intervention . The intervention to prevent reoccurrence will be placed on the care plan . The Care Plan dated 08/22/22, for Resident #40, read in part, .Resident is at risk for falls AEB: weakness, unsteadiness and extensive assistance required for transfers R/T neuropathy, incontinence, and dementia .Long Term Goal Target Date: 09/06/2023 .Resident will be free of falls and injury through next review . The care plan, dated 08/22/22, read in part, .Approach [Interventions], for the following falls: a. 11/17/22 - fall with no injuries - resident encouraged to call for help when needing to get up. verbal reminders will be given frequently. b. 12/28/22 - fall with no injury - keep chair lift unplugged unless staff is in room to assist resident up out of chair. c. 06/16/23 - fall- fracture R humerus-move resident to room closer to nurse's station . The facility's care plan related to the falls that had occurred on 01/05/23, 02/20/23, and 05/31/23 were not listed on the plan of care and the facility did not implement fall interventions to prevent or decrease the risk for falls or injury. The fall dated 06/16/23 was documented in the care plan as no injury and was updated on 08/01/23 on the day of survey to a fracture of the right humerus. The facility submitted event reports dated for 11/17/22, 12/28/22, 01/05/23, 02/20/23, 05/31/23, and 06/16/23 for Resident #40. An OSDH Final Incident Report Form dated 06/16/23, read in part, .resident informed staff she was trying to go to bed from recliner, Resident is unable to transfer on her own and doesn't always remember this and forgets to use call light. Resident has been moved closer to nurses' station and has a bed alarm and chair alarm in place to monitor when she is attempting to get up. Right arm has been placed in sling and to f/u with ortho . A Radiology Test Information' dated 06/16/23, for Resident #40, read in part, .Right Shoulder .Indication: Injury with right shoulder pain .Findings: There is an impacted fracture of the right proximal humeral neck . A significant change assessment, dated 06/29/23, for Resident #40, read in part, .Section J, Health Conditions: Did the resident have a fall in the last month prior to admission/entry or reentry? Yes. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? Yes. Did the resident have any fracture related to falls in the 6 months prior to admission/entry or reentry? Yes .Section P, Restraints and Alarms .bed alarm and chair alarm: No . On 08/01/23 at 02:02 p.m., no bed or chair alarm was observed in Resident #40's room. Resident #40 was asked if their lift chair worked. They were able to activate the chair up and down. There was no staff in the room as outlined as one of the interventions for a fall that had occurred on 12/28/22. On 08/01/23 at 02:05 p.m., CMA #2 was asked if Resident #40 had a bed/chair alarm. They reported the resident did not have a bed or chair alarm and did not know of them having one. On 08/01/23 at 02:10 p.m., LPN #2 was asked if Resident #40 had a bed/chair alarm. They stated, No. They were asked if they ever had a bed/chair alarm. They stated maybe last year. They were asked if resident #40 was moved closer to the nurse's station. They stated after their fall they were moved closer to the nurse's station. On 08/01/23 at 02:25 p.m., the assessment coordinator was asked about the significant change assessment dated [DATE]. They were asked about the section related to falls. They stated it documented a fall history in the last month and in the last 2-6 months. They were asked about a chair/bed alarm section on the assessment. They stated just a wheelchair was documented. They stated, I don't have an alarm for the resident. On 08/01/23 at 02:49 p.m., LPN #2 was asked if Resident #40's lift chair was functional. They stated, Yes, is it plugged in? They used the remote to lift Resident #40's legs in the chair. They stated it was care planned for the chair to be unplugged, but they have new staff, so they will need to in-service them.

Based on observation, interview, and record review, it was determined the facility failed to ensure a comprehensive care plan was in place for one (#51) of five residents who were reviewed for antipsychotic medication. The facility reported 18 residents received antipsychotic medication. Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A pharmacy recommendation, dated 04/21/21, documented the resident received [MEDICATION(S)] 0.5 mg twice daily for behavioral and psychological symptoms of dementia. The recommendation documented for the physician to consider a dose reduction to [MEDICATION(S)] 0.25 mg twice daily if appropriate. The recommendation documented the physician disagreed and had a rationale the resident was stable. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 07/03/21, documented the resident's cognition was moderately impaired. The assessment documented the resident received an antipsychotic medication for seven days of the look-back period. The assessment documented the resident had a gradual dose reduction attempted on 06/16/21. The care plan contained no documentation of antipsychotic medication. On 07/21/21 at 11:00 a.m., the Minimum Data Set coordinator confirmed [MEDICATION(S)] should have been care planned.

Based on observation, interview, and record review, it was determined the facility failed to notify a resident representative when a change of condition occurred for one (#28) of 30 residents reviewed. The facility reported 55 residents lived in the facility. Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses's noted, dated 01/20/21 12:32 AM, documented the resident was found lying on the floor mat beside the bed on her back. The note documented no apparent injuries. The note contained no documentation the resident's representative had been notified of the fall. A nurse's note, dated 01/29/21 01:23 PM, documented the resident was moved to room [ROOM NUMBER] b. The note contained no documentation the resident's representative had been notified of the room change. A quarterly assessment, dated 06/02/21, documented the resident was moderately impaired with cognition, exhibited no depression and wandered four to six days of the look back period. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident was always incontinent of bowel and bladder. A nurse's note, dated 06/26/21 03:00 AM, documented the resident had a boil to area just above the mons pubis. The note documented for this nurse to inform the oncoming shift to contact her physician later this morning. The note documented the area was red with purulent exudate. The note contained no documentation the resident's representative had been notified. A nurse's note, dated 06/27/21 02:24 AM, documented the resident had a boil to area just above the mons pubis discovered on 6/26/21 and reported to the oncoming shift so they could contact her physician. The note documented the area was red with purulent exudate. The note documented no note was in the chart since this nurse reported to oncoming shift, and it was unknown if the physician was contacted. The note contained no documentation the resident's representative had been notified. On 07/19/21 02:33 PM, the resident's representative reported the resident's legs were observed to be discolored due to circulation. The resident's representative reported the facility had not notified her of the discoloration to the resident's lower extremities. The resident's representative reported she had not been notified of multiple room changes. On 07/20/21 03:31 PM, the resident was observed lying in bed on her back with her eyes closed. On 07/22/21 10:30 AM, the director of nurses (DON) reported resident representative notification should be documented in the clinical record. The DON reported if the family had been notified of changes the staff should have documented in the clinical record when they were notified.

Based on observation, interview, and record review, it was determined the facility failed to update a care plan when a resident had a change in condition for one (#32) of 30 residents reviewed. The facility reported 55 residents lived in the facility. Findings: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/11/21, documented the resident was cognitively intact, exhibited no depression, and required limited assistance with activities of daily living (ADLs). A five day comprehensive assessment, dated 07/01/21, documented the resident was cognitively intact and required limited assistance with ADL's. The assessment documented the resident had no impairments with upper or lower extremities. A nurse's note, dated 06/21/21 06:15 PM, documented the aide reported the resident was not acting right. The note documented the resident was leaning to the right side and the right arm was flaccid and speech was slurred. The note documented the resident's face was lax on the right side. The note documented the physician was notified and the resident was sent to the local emergency room . A hospital [name deleted] history and physical assessment, dated 06/21/21, documented the resident had a stroke/[CONDITION(S)]. An updated care plan, dated 06/21/21, contained no documentation regarding the resident's change in condition related to the stroke. On 07/20/21 03:34 PM, the resident was observed sitting up in her wheelchair in the lobby watching tv. The resident's right arm was observed flaccid lying across her abdomen. On 07/21/21 08:21 AM, the resident was observed eating breakfast using her left hand. On 07/21/21 10:44 AM, certified nurse aide (CNA) #1 reported the resident required assistance with incontinent care and showers. The CNA reported she was unsure where to find information regarding care to provide to the residents. On 07/21/21 10:49 AM, CNA #2 reported since the resident had a stroke she needed assistance with almost everything, The CNA reported she was unsure where to find information regarding care to provide to the residents. On 07/21/21 10:52 AM licensed practical nurse (LPN) #1 reported the resident required total assistance. The LPN reported the resident utilized her left hand to eat. The LPN reported the resident was receiving skilled therapy since the stroke. The LPN reported CNAs could find assistance on ADLs in the electronic record. The LPN reported the CNA's should know where to find ADL assistance information. On 07/22/21 10:26 AM, the director of nurses reported the assessment completed on 07/01/21 was inaccurate with ADL's and the care plan should have been updated.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free of unnecessary [CONDITION(S)] medications for two (#9 and #51) of five residents reviewed for unnecessary medications. The facility reported 18 residents received antipsychotic medications. Findings: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses which included metabolic [CONDITION(S)], other recurrent depressive disorders, unspecified mood [affective] disorder, and anxiety disorder. A quarterly assessment, dated 05/05/21, documented the resident was moderately impaired with cognition. The assessment documented the resident never felt tired or had little energy. The assessment documented the resident required supervision or was independent with activities of daily living. The assessment documented the resident had received an antipsychotic for seven days of the look-back period. A physician's order, dated 06/15/21, documented [MEDICATION(S)] 0.25 mg 1 tablet twice a day for unspecified mood [affective] disorder. The order documented a change from [MEDICATION(S)] 0.25 mg 1 tablet three times a day for unspecified mood [affective] disorder. On 07/19/21 01:50 PM, the resident was observed lying in bed with her eyes closed. On 07/20/21 08:44 AM, the resident was observed lying in bed, facing the wall. On 07/20/21 01:26 PM, the resident was observed lying in bed with her eyes closed. On 07/21/21 08:46 AM, the resident was observed lying in bed, eyes closed, and facing the wall. On 07/21/21 09:00 AM, LPN #2 reported the resident was independent with most ADLs. The LPN reported the resident did not come out of her room often, and spent most of her time in bed. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses which included heart failure, Alzheimer's late onset, major depressive disorder, single episode, unspecified, and generalized anxiety disorder. A pharmacy recommendation, dated 04/21/21, documented the resident received [MEDICATION(S)] 0.5 mg twice daily for behavioral and psychological symptoms of dementia. The recommendation documented for the physician to consider a dose reduction to [MEDICATION(S)] 0.25 mg twice daily if appropriate. The recommendation documented the physician disagreed, with the rationale the resident was stable. A physician's order, dated 06/15/21, documented [MEDICATION(S)] tablet, 0.25 mg, 1 tablet by mouth twice a day at 06:00 a.m., and 11:00 a.m. for major depressive disorder, single episode, unspecified. A quarterly assessment, dated 07/03/21, documented the resident's cognition was moderately impaired. The assessment documented the resident received an antipsychotic medication for seven days of the look-back period. The assessment documented the resident had a gradual dose reduction attempted on 06/16/21. On 07/19/21 09:51 AM, the resident was observed lying in bed with his eyes closed. On 07/20/21 08:47 AM, the resident was observed lying in bed with eyes closed. On 07/20/21 01:28 PM, the resident was observed lying in bed. On 07/21/21 08:48 AM, the resident was observed lying in bed with his eyes closed. On 07/22/21 08:44 AM, the resident was observed lying in bed with his eyes closed. On 07/22/21 10:31 AM, the DON and ADON reported major depressive disorder was not an appropriate clinical indication for the use of an antipsychotic medication. The DON and ADON reported unspecified mood disorder was not an appropriate clinical indication for the use of an antipsychotic medication.

Based on observation, interview, and record review, it was determined the facility failed to ensure sanitary conditions were followed during meal preparation. The administrator reported 57 residents received their meals from the kitchen. Findings: A facility cell phone policy, documented, .Using a cell phone for personal use is prohibited in public areas and common areas of the facility and in residents' rooms. Cell phones are to be kept on silent or vibrate. Ear buds and/or headphones may not be used for cell phones or any personal device . On 07/19/21 at 12:01 p.m., during lunch preparation, dietary aide (DA) #1 was observed reaching in her pocket to retrieve her cell phone to answer a call. The DA continued to prepare meal trays without performing any type of hand hygiene. On 07/19/21 at 12:11 p.m., during lunch preparation, DA #1 was observed to answer her cell phone. The DA continued to prepare trays without performing any type of hand hygiene. On 07/19/21 at 12:16 p.m., during lunch preparation, DA #1 was observed to answer her cell phone. The DA continued to prepare trays without performing any type of hand hygiene. On 07/20/21 at 11:57 a.m., during a follow up visit to the kitchen, DA #1 was observed preparing lunch trays. The DA stopped to retrieve her cell phone from her pocket and answered a call. The DA continued to prepare lunch trays without changing gloves or performing proper hand hygiene. On 07/20/21, the dietary manager (DM) reported cell phones should never be used in the kitchen. The DM reported they have a facility cell phone policy. The DM reported proper hand hygiene was expected at all times.

Based on observation, interview, and record review, it was determined the facility failed to accurately complete a comprehensive assessment for one (#32) 30 residents reviewed. The facility reported 55 residents lived in the facility. Findings: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/11/21, documented the resident was cognitively intact, exhibited no depression, and required limited assistance with activities of daily living (ADLs). A five day comprehensive assessment, dated 07/01/21, documented the resident was cognitively intact and required limited assistance with ADL's. The assessment documented the resident had no impairments with upper or lower extremities. A nurse's note, dated 06/21/21 06:15 PM, documented the aide reported the resident was not acting right. The note documented the resident was leaning to the right side and the right arm was flaccid and speech was slurred. The note documented the resident's face was lax on the right side. The note documented the physician was notified and the resident was sent to the local emergency room . A hospital [name deleted] history and physical assessment, dated 06/21/21, documented the resident had a stroke/[CONDITION(S)]. An updated care plan, dated 06/21/21, contained no documentation regarding the resident's change of condition related to the stroke. On 07/20/21 03:34 PM, the resident was observed sitting up in her wheelchair in the lobby watching tv. The resident's right arm was observed flaccid lying across her abdomen. On 07/21/21 08:21 AM, the resident was observed eating breakfast using her left hand. On 07/21/21 10:44 AM, certified nurse aide (CNA) #1 reported the resident required assistance with incontinent care and showers. The CNA reported she was unsure where to find information regarding care to provide to the residents. On 07/21/21 10:49 AM, CNA #2 reported since the resident had a stroke she needed assistance with almost everything, The CNA reported she was unsure where to find information regarding care to provide to the residents. On 07/21/21 10:52 AM licensed practical nurse (LPN) #1 reported the resident required total assistance. The LPN reported the resident utilized her left hand to eat. The LPN reported the resident was receiving skilled therapy since her stroke. The LPN reported CNAs could find assistance on ADLs in the electronic record. The LPN reported the CNA's should know where to find ADL assistance information. On 07/22/21 10:26 AM, the director of nurses reported the assessment completed on 07/01/21 was inaccurate with ADL's and the care plan should have been updated.

Based on observation, interview, and record review, it was determined the facility failed to ensure a comprehensive assessment was accurate, to include bed rails, for one (#29) of 25 residents reviewed. The facility reported 52 residents lived in the facility. Findings: Resident #29 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An annual assessment, dated 12/11/19, documented the resident was moderately impaired with cognition and was totally dependent with activities of daily living. The assessment contained no document regarding the use of bed rails. The resident was observed to have full bed rails throughout the survey. On 01/29/20 at 1:53 p.m., three staff members reported the resident had full bed rails for several years due to a history of [MEDICAL CONDITION]. On 01/29/20 at 2:07 p.m., the director of nurses reported the full bed rails should have been included on the annual assessment.

Based on observation, interview, and record review, it was determined the facility failed to ensure comprehensive care plans were complete and accurate for three (#29, 32 and #40) of 25 residents reviewed. The facility reported 52 residents lived in the facility. Findings: 1. Resident #29 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A care plan, dated 11/20/19, contained no documentation regarding the use of bed rails or history of [MEDICAL CONDITION]. An annual assessment, dated 12/11/19, documented the resident was moderately impaired with cognition and was totally dependent with activities of daily living. The assessment contained no document regarding the use of bed rails. The resident was observed to have full bed rails throughout the survey. On 01/29/20 at 1:53 p.m., three staff members reported the resident had full bed rails for several years due to a history of [MEDICAL CONDITION]. On 01/29/20 at 2:07 p.m., the director of nurses reported the full bed rails should have been included on the annual assessment and the care plan. 2. Resident #40 was admitted to the facility on [DATE]. A care plan, updated on 10/03/19, contained no documentation regarding the use of an indwelling urinary catheter. A quarterly assessment, dated 12/27/19, documented the resident was cognitively intact. The assessment contained no documentation regarding the use of an indwelling urinary catheter. The resident was observed throughout the survey with an indwelling urinary catheter. On 01/27/20 at 3:09 p.m., the resident reported she was unsure why she had an indwelling urinary catheter. On 01/29/20 at 3:53 p.m., the director of nurses (DON) reported the resident had the indwelling urinary catheter since she was admitted to hospice services. The DON reported the use of the indwelling urinary catheter should have been addressed on the resident's care plan. 3. Resident #32 was admitted to the facility on [DATE]. A care plan, dated 12/06/19, documented two problem areas of communication and visual function. The comprehensive care plan was incomplete. An admission assessment, dated 12/13/19, documented the resident was moderately impaired with cognition and exhibited no depression or behaviors. The assessment documented the resident required limited assistance with dressing and hygiene. The assessment documented the resident utilized a walker when ambulating. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident received insulin injections for seven of the seven day look back period. The care area assessment summary documented the areas of cognitive loss, visual function, communication, activities of daily living, urinary incontinence, falls, nutritional status, fluid maintenance, dental care, and pressure ulcer would be addressed on the care plan. On 01/28/20 at 3:23 p.m., the resident was observed utilizing a rolling walker to ambulate. On 01/29/20 at 5:21 p.m., the director of nurses reported the care plan should have been completed with all of the areas addressed on the assessment.

Based on observation, interview, and record review, it was determined the facility failed to prevent the use of unnecessary medications an anticoagulant for one (#2) of five residents reviewed for unnecessary medications. The facility reported three residents required an anticoagulant medication. Findings: Resident #2 was admitted to the facility on [DATE]. An admission assessment, dated 10/14/19, documented the resident was cognitively intact. The assessment documented the resident received an anticoagulant for seven days of the look back period. A care plan, dated 10/18/19, documented the resident was at risk for bleeding related to [MEDICATION NAME] therapy. The care plan documented a goal was for the resident's [MEDICATION NAME] time/international normalized ratio (PT/INR) to be within normal limits. The care plan documented for the staff to administer [MEDICATION NAME] as ordered, monitor PT/INR as ordered and to monitor the resident for signs and symptoms of bleeding. A laboratory report, dated 11/01/19 and 11/04/19, documented the PT/INR to be within normal range. A physician's orders [REDACTED]. A laboratory report, dated 11/12/19, documented the PT/INR to be elevated. The laboratory report had not been noted nor did the report document the physician had been notified. A laboratory report, dated 11/19/19, documented the PT/INR to be elevated. The laboratory report had not been noted by the nurse. A physician's orders [REDACTED]. A nurse's note, dated 11/19/19 at 1:40 p.m., documented the PT/INR was elevated, physician notified, and [MEDICATION NAME] decreased. The note documented for the staff to redraw the PT/INR on 11/26/19. A laboratory report, dated 11/26/19, documented the PT/INR to be elevated. The report had been noted and faxed to the physician. A pharmacy consult report, dated 01/21/20, documented the resident remains on [MEDICATION NAME] and there were no INR results for (MONTH) or (MONTH) for review. The report documented to ensure INR was drawn monthly. A laboratory report, dated 01/28/20, documented the PT/INR to be elevated. A nurse's note, dated 01/28/20 at 8:42 p.m., documented the physician had been notified regarding the elevated PT/INR and awaiting orders. The clinical record contained no laboratory values for a PT/INR from 11/26/19 until 01/28/20 while the resident remained on [MEDICATION NAME] (anticoagulant). On 01/28/20 at 2:50 p.m., the resident was observed sitting up on the side of her bed. The resident reported she was unaware of her current medications. On 01/29/20 at 5:00 p.m., the director of nurses reported the PT/INR should have been completed more frequently to ensure the resident received the adequate dose of [MEDICATION NAME].

Based on observation and interview, it was determined the facility failed to ensure infection prevention and control measures were utilized when cleaning a glucometer between two (#32 and #37) of two residents reviewed. The facility reported 12 residents utilized a glucometer. Findings: On 01/28/20 at 4:30 p.m., licensed practical nurse (LPN) #2 was observed to provide a finger stick blood sugar to resident #37. The LPN cleaned the glucometer with an alcohol pad. On 01/28/20 at 4:35 p.m., LPN #2 was observed to provide a finger stick blood sugar to resident #32. The same glucometer was used as above. The LPN cleaned the glucometer with an alcohol pad. The LPN reported the glucometer was shared between residents. The LPN reported she was unsure what the policy was but she had always used alcohol pads to clean the glucometer. On 01/29/20 at 5:00 p.m., the director of nurses reported the staff should clean the glucometer with micro kill bleach wipes.

Based on observation, interview, and record review, it was determined the facility failed to ensure a baseline care plan was completed to provide person centered care for one (#32) of one resident reviewed. The facility reported one new admission in the past 30 days. Findings: Resident #32 was admitted to the facility on [DATE]. A baseline care plan, dated 12/06/19, contained no initial goals, physician orders, or dietary orders. A care plan, dated 12/06/19, documented two problem areas of communication and visual function. The comprehensive care plan was incomplete. An admission assessment, dated 12/13/19, documented the resident was moderately impaired with cognition and exhibited no depression or behaviors. The assessment documented the resident required limited assistance with dressing and hygiene. The assessment documented the resident utilized a walker when ambulating. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident received insulin injections for seven of the seven day look back period. The care area assessment summary documented the areas of cognitive loss, visual function, communication, activities of daily living, urinary incontinence, falls, nutritional status, fluid maintenance, dental care, and pressure ulcer would be addressed on the care plan. On 01/28/20 at 3:23 p.m., the resident was observed utilizing a rolling walker to ambulate. On 01/29/20 at 5:21 p.m., the director of nurses reported the baseline care plan should have been accurately completed.

Based on observation, interview, and record review, it was determined the facility failed to provide care and services as ordered by the physician for one (#32) of two residents reviewed with pressure ulcers. The facility reported two residents had a pressure ulcer. Findings: Resident #32 was admitted to the facility on [DATE]. A care plan, dated 12/06/19, documented two problem areas of communication and visual function. The care plan contained no documentation regarding interventions to prevent pressure ulcer or diabetes mellitus. An admission assessment, dated 12/13/19, documented the resident was moderately impaired with cognition and exhibited no depression or behaviors. The assessment documented the resident required limited assistance with dressing and hygiene. The assessment documented the resident utilized a walker when ambulating. The assessment documented the resident was occasionally incontinent of bowel and bladder. The assessment documented the resident was at risk for developing a pressure ulcer. The assessment documented the resident received insulin injections for seven of the seven day look back period. The care area assessment summary documented the areas of cognitive loss, visual function, communication, activities of daily living, urinary incontinence, falls, nutritional status, fluid maintenance, dental care, and pressure ulcer would be addressed on the care plan. A nurse's note, dated 01/17/20 at 5:46 p.m., documented the resident had an open area 0.4 x 0.5 centimeters (cm) to left inner pinky toe. The physician was notified and orders were received to cleanse wound with normal saline, apply [MEDICATION NAME] daily for seven days and refer to wound care physician. A physician's orders [REDACTED]. A nurse's note, dated 01/20/20 at 8:57 a.m., documented the wound physician observed the wound to the resident's toe. The wound measured 0.5 x 0.3 cm. The note documented to continue current treatment as toe had shown signs of improvement. An initial wound evaluation and management summary, dated 01/20/20, documented for the staff to treat the wound with Mupriocin and apply a non-sterile gauze sponge daily for 30 days. Treatment sheets, dated 01/24/20 through 01/26/20, contained no documentation the wound had been treated as ordered. A nurse's note, dated 01/27/20 at 3:01 p.m., documented the wound care physician observed the resident's wound. The note documented the wound measured 0.3 x 0.3 x 0.1 cm. A wound evaluation and management summary, dated 01/27/20, documented for the staff to treat the wound with Mupriocin and apply a non-sterile gauze sponge daily for 23 days. On 01/28/20 at 3:16 p.m., certified medication aide (CMA) removed the resident's sock. The resident was observed to have a band aid on the left foot 5th digit. The band aid had dry crusty areas to the lower part of the band aid. The band aid had no date or time. The resident stated, They get to it when they can. The resident reported the staff did not change the dressing daily. The resident reported the staff change the dressing when they think it needs to be changed. On 01/29/20 at 5:21 p.m., the director of nurses reported the wound care orders should have been followed as written. The DON reported the staff should have received a clarification of the order.

On 09/20/17 at 4:15 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to notify the physician and family when a resident had a fall with a major injury. The resident experienced a fracture to the left femoral neck. The facility had identified the problem regarding the lack of physician and family notification for the fall on 09/07/17. The facility had conducted in-services for their staff on 09/08/17 regarding change of condition reporting. Interviews were conducted with licensed staff members to verify their knowledge of reporting a change of condition to verify the in-services had been conducted as documented. On 09/20/17 at 4:37 p.m., the OSDH verified an immediate jeopardy situation had existed related to the facility's failure to provide notification to the physician and family when a resident had a change in condition. The OSDH verified a past non-compliance situation had occurred in which the facility had identified and put corrective actions in place. On 09/20/17 at 4:44 p.m., the ADM, the DON, and the nurse consultant were notified of the IJ situation at past non-compliance. The ADM, DON, and the nurse consultant verbalized understanding. Based on observation, record review, and interview, it was determined the facility failed to provide notification and/or consult with the resident's physician and/or family for one (#3) of four residents reviewed for physician and family notification. The facility failed to notify the physician and family of a fall with major injury for resident #3. Resident #3 experienced a fall which resulted in a fracture to the left femoral neck. The ADM reported 66 residents lived in the facility. Findings: A policy titled Assessing Falls and Their Causes, dated (MONTH) 2010, documented, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .1. a. If a resident has just fallen .nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. b. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. c. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. d. Nursing staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone .e. Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record. f. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 07/03/16, documented the resident was at risk for falls as a problem. A quarterly assessment, dated 09/01/17, documented the resident was severely impaired with cognition, required extensive assistance of two or more staff for transfers and bed mobility. The assessment documented the resident required extensive assistance of one staff member for dressing, eating, hygiene and bathing. The assessment documented the resident was always incontinent of bladder and frequently incontinent of bowel. An updated care plan, dated 09/01/17, documented the resident was at risk for falls as a problem. A goal was for the resident to be free from injury with any falls. Approaches listed were for the staff to assist with transfers, observe for any unsafe actions and intervene, ensure bed and chair alarm were in place, and a hi-lo bed. A physician's orders [REDACTED]. A nurse's note, dated 09/08/17, documented, Report to SN from 10-6 SN of resident falling with injury to L (left) forearm-skin tear to outer elbow measuring 3.5 x 2.8 x 0.1 cm. Skin tear cleaned with NSS (normal saline solution) steri strips place and transparent dressing over; Bruise to inner LFA (left forearm) measuring 13 x 7 cm. Tenderness to L torso with ROM (range of motion) no visible injury. Mobile X-ray of LFA, L ribs, & L hip ordered. (Name deleted) hospice notified and calls placed to wife with no answer. Will cont (continue) to monitor. (Name deleted) physician notified. A nurse's note, dated 09/08/17 at 10:30 a.m., documented x-rays and UA (urinalysis) obtained. An incident report, dated 09/08/17, documented, .Occurrence date 9-7-17 time 1930/2000 (7:30 p.m.-8:00 p.m.) app (approximately) .witnessed fall .mobility alarm sounding .mobility chair .fall history .Narrative of occurrence and description of injuries: Fall with injury to (Lt) (left) FA (forearm) ST (skin tear) outer elbow; with bruise inner LFA, Tenderness (Lt) torso no visible injury. Xray LFA, (Lt) ribs (Lt) hip. Resident stood up in hallway of B wing grabbed hall rail and stood up and fell .Immediate Action Taken to minimize reoccurrence: 2-10 and 10-6 Nurses suspended. 15 min checks . .Immediate Actions Taken .First aid given by ADON date 09/08/17 time 0650 (6:50 a.m.) .Type of aid: Tx (treatment) ST; Xray ordered . The clinical record contained no documentation the resident had been assessed, monitored, or had interventions initiated from the time of the fall on 09/07/17 at approximately 7:30 p.m. until 09/08/17 at approximately 6:00 a.m. The clinical record contained no documentation the physician and/or family had been notified of the fall with a major injury. An X-ray report, dated 09/08/17, documented the resident had a subcapital [MEDICAL CONDITION] femoral neck (hip). A state reportable incident report, dated 09/08/17, documented the investigation regarding the residents fall had been completed and two nurses (RN #1 and LPN #1) had been terminated and reported to the Oklahoma Board of Nursing. An administrative investigation checklist and summary, dated 09/13/17, documented, .Family notified of occurrence: No .Physician notified of occurrence: No .Conclusion: Both 2-10 and 10-6 nurses were neglectful of their duties and responsibility of resident. On 09/20/17 at 9:50 a.m., another resident's unidentified family member reported the staff had not called to notify of a fall at the time of occurrence. The family member reported the staff waited to report to him/her upon arrival to the facility the next day. On 09/20/17 at 10:00 a.m., an unidentified family member reported the staff had not notified the family of the resident's fall until the next day when a family member arrived to visit. On 09/20/17 at 12:45 p.m., the resident was observed lying in bed with his eyes closed and a family member at his bedside. On 09/20/17 at 1:45 p.m., CMA #1 was questioned regarding the resident's fall. The CMA reported she did not see the resident fall. The CMA reported a licensed nurse had asked her to assist in getting the resident up out of the floor. The CMA was asked how the resident was assisted in getting up. The CMA reported a gait belt was utilized in standing the resident to assist back to his wheelchair. The CMA reported the resident looked like he was in pain and she had reported to the charge nurse. On 09/20/17 at 2:10 p.m., the DON was questioned regarding the resident's fall. The DON was asked if the physician or family had been notified regarding the resident's fall with major injury. The DON stated, No. The DON was asked if both the physician and family should have been notified. The DON stated, Yes. The DON reported she had identified the problem when the staff had not assessed, monitored, and intervened. The DON reported she had put interventions in place when she became aware of the situation. The DON reported the facility had implemented a plan of correction and was monitoring for quality assurance purposes.

On 09/20/17 at 4:15 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to identify and intervene when a resident had a fall with a major injury. The resident experienced a fracture to the left femoral neck. The facility had identified the problem regarding the resident's fall not being assessed, monitored, or intervened on 09/07/17. The facility had conducted in-services for their staff on 09/08/17; and had implemented a system for assessing, monitoring, and intervening in the event of an incident or accident. Interviews were conducted with licensed staff members to verify their knowledge of the monitoring system for assessing, monitoring, and intervening to verify the in-services had been conducted as documented. On 09/20/17 at 4:37 p.m., the OSDH verified an immediate jeopardy situation had existed related to the facility's failure to assess, monitor, and intervene when a resident had a fall with a major injury. The OSDH verified a past non-compliance situation had occurred in which the facility had identified and put corrective actions in place. On 09/20/17 at 4:44 p.m., the ADM, the DON, and the nurse consultant were notified of the IJ situation at past non-compliance. The ADM, DON, and the nurse consultant verbalized understanding. Based on observation, record review, and interview, it was determined the facility failed to provide necessary care and services to ensure the highest level of well-being for one (#3) of four residents reviewed for falls. The facility failed to assess, monitor, and/or intervene after a fall for resident #3. Resident #3 experienced a fracture to the left femoral neck. The ADM reported 66 residents lived in the facility. Findings: A policy titled Assessing Falls and Their Causes, dated (MONTH) 2010, documented, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .1. a. If a resident has just fallen .nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. b. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. c. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. d. Nursing staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone .e. Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record. f. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 07/03/16, documented the resident was at risk for falls as a problem. A quarterly assessment, dated 09/01/17, documented the resident was severely impaired with cognition, required extensive assistance of two or more staff for transfers and bed mobility. The assessment documented the resident required extensive assistance of one staff member for dressing, eating, hygiene, and bathing. The assessment documented the resident was always incontinent of bladder and frequently incontinent of bowel. An updated care plan, dated 09/01/17, documented the resident was at risk for falls as a problem. A goal was for the resident to be free from injury with any falls. Approaches listed were for the staff to assist with transfers, observe for any unsafe actions and intervene, ensure bed and chair alarm were in place, and a hi-lo bed. A physician's orders [REDACTED]. A nurse's note, dated 09/08/17, documented, Report to SN from 10-6 SN of resident falling with injury to L (left) forearm-skin tear to outer elbow measuring 3.5 x 2.8 x 0.1 cm. Skin tear cleaned with NSS (normal saline solution) steri strips place and transparent dressing over; Bruise to inner LFA (left forearm) measuring 13 x 7 cm. Tenderness to L torso with ROM (range of motion) no visible injury. Mobile X-ray of LFA, L ribs, & L hip ordered. (Name deleted) hospice notified and calls place to wife with no answer. Will cont (continue) to monitor. (Name deleted) physician notified. A nurse's note, dated 09/08/17 at 10:30 a.m., documented x-rays and UA (urinalysis) obtained. An incident report, dated 09/08/17, documented, .Occurrence date 9-7-17 time 1930/2000 (7:30 p.m.-8:00 p.m.) app (approximately) .witnessed fall .mobility alarm sounding .mobility chair .fall history .Narrative of occurrence and description of injuries: Fall with injury to (Lt) (left) FA (forearm) ST (skin tear) outer elbow; with bruise inner LFA, Tenderness (Lt) torso no visible injury. Xray LFA, (Lt) ribs (Lt) hip. Resident stood up in hallway of B wing grabbed hall rail and stood up and fell .Immediate Action Taken to minimize reoccurrence:2-10 and 10-6 Nurses suspended. 15 min checks . .Immediate Actions Taken .First aid given by ADON date 09/08/17 time 0650 (6:50 a.m.) .Type of aid: Tx (treatment) ST; Xray ordered . The clinical record contained no documentation the resident had been assessed, monitored, or had interventions initiated from the time of the fall on 09/07/17 at approximately 7:30 p.m. until 09/08/17 at approximately 6:00 a.m. The clinical record contained no documentation the physician and/or family had been notified of the fall with major injury. An X-ray report, dated 09/08/17, documented the resident had a subcapital [MEDICAL CONDITION] femoral neck. A state reportable incident report, dated 09/08/17, documented the investigation regarding the resident's fall had been completed and two nurses (RN #1 and LPN #1) had been terminated and reported to the Oklahoma Board of Nursing. An administrative investigation checklist and summary, dated 09/13/17, documented, .Family notified of occurrence: No .Physician notified of occurrence: No .Conclusion: Both 2-10 and 10-6 nurses were neglectful of their duties and responsibility of resident. On 09/20/17 at 10:00 a.m., an unidentified family member of the resident reported the staff had not notified the family of a resident's fall until the next day when a family member arrived to visit. The family member also reported a staff member had stated, If that had been on my watch I would have had an ambulance here. The family member reported one staff member had stated, We have totally fouled up. On 09/20/17 at 12:45 p.m., the resident was observed lying in bed with his eyes closed and a family member at his bedside. On 09/20/17 at 1:45 p.m., CMA #1 was questioned regarding the resident's fall. The CMA reported she did not see the resident fall. The CMA reported a licensed nurse had asked her to assist in getting the resident up out of the floor. The CMA was asked how the resident was assisted in getting up. The CMA reported a gait belt was utilized in standing the resident to assist back to his wheelchair. The CMA reported the resident looked like he was in pain and she had reported to the charge nurse. On 09/20/17 at 2:10 p.m., the DON was questioned regarding the resident's fall. The DON was asked when the resident had fallen. The DON reported on 09/07/17 at approximately 7:30-8:00 p.m. The DON was asked if the resident had been assessed after his fall. The DON stated, I don't think she did a full assessment. The DON was asked if she thought a full assessment should be completed after a fall. The DON stated, Yes. The DON was then asked if she thought the resident should have been assessed in a more timely manner. The DON stated, Yes. The DON reported the 2-10 shift and 10-6 shift nurses had been terminated due to failure to follow company policy and procedures. The DON reported she had identified the problem when the staff had not assessed, monitored, and intervened. The DON reported she had put interventions in place when she became aware of the situation. The DON reported the facility had implemented a plan of correction and was monitoring for quality assurance purposes. On 09/20/17 at 3:10 p.m., CNA #1 was questioned in regard to the resident's fall. The CNA reported she heard an alarm sounding and stepped out of another resident's room. The CNA reported she observed the resident standing in the hallway holding onto the rail but fell before she could get to him. The CNA reported she summoned for the nurse to assist her. The CNA reported she, along with the nurse and another CNA, assisted the resident to his wheelchair. The CNA reported a gait belt was used to assist the resident to a standing position. The CNA reported the resident had not been assessed by the licensed nurse prior to being moved. The CNA reported the resident looked like he was in pain and reported to the charge nurse. On 09/20/17 at 4:05 p.m., the ADON was questioned regarding the resident's fall. The ADON reported she had came in on 09/08/17 at 6:00 a.m. and received report from the 10-6 shift nurse regarding the resident's fall. The ADON reported she then assessed the resident. The ADON reported the resident flinched when she touched near his left hip. The ADON also reported a skin tear to the left elbow had not been addressed. The ADON reported she had asked the 10-6 shift nurse if she had completed vital signs or notified anyone and the nurse reported she had done nothing. The ADON stated, I told the family my nurses were negligent. The ADON reported she then notified hospice, the physician, the family, and obtained an x-ray.

Based on record review and interview, it was determined the facility failed to notify the physician of an admission requiring orders for medications and treatments for one (#90) of 30 residents reviewed for physician notification. The facility failed to notify the physician when: a) resident #90 was admitted to the facility. b) medication orders were needed for resident #90. c) resident #90 had +4 [MEDICAL CONDITION] with weeping to both lower extremities. d) resident #90 experienced a change in condition. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance as: .Patient has [MEDICAL CONDITION] noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/[MEDICAL CONDITION] noted to bilateral lower extremities .Heart is [MEDICAL CONDITION] .[MEDICAL CONDITION] .EKG .[MEDICAL CONDITION] flutter with a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute [MEDICAL CONDITION]. 2.[MEDICAL CONDITION]. 3. [MEDICAL CONDITION] of the lower extremities. 4. Pneumonia, healthcare required. 5. [MEDICAL CONDITION] flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days . The ADM reported 59 residents lived in the facility. Findings: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A list of medications form faxed to the facility from the discharging hospital physician, documented, .Fax .Received Time May 4 2017 3:05 PM . The medications listed were: .[MEDICATION NAME] 125 mcg QAM .[MEDICATION NAME] 60 MG Q 8H .[MEDICATION NAME] 40 MG BID .Insulin Detemir 15 UNIT QHS .Insulin R (Regular Insulin) 1 UNIT SS .[MEDICATION NAME] 1 APPLIC BID .Magnesium Chloride 64 MG Q 4H .[MEDICATION NAME] ER 25 MG DAILY .Nicotine 1 PATCH Q 24H .Pantoprazole 40 MG Q 24 H .Potassium Chloride 20 MEQ BID . A hand written note at the bottom of the page documented, weeping feet .End Stage [MEDICAL CONDITION] . The resident's primary physician at the facility had not been notified regarding the resident's [DIAGNOSES REDACTED]. The resident's family provided a packet with paper copies which included admission orders [REDACTED]. The packet documented [DIAGNOSES REDACTED]. The medications listed were: [MEDICATION NAME] Cap 25 mg every 6 hours PRN; Magox Tab 250 mg BID; [MEDICATION NAME] 24 21/24 hr (Nicotine), 1 patch every 24 hours; and [MEDICATION NAME] 5 mg every 6 hours PRN moderate pain x 14 days. A nursing evaluation, dated 05/04/17, documented the resident arrived from a hospital via private vehicle. The assessment documented the resident was alert and oriented to person, place, and time. The assessment documented the resident had a history of [REDACTED]. The evaluation, dated 05/04/17, documented the resident had limited range of motion to lower extremities related to +4 [MEDICAL CONDITION] and both feet weeping. The evaluation, dated 05/04/17, contained a nurse's note which documented, .Diagnosis-Severe [MEDICAL CONDITION], End Stage [MEDICAL CONDITION] secondary to alcohol consumption, discharged today at 1630 (4:30 p.m.) from hospital (name deleted) arrived at our facility at 20:00 (8:00 p.m.) .Lungs have slight wheeze lower lobes resp (respirations) labored with slight exerction (sic) .+4 [MEDICAL CONDITION] lower extremities-Some weeping noted to top of feet . The physician had not been notified regarding the resident's condition upon admission to the facility. An interdisciplinary initial care plan, dated 05/04/17, documented the resident had [MEDICAL CONDITION] to his lower extremities. A nurse's note, dated 05/06/17 at 1:00 p.m., documented, Resident in bed with eyes closed has been in bed all shift. Son arrived & client got up in wheelchair with stand by assist. Severe [MEDICAL CONDITION] to BLE (bilateral lower extremities) with treatment order. Will continue to monitor. The physician had not been notified regarding the resident's severe [MEDICAL CONDITION] to BLE. A nurse's note, dated 05/07/17 at 1:00 p.m., documented, .Continued [MEDICAL CONDITION]. Increased incontinence. Will continue to monitor. The physician had not been notified regarding severe [MEDICAL CONDITION] to BLE. A nurse's note, dated 05/07/17 at 3:00 p.m., documented, .Has continued [MEDICAL CONDITION] and weeping to BLE. Incontinent of urine. Alert, frequently disoriented . The physician had not been notified regarding severe [MEDICAL CONDITION] to BLE or the resident's change in mental status. A nurse's note, dated 05/07/17 at 7:45 p.m., documented, .Reports pain meds not working. However no visible s/s (signs or symptoms) of pain. Severe [MEDICAL CONDITION] BLE with weeping. The physician had not been notified regarding the resident's severe [MEDICAL CONDITION] to BLE or the ineffectiveness of the resident's medications for pain. A nurse's note, dated 05/08/17 at 1:00 p.m., documented, .faxed Dr. (name deleted) office and called, sent [DIAGNOSES REDACTED]. (name deleted) assess and see what he wants to do with resident, awaiting response. A nurse's note, dated 05/08/17 at 2:00 p.m., documented, Resident family here to visit him, decided to take him to the (name deleted) hospital-R/T (related to) the swelling in his lower extremities Both lower extremities wrapped with gauze . A nurse's note, dated 05/08/17 at 8:00 p.m., documented, Received call form (name deleted) hospital that resident was going to be admitted this evening . A Medication Administration Record [REDACTED]. The medications listed on the faxed hospital discharge and admission to the facility, dated 05/04/17 at 3:05 p.m., had not been administered to the resident. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance: .SKIN: Patient has [MEDICAL CONDITION] noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/[MEDICAL CONDITION] noted to bilateral lower extremities .CVS: Heart is [MEDICAL CONDITION] .[MEDICAL CONDITION] .EKG interpreted by me [MEDICAL CONDITION] flutter with 21 AV conduction at a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute [MEDICAL CONDITION]. 2.[MEDICAL CONDITION]. 3. [MEDICAL CONDITION] of the lower extremities. 4. Pneumonia, healthcare required. 5. [MEDICAL CONDITION] flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days. 7. Chronic alcoholic liver disease with hepatic [MEDICAL CONDITION]. 8. [MEDICAL CONDITION] with tobacco use disorder. 9. [DIAGNOSES REDACTED]. 10. [MEDICAL CONDITION]. 11. Type 2 diabetes. 12. Alcoholic [DIAGNOSES REDACTED] . .RECOMMENDATIONS: Admission to the ICU. I am going to get a central line in him to be able to evaluate his CVP's (central venous pressures) to judge his fluid necessities, start treating his [MEDICAL CONDITION]. I have put him on broad-spectrum antibiotics to include [MEDICATION NAME] and [MEDICATION NAME] and [MEDICATION NAME]. Cultures are performed of the blood . .EXPECTED LENGTH OF STAY Five to 7 days . A facility in-service/training sign-in sheet, dated 06/01/17, documented areas addressed were admissions, readmits, and incident reports (IRs). A facility in-service/training sign-in sheet, dated 06/02/17, documented areas addressed were admit, readmits, IRs; admission charge nurse, ADON, DON, notify pharmacy and physician asap (as soon as possible) D/T (due to) medications not ordered. A quality improvement data collection form, dated 06/30/17, documented a list of residents who had been admitted for the month of June and a check list to ensure the physician and pharmacy had been notified. On 07/05/17 at 11:45 a.m., the DON and the Regional Clinical Director were asked who was responsible for assessing new admits. The DON reported the ADON was responsible. The DON was then asked who was responsible if the ADON was not available. The DON reported the charge nurse or herself. The DON was asked how soon the assessment should be completed on a new admit. The DON reported the day the resident was admitted . The DON was asked how soon the physician should be notified of a new admission. The DON reported the same day the resident arrived. The DON was asked if the physician should have been notified when the resident was admitted to the facility at 8:00 p.m. The DON stated, Yes. The DON was shown the nurses' notes regarding the resident's lower extremities and was asked if the physician should have been notified of the resident's continued [MEDICAL CONDITION]. The DON stated, Yes. On 07/05/17 at 1:57 p.m., LPN #3 was asked if she recalled when the resident was admitted to the facility. The LPN stated, My first admit here, he didn't get here until late. The LPN was asked if she called the physician. The LPN stated, I didn't call the doctor. The LPN was asked if she should have called the physician. The LPN stated, Yes. The LPN was then asked if she worked the next day. The LPN stated, Yes. The LPN was asked if the resident had [MEDICAL CONDITION] to his lower extremities. The LPN stated, Yes. The LPN was asked with +4 [MEDICAL CONDITION] and weeping to lower extremities was the resident receiving a diuretic. The LPN stated, He should have been. The LPN was asked if she should have called the physician regarding the resident's [MEDICAL CONDITION]. The LPN stated, Yes, I probably should have. The LPN was asked if she had received an in-service regarding physician notification. The LPN stated, Yes. On 07/05/17 at 2:05 p.m., LPN #1 was asked if she had received an in-service regarding physician notification. The LPN stated, Yes.

Based on record review and interview, it was determined the facility failed to provide care and services to maintain the highest level of well-being for one (#90) of 30 residents reviewed for timely provision of care. The facility failed to thoroughly assess, monitor, and intervene when the resident presented with +4 [MEDICAL CONDITION] and weeping to bilateral lower extremities. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance as: .Patient has [MEDICAL CONDITION] noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/[MEDICAL CONDITION] noted to bilateral lower extremities .Heart is [MEDICAL CONDITION] .[MEDICAL CONDITION] .EKG .[MEDICAL CONDITION] flutter with a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute [MEDICAL CONDITION]. 2.[MEDICAL CONDITION]. 3. [MEDICAL CONDITION] of the lower extremities. 4. Pneumonia, healthcare required. 5. [MEDICAL CONDITION] flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days . The ADM reported 59 residents lived in the facility. Findings: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A list of medications form faxed to the facility from the discharging hospital physician, documented, .Fax .Received Time May 4 2017 3:05 PM . The medications listed were: .[MEDICATION NAME] 125 mcg QAM .[MEDICATION NAME] 60 MG Q 8H .[MEDICATION NAME] 40 MG BID .Insulin Detemir 15 UNIT QHS .Insulin R (Regular Insulin) 1 UNIT SS .[MEDICATION NAME] 1 APPLIC BID .Magnesium Chloride 64 MG Q 4H .[MEDICATION NAME] ER 25 MG DAILY .Nicotine 1 PATCH Q 24H .Pantoprazole 40 MG Q 24 H .Potassium Chloride 20 MEQ BID . A hand written note at the bottom of the page documented, weeping feet .End Stage [MEDICAL CONDITION] . The physician and pharmacy had not been notified regarding the [DIAGNOSES REDACTED]. The above admitting orders from the discharging hospital had not been implemented by the facility on admission of the resident. The resident's family provided a packet with paper copies which included admission orders [REDACTED]. The packet documented [DIAGNOSES REDACTED]. The medications listed were: [MEDICATION NAME] Cap 25 mg every 6 hours PRN; Magox Tab 250 mg BID; [MEDICATION NAME] 24 21/24 hr (Nicotine) 1 patch every 24 hours; and [MEDICATION NAME] 5 mg every 6 hours PRN moderate pain x 14 days. A nursing evaluation, dated 05/04/17, documented the resident arrived from a hospital via private vehicle. The assessment documented the resident was alert and oriented to person, place, and time. The assessment documented the resident had a history of [REDACTED]. The evaluation, dated 05/04/17, documented the resident had limited range of motion to lower extremities related to +4 [MEDICAL CONDITION] and both feet weeping. The evaluation, dated 05/04/17, contained a nurse's note which documented, .Diagnosis-Severe [MEDICAL CONDITION], End Stage [MEDICAL CONDITION] secondary to alcohol consumption, discharged today at 1630 (4:30 p.m.) from hospital (name deleted) arrived at our facility at 20:00 (8:00 p.m.) .Lungs have slight wheeze lower lobes resp (respirations) labored with slight exerction (sic) .+4 [MEDICAL CONDITION] lower extremities-Some weeping noted to top of feet . The physician had not been notified regarding the resident's condition upon admission to the facility. An interdisciplinary initial care plan, dated 05/04/17, documented the resident had [MEDICAL CONDITION] to his lower extremities. A nurse's note, dated 05/06/17 at 1:00 p.m., documented, Resident in bed with eyes closed has been in bed all shift. Son arrived & client got up in wheelchair with stand by assist. Severe [MEDICAL CONDITION] to BLE (bilateral lower extremities) with treatment order. Will continue to monitor. The physician had not been notified regarding the resident's severe [MEDICAL CONDITION] to BLE. A nurse's note, dated 05/07/17 at 1:00 p.m., documented, .Continued [MEDICAL CONDITION]. Increased incontinence. Will continue to monitor. The physician had not been notified regarding severe [MEDICAL CONDITION] to BLE. A nurse's note, dated 05/07/17 at 3:00 p.m., documented, .Has continued [MEDICAL CONDITION] and weeping to BLE. Incontinent of urine. Alert, frequently disoriented . The physician had not been notified regarding severe [MEDICAL CONDITION] to BLE or the resident's change in mental status. A nurse's note, dated 05/07/17 at 7:45 p.m., documented, .Reports pain meds not working. However no visible s/s (signs or symptoms) of pain. Severe [MEDICAL CONDITION] BLE with weeping. The physician had not been notified regarding the resident's severe [MEDICAL CONDITION] to BLE or the ineffectiveness of the resident's medications for pain. A nurse's note, dated 05/08/17 at 1:00 p.m., documented, .faxed Dr. (name deleted) office and called, sent [DIAGNOSES REDACTED]. (name deleted) assess and see what he wants to do with resident, awaiting response. A nurse's note, dated 05/08/17 at 2:00 p.m., documented, Resident family here to visit him, decided to take him to the (name deleted) hospital-R/T (related to) the swelling in his lower extremities Both lower extremities wrapped with gauze . A nurse's note, dated 05/08/17 at 8:00 p.m., documented, Received call form (name deleted) hospital that resident was going to be admitted this evening . A Medication Administration Record [REDACTED]. The medications listed on the faxed hospital discharge and admission to the facility, dated 05/04/17 at 3:05 p.m., had not been administered to the resident. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance: .SKIN: Patient has [MEDICAL CONDITION] noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/[MEDICAL CONDITION] noted to bilateral lower extremities .CVS: Heart is [MEDICAL CONDITION] .[MEDICAL CONDITION] .EKG interpreted by me [MEDICAL CONDITION] flutter with 21 AV conduction at a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute [MEDICAL CONDITION]. 2.[MEDICAL CONDITION]. 3. [MEDICAL CONDITION] of the lower extremities. 4. Pneumonia, healthcare required. 5. [MEDICAL CONDITION] flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days. 7. Chronic alcoholic liver disease with hepatic [MEDICAL CONDITION]. 8. [MEDICAL CONDITION] with tobacco use disorder. 9. [DIAGNOSES REDACTED]. 10. [MEDICAL CONDITION]. 11. Type 2 diabetes. 12. Alcoholic [DIAGNOSES REDACTED] . .RECOMMENDATIONS: Admission to the ICU. I am going to get a central line in him to be able to evaluate his CVP's (central venous pressures) to judge his fluid necessities, start treating his [MEDICAL CONDITION]. I have put him on broad-spectrum antibiotics to include [MEDICATION NAME] and [MEDICATION NAME] and [MEDICATION NAME]. Cultures are performed of the blood . .EXPECTED LENGTH OF STAY Five to 7 days . A facility in-service/training sign-in sheet, dated 06/01/17, documented areas addressed were admissions, readmits, and incident reports (IRs). A facility in-service/training sign-in sheet, dated 06/02/17, documented areas addressed were admit, readmits, IRs; admission charge nurse, ADON, DON, notify pharmacy and physician asap (as soon as possible) D/T (due to) medications not ordered. A quality improvement data collection form, dated 06/30/17, documented a list of residents who had been admitted for the month of June and a check list to ensure the physician and pharmacy had been notified. On 07/05/17 at 11:45 a.m., the DON and the Regional Clinical Director were asked who was responsible for assessing new admits. The DON reported the ADON was responsible. The DON was then asked who was responsible if the ADON was not available. The DON reported the charge nurse or herself. The DON was asked how soon the assessment should be completed on a new admit. The DON reported the day the resident was admitted . The DON was asked how soon the physician should be notified of a new admission. The DON reported the same day the resident arrived. The DON was shown the list of medications from the discharging hospital. The DON reported the list of medications should have been sent to the pharmacy. The DON was asked who was responsible for sending the list of medications to the pharmacy. The DON reported the charge nurse. The DON was asked how long the resident went without his medications. The DON stated, I'm not sure, it wasn't brought to my attention until he was re-admitted on [DATE]. The DON was asked how long the resident was hospitalized . The DON stated, He came back on the 18th. The DON was asked if he was hosptalized on [DATE] and came back on 05/18/17. She stated, Yes. The DON was asked if she thought the resident's hospitalization could have been prevented if the resident had received his medication. The DON stated, True. The DON was asked if the physician would normally order the medications the resident was discharged with from the hospital. The DON stated, Yes, until he comes out to see them, then he might change them. On 07/05/17 at 1:57 p.m., LPN #3 was asked if she recalled when the resident was admitted to the facility. The LPN stated, My first admit here, he didn't get here until late. The LPN was asked if she called the physician. The LPN stated, I didn't call the doctor. The LPN was asked if she should have called the physician. The LPN stated, Yes. The LPN was then asked if she worked the next day. The LPN stated, Yes. The LPN was asked if the resident had [MEDICAL CONDITION] to his lower extremities. The LPN stated, Yes. The LPN was asked with +4 [MEDICAL CONDITION] and weeping to the resident's lower extremities, was the resident receiving a diuretic. The LPN stated, He should have been. The LPN was asked if she should have called the physician regarding the resident's [MEDICAL CONDITION]. The LPN stated, Yes, I probably should have. On 07/05/17 at 2:05 p.m., LPN #1 was asked if she recalled the resident. The LPN stated, Yes. The LPN was asked if his lower extremities were [MEDICAL CONDITION]. The LPN stated, Yes. The LPN was asked if the resident was receiving a diuretic. The LPN stated, I don't recall.

Based on record review and interview, it was determined the facility failed to provide pharmaceutical services for one (#90) of 30 residents reviewed for pharmaceutical services. The facility failed to ensure the resident had medications available for administration upon admission and for four days following admission. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance as: .Patient has pitting edema noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/cellulitis noted to bilateral lower extremities .Heart is tachycardic .peripheral edema .EKG .atrial flutter with a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute delirium. 2. Sepsis. 3. Cellulitis of the lower extremities. 4. Pneumonia, healthcare required. 5. Atrial flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days . The ADM reported 59 residents lived in the facility. Findings: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A list of medications form faxed to the facility from the discharging hospital physician, documented, .Fax .Received Time May 4 2017 3:05 PM . The medications listed were: .Digoxin 125 mcg QAM .Diltiazem 60 MG Q 8H .Furosemide 40 MG BID .Insulin Detemir 15 UNIT QHS .Insulin R (Regular Insulin) 1 UNIT SS .Ketoconazole 1 APPLIC BID .Magnesium Chloride 64 MG Q 4H .Metoprolol Succinate ER 25 MG DAILY .Nicotine 1 PATCH Q 24H .Pantoprazole 40 MG Q 24 H .Potassium Chloride 20 MEQ BID . A hand written note at the bottom of the page documented, weeping feet .End Stage CHF . The physician and pharmacy had not been notified regarding the [DIAGNOSES REDACTED]. The above admitting orders from the discharging hospital had not been implemented by the facility on admission of the resident. The resident's family provided a packet with paper copies which included admission orders [REDACTED]. The packet documented [DIAGNOSES REDACTED]. The medications listed were: Librium Cap 25 mg every 6 hours PRN; Magox Tab 250 mg BID; Nicotrol 24 21/24 hr (Nicotine) 1 patch every 24 hours; and Oxycodone 5 mg every 6 hours PRN moderate pain x 14 days. A nursing evaluation, dated 05/04/17, documented the resident arrived from a hospital via private vehicle. The assessment documented the resident was alert and oriented to person, place, and time. The assessment documented the resident had a history of [REDACTED]. The evaluation, dated 05/04/17, documented the resident had limited range of motion to lower extremities related to +4 edema and both feet weeping. The evaluation, dated 05/04/17, contained a nurse's note which documented, .Diagnosis-Severe CHF, End Stage Cirrhosis secondary to alcohol consumption, discharged today at 1630 (4:30 p.m.) from hospital (name deleted) arrived at our facility at 20:00 (8:00 p.m.) .Lungs have slight wheeze lower lobes resp (respirations) labored with slight exerction (sic) .+4 pitting edema lower extremities-Some weeping noted to top of feet . The physician had not been notified regarding the resident's condition upon admission to the facility. An interdisciplinary initial care plan, dated 05/04/17, documented the resident had edema to his lower extremities. A nurse's note, dated 05/06/17 at 1:00 p.m., documented, Resident in bed with eyes closed has been in bed all shift. Son arrived & client got up in wheelchair with stand by assist. Severe edema to BLE (bilateral lower extremities) with treatment order. Will continue to monitor. The physician had not been notified regarding the resident's severe edema to BLE. A nurse's note, dated 05/07/17 at 1:00 p.m., documented, .Continued edema. Increased incontinence. Will continue to monitor. The physician had not been notified regarding severe edema to BLE. A nurse's note, dated 05/07/17 at 3:00 p.m., documented, .Has continued edema and weeping to BLE. Incontinent of urine. Alert, frequently disoriented . The physician had not been notified regarding severe edema to BLE or the resident's change in mental status. A nurse's note, dated 05/07/17 at 7:45 p.m., documented, .Reports pain meds not working. However no visible s/s (signs or symptoms) of pain. Severe edema BLE with weeping. The physician had not been notified regarding the resident's severe edema to BLE or the ineffectiveness of the resident's medications for pain. A nurse's note, dated 05/08/17 at 1:00 p.m., documented, .faxed Dr. (name deleted) office and called, sent [DIAGNOSES REDACTED]. (name deleted) assess and see what he wants to do with resident, awaiting response. A nurse's note, dated 05/08/17 at 2:00 p.m., documented, Resident family here to visit him, decided to take him to the (name deleted) hospital-R/T (related to) the swelling in his lower extremities Both lower extremities wrapped with gauze . A nurse's note, dated 05/08/17 at 8:00 p.m., documented, Received call form (name deleted) hospital that resident was going to be admitted this evening . A Medication Administration Record [REDACTED]. The medications listed on the faxed hospital discharge and admission to the facility, dated 05/04/17 at 3:05 p.m., had not been administered to the resident. An emergency department provider record, dated 05/08/17 at 5:02 p.m., documented the resident's general appearance: .SKIN: Patient has pitting edema noted of all 4 extremities. He also has serous filled blisters to be [DIAGNOSES REDACTED]/cellulitis noted to bilateral lower extremities .CVS: Heart is tachycardic .peripheral edema .EKG interpreted by me atrial flutter with 21 AV conduction at a rate of 125 bpm (beats per minute) . Diagnoses: [REDACTED]. Patient Disposition: Patient was admitted to ICU (intensive care unit) on 05/08/17 at 10:01 p.m. An ICU record, dated 05/08/17 at 10:16 p.m., documented, .1. Acute delirium. 2. Sepsis. 3. Cellulitis of the lower extremities. 4. Pneumonia, healthcare required. 5. Atrial flutter with rapid response. 6. Noncompliant. Patient has not been on any medications in the nursing home for 4 to 5 days. 7. Chronic alcoholic liver disease with hepatic [DIAGNOSES REDACTED]. 8. Chronic obstructive pulmonary disease with tobacco use disorder. 9. [DIAGNOSES REDACTED]. 10. Hyponatremia. 11. Type 2 diabetes. 12. Alcoholic [DIAGNOSES REDACTED] . .RECOMMENDATIONS: Admission to the ICU. I am going to get a central line in him to be able to evaluate his CVP's (central venous pressures) to judge his fluid necessities, start treating his congestive heart failure. I have put him on broad-spectrum antibiotics to include Zosyn and clindamycin and levofloxacin. Cultures are performed of the blood . .EXPECTED LENGTH OF STAY Five to 7 days . A facility in-service/training sign-in sheet, dated 06/01/17, documented areas addressed were admissions, readmits, and incident reports (IRs). A facility in-service/training sign-in sheet, dated 06/02/17, documented areas addressed were admit, readmits, IRs; admission charge nurse, ADON, DON, notify pharmacy and physician asap (as soon as possible) D/T (due to) medications not ordered. A quality improvement data collection form, dated 06/30/17, documented a list of residents who had been admitted for the month of June and a check list to ensure the physician and pharmacy had been notified. On 07/05/17 at 11:45 a.m., the DON and the Regional Clinical Director were asked who was responsible for assessing new admits. The DON reported the ADON was responsible. The DON was then asked who was responsible if the ADON was not available. The DON reported the charge nurse or herself. The DON was asked how soon the assessment should be completed on a new admit. The DON reported the day the resident was admitted . The DON was asked how soon the physician should be notified of a new admission. The DON reported the same day the resident arrived. The DON was shown the list of medications from the discharging hospital. The DON reported the list of medications should have been sent to the pharmacy. The DON was asked who was responsible for sending the list of medications to the pharmacy. The DON reported the charge nurse. The DON was asked how long the resident went without his medications. The DON stated, I'm not sure, it wasn't brought to my attention until he was re-admitted on [DATE]. The DON was asked how long the resident was hospitalized . The DON stated, He came back on the 18th. The DON was asked if he was hosptalized on [DATE] and came back on 05/18/17. She stated, Yes. The DON was asked if she thought the resident's hospitalization could have been prevented if the resident had received his medication. The DON stated, True. The DON was asked if the physician would normally order the medications the resident was discharged with from the hospital. The DON stated, Yes, until he comes out to see them, then he might change them. On 07/05/17 at 1:57 p.m., LPN #3 was asked if she recalled when the resident was admitted to the facility. The LPN stated, My first admit here, he didn't get here until late. The LPN was asked if she called the physician. The LPN stated, I didn't call the doctor. The LPN was asked if she should have called the physician. The LPN stated, Yes. The LPN was then asked if she worked the next day. The LPN stated, Yes. The LPN was asked if the resident had edema to his lower extremities. The LPN stated, Yes. The LPN was asked with +4 edema and weeping to the resident's lower extremities, was the resident receiving a diuretic. The LPN stated, He should have been. The LPN was asked if she should have called the physician regarding the resident's edema. The LPN stated, Yes, I probably should have. The LPN was asked if she had received an in-service regarding physician and pharmacy notification for new admits. The LPN stated, Yes. On 07/05/17 at 2:05 p.m., LPN #1 was asked if she recalled the resident. The LPN stated, Yes. The LPN was asked if his lower extremities were edematous. The LPN stated, Yes. The LPN was asked if the resident was receiving a diuretic. The LPN stated, I don't recall. LPN #1 was asked if she had received an in-service regarding physician and pharmacy notification for new admits. The LPN stated, Yes.

Based on observation, record review, and interview, it was determined the facility failed to provide the necessary care and services to maintain well-being for one (#2) of three residents reviewed for well-being. The facility failed to ensure: a) Resident #2 was transferred as ordered by the physician and care plan. b) X-ray exams were completed as ordered by the physician for resident #2. c) When resident #2 experienced pain and swelling in the left leg, + assessment and monitoring was conducted. d) Unnecessary medication orders were not obtained for [MEDICATION NAME] when resident #2 experienced increased pain, restlessness, calling out for help, and increased use of call light. Resident #2 experienced increased, prolonged pain and a left femur fracture. The ADM reported 66 residents resided at the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 06/06/16, documented, TRANSFER BY MECHANICAL LIFT FROM BED TO CHAIR & CHAIR TO BED. MAY USE 2 ASSIST FROM CHAIR TO TOILET & TOILET TO CHAIR. A quarterly assessment, dated 03/09/17, documented the resident was moderately impaired in cognition, was totally dependent on two or more staff members for transfers, did not ambulate, required extensive assistance of one staff member for dressing, and personal hygiene. The assessment documented the resident was impaired in both upper and lower extremities. The assessment documented the resident was always continent of bowel and bladder. A care plan, dated 03/14/17, documented, To start Hoyer lift x 2 (two person) assisted. Educated wife and (name deleted) of safety measures & not to get up any other way . A care plan, dated 03/21 (year not documented), documented, Educated family wife .on usage of Hoyer lift always each day. A care plan, dated 03/22 (year not documented), documented, Educated on usage BSC (bedside commode) x 2 staff . A nurse's note, dated 03/14/17 at 8:30 a.m., documented, CNA reported that during transfering (sic) resident to shower chair, he lost his footing & slipped-she lost control of transfer & eased him to the floor. Called for assist. & together picked resident up c (with) gait belt. Dr. (name deleted) was notified by phone. I admitted to Dr. (named deleted) we would observe bruise x 7 days for s/s (signs and symptoms) of complications. No other orders were received @ (at) this time. A nurse's note, dated 03/14/17 at 9:00 a.m., documented the resident's spouse was notified of the incident and the resident and spouse were notified the resident would need to be transferred with the use of the Hoyer lift. A nurse's note, dated 03/22/17 at 8:30 a.m., documented, The resident was on the commode. CNA stated that while he was standing holding on the bar & she was pulling his britches down & his l (left) ft. (foot) slipped back & she went to grab him & fell on top of l leg. The nurse's note documented the resident complained of pain in the left leg and was assisted by two staff members to transfer into wheelchair and returned to bed with the use of a mechanical lift. The nurse's note documented, .resident hollered out @ (at) hip site, knee site, & calf site. Called for mobile x-ray stat. A physician's orders [REDACTED]. A nurse's note, dated 03/22/17 at 9:30 a.m., documented, Mobile x-ray had not arrived & dispatch couldn't give ETA (estimated time of arrival). Mrs. (name deleted) very upset. Dr. (name deleted) notify & order received to send to ER for evaluation. A physician's orders [REDACTED]. A form titled, Nursing Home to Hospital Transfer Form, dated 03/22/17, documented the resident was transferred to the hospital after a fall and complained of left hip and leg pain. The clinical record did not document the form was sent with the resident at the time of transfer. A nurse's note, dated 03/22/17 at 11:00 a.m., documented, .called that resident was ready to be picked up. No evidence of Fx. (fracture). A nurse's note, dated 03/22/17 at 11:50 a.m., documented the resident returned to the facility from the local emergency department by the facility transport with no new orders. The clinical record did not contain hospital documentation of the treatment, diagnosis, or x-ray results. A nurse's note, dated 03/22/17 at 5:00 p.m., documented, Has remained in bed this shift c/o (complains of) pain and prn (as needed) pain med. was given. A nurse's note, dated 03/23/17 at 12:15 a.m., documented, Resting in bed, c/o (complains of) pain/soreness to LLE (left lower extremity) s/p (status [REDACTED]. States only painful when being repositioned . A nurse's note, dated 03/23/17 at 7:45 a.m., documented no injuries were noted from fall. A nurse's note, dated 03/24/17 at 7:30 a.m., documented the resident was transferred by a mechanical lift and assisted by three staff members to the bedside commode. A nurse's note, dated 03/25/17 at 9:00 a.m., documented, . extensive assist. c (with) transfer. Complete shower given tolerated well 0 acute distress. The clinical record did not contain documentation the resident's left leg was assessed. A nurse's note, dated 03/26/17 at 1:30 a.m., documented, .pain relieved d/t (due to) pain med. [MEDICATION NAME] 10 mg. was given. The clinical record, dated 03/27/17, did not contain documentation the resident's left leg was monitored and assessed. A Medication Administration Record [REDACTED]. A nurse's note, dated 03/28/17 at 10:00 a.m., documented the resident was being transferred by a mechanical lift and no complaints were voiced. A Medication Administration Record, [REDACTED]. The March 2017 Medication Administration Record [REDACTED]. The clinical record did not contain documentation of the resident's left hip and left leg assessment until 04/02/17 at 9:00 a.m. The nurse's note documented the resident complained of pain to his left inner thigh. A nurse's note, dated 04/03/17 at 1:10 a.m., documented the resident used the call light every five to ten minutes. The nurse's note documented the resident was unable to state his needs. The note documented the resident would look at the nurse and CNA and say, Help me, but was unable to communicate with the staff his needs. The nurse note documented a fax was sent to the resident's doctor. A nurse's note, dated 04/03/17 at 9:00 a.m., documented, Cont to note Lg. (large) yellow bruise inside L (left) thigh. Dr. (name deleted) notified. Also reported L-ft. & leg swollen, cont. on [MEDICATION NAME]. New order for Seroquil 50 mg. BID (twice daily). A nurse note, dated 04/04/17 at 1:40 a.m., documented, Cont. to use call light multiple times s (without) being able to state need. A nurse note, dated 04/05/17 at 5:30 a.m., documented, Resident rested this shift. Slept much better .Began [MEDICATION NAME] 50 mg. BID on 4-4-17. The clinical record did not contain documentation the resident's left hip/leg or bruising was assessed. The clinical record did not contain documentation the resident's left leg was assessed and monitored on 04/06/17, 04/07/17, 04/08/17, 04/09/17, 04/10/17, 04/11/17, 04/12/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/18/17, 04/19/17, 04/20/17, 04/21/17, 04/22/17, and 04/23/17. A nurse's note, dated 04/24/17 at 10:00 p.m., documented, +1 to 2 [MEDICAL CONDITION] noted in feet l (left) foot up to thigh appears larger than r (right) leg/foot .Faint yellowish discoloration noted to l (left) ^ (upper) thigh .constantly on call light today this shift . A nurse's note, dated 04/24/17 at 10:10 p.m., documented, CNAs report pain to L (left) leg when they reposition or change him. The clinical record did not contain documentation the resident's left leg was assessed and monitored. A nurse's note, dated 04/25/17 at 5:30 a.m., documented the resident had not slept until 5:15 a.m. The nurse's note documented the resident used the call light 19 times in 1.5 hours. The note documented the resident was unable to tell staff what he needed. The note documented when the call light was answered the resident stated, help me help me. The note documented the resident denied pain at that time. A nurse's note, dated 04/25/17 at 5:15 p.m., documented, .Screaming out 'help me' denies pain/discomfort when ask. L (left) foot 2+ [MEDICAL CONDITION], cannot get shoe on, feet elevated this shift in recliner. Dr. (name deleted) call requesting copy of MAR (medication administration record). Communication sent yesterday to his/her office about [MEDICAL CONDITION] to left leg et. (and) continuous being being (sic) on call-light. MARS sent to Dr. (name deleted) 0 N.O.'s (new orders) @ this time . A nurse's note, dated 04/26/17 at 5:45 a.m., documented the resident was awake all night yelling, Help me, help me, and was unable to tell staff what his needs were. The nurse's note documented the resident denied pain. Fax sent to Dr. (name deleted) & behavior sheet w (with) meds sent. A nurse's note, dated 04/26/17, documented, Dr. (name deleted) called & discussed what to do c (with) resident. received new order for psych eval. A nurse's note, dated 04/26/17 at 5:45 p.m., documented, Upon transfer res. (resident) c/o (complain of) pain upon movement of l (left) leg Conts. to have 1-2+ [MEDICAL CONDITION]. Yellowish (light) color noted to (arrow up sign) left leg. Also, besides pain to l leg, CNAs report L leg laying out et just 'flops' around. Communication sent to Dr. (name deleted). A nurse's note, dated 04/27/17 at 9:30 a.m., documented the physician called and ordered for the resident to have [MEDICATION NAME] increased to 80 mg in the a.m. for three days and the evening dose was to remain at 40 mg. in the evening. A nurse's note, dated 04/27/17 at 7:40 p.m., documented, Cont. to monitor [MEDICAL CONDITION] 1-2 + pitting in L leg, thigh, calf and, et. l foot. Unable to put shoe on L foot. Cont. to monitor . A nurse's note, dated 04/28/17 at 10:00 a.m., documented the resident was receiving additional [MEDICATION NAME] and the resident continued of have 2+ non-[MEDICAL CONDITION]. A nurse's note, dated 04/29/17 at 10:00 a.m., documented the resident continued to have 2+ [MEDICAL CONDITION] to the left leg and foot. A nurse's note, dated 04/29/17 at 5:00 p.m., documented the resident continued to have 2-3+ [MEDICAL CONDITION] to left foot and ankle. A nurse's note, dated 05/01/17 at 5:10 a.m., documented the resident continued to utilize the call light frequently. When the resident was asked what he needed, he continued to state, Help me, help me. The nurse's note documented the resident had been pain free until that moment. The resident reported he was hurting all over. [MEDICATION NAME] 10/325 was administered for pain. A radiology report with a faxed time that was stamped dated 05/02/17 at 8:11 a.m. documented a left knee x-ray had been completed on 03/22/17 at the local emergency department. The radiology report findings documented a left knee four-view x-ray was completed due to complaints of injury with left knee pain. The radiologist findings documented no acute findings. The report did not document the resident's left leg was x-rayed. The resident's left leg was not reassessed until 05/03/17. A nurse's note, dated 05/03/17 at 11:30 a.m., documented, Talked to PCP re: (regarding) continued c/o L leg-pain. Rc'd (received) order to x-ray L hip-femur-ankle & foot. Contacted (name deleted) mobile x-ray . A nurse's note, dated 05/03/17, documented the mobile x-ray had completed the resident's x-rays and the resident was diagnosed with [REDACTED]. A nurse's note, dated 05/03/17 at 1:45 p.m., documented an addendum. The resident's spouse reported she understood the resident received a left hip x-ray while at the local emergency department on 03/22/17 and the x-ray was negative for fracture. Later after the resident's spouse was notified of the left fracture the staff asked the resident's spouse, .Didn't you say you thought Hosp. ER did hip x-ray. The nurse's note documented the spouse stated, I don't really remember. The resident's clinical record documented on 05/03/17 at 3:00 p.m., the resident's physician returned the telephone call. The record documented the physician requested the resident be transferred to the family's hospital of choice. The record documented at 4:45 p.m., the resident was transferred to a tertiary care facility for an orthopedic evaluation of the left femur fracture. A nurse's note, dated 05/05/17 at 5:40 p.m., documented the resident had returned from an Ardmore hospital via ambulance. The note documented the resident did not have surgical repair of the fracture. The note documented the resident remained a two-person transfer with a sling and mechanical lift. The note documented the resident's skin was intact and a stage 1 pressure wound was observed. The resident's clinical record documented the resident continued to require pain medication for leg and body pain after returning to the facility. A physician's orders [REDACTED]. On 05/16/17 at 9:15 a.m., the resident was observed in his room sitting in his wheelchair with his eyes closed. The resident was well groomed. The resident was observed to have lift sling in place and an additional sling was lying on the chair arm of the recliner. At that time, the resident's spouse was visiting. The spouse was asked how the resident was to be transferred. The resident's spouse reported after the resident had experience two falls the facility was to only transfer the resident with the use of a lift and two staff members. On 05/16/17 at 2:45 p.m., LPN #1 was interviewed. The nurse was asked how the resident was to be transferred. The LPN reported the resident was to be transferred with the use of a Hoyer lift and two staff members were to assist. During the interview on 05/16/17 at 2:45 p.m., LPN #1 reported one CNA had transferred the resident without assistance when the resident experienced a fall on 03/14/17 and again on 03/22/17. The LPN was asked how the resident was to be transferred. The LPN reported with a lift and two person assistance. The LPN reported the CNA is no longer employed at the facility. On 05/16/17 at 4:10 p.m., the ADM was interviewed. The ADM was asked if the facility was adequately staffed with CNAs. The ADM reported the facility was in the process of recruiting staff. On 05/17/17 at 9:22 a.m., the corporate nurse was asked if the resident was transferred properly to prevent injury. The nurse reported no and education was in the process of being conducted. On 05/17/17 at 10:20 a.m., the corporate nurse was asked if the staff followed the physician's orders [REDACTED].#2 on 03/14/17 and 03/22/17 for transfers. The corporate nurse reported no and staff education was in the process of being conducted. On 05/17/17 at 2:00 p.m., CNA staff interviews were conducted. Seven CNAs were interviewed. CNA #1 was asked how resident #2 was to be transferred. The CNA reported after the resident had fallen twice the resident was to be transferred with the use of a Hoyer lift and two staff members. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 was asked how staff members knew which residents required transfer assistance. The CNA reported a Daily Care Guide was utilized for resident care. The CNA reported the daily care guide documented how residents were to be transferred. The CNA reported walking rounds were also conducted at shift change and residents who had experienced changes in care were discussed. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 reported after resident #2 was transferred in the shower and the bedside commode by one CNA, which resulted in an injury to the resident, the CNAs were to only transfer resident #2 utilizing a Hoyer lift and two staff members. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 reported the resident no longer goes into the bathroom or utilized a bedside commode. The CNA reported the resident was to urinate in his urinal and use a bedpan for bowel movements. The CNA reported the resident had a broken left leg and it was painful for the resident to move or be repositioned. During the interviews on 05/17/17 at 2:00 p.m., each CNA interviewed was able to explain how resident #2 was to be transferred. The CNAs reported resident #2 was injured during a fall and two staff members were to transfer the resident using the Hoyer lift. On 05/18/17 at 9:50 a.m., a copy of the emergency record for 03/22/17 was obtained. The record documented the physician's assistant documented an exam of the resident's left knee was conducted and the resident's knee was x-rayed. The record documented the physician's assistant exam documented the resident's left knee was painful and tender. The record documented the exam documented, ROM (range of motion): limited passive range of motion due to pain, in the left knee, Circulation is intact to all extremities. The record documented the emergency department nurse's note documented the resident received a pain injection while in the emergency. The nursing home clinical record contained no documentation from the emergency department of care instructions for the resident or the radiological studies conducted while at the emergency roiagnom on [DATE]. On 05/18/17 at 10:30 a.m., a telephone interview was conducted with the attending physician. The physician reported he/she was under the impression the x-rays ordered on [DATE] for the resident's left hip and left leg had been completed while in the emergency department on 03/22/17. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported the facility staff had been in contact with him/her regarding the resident's continued pain and restlessness. The physician reported staff had been asked about the x-ray results from the 03/22/17 emergency department visit. The physician reported he/she was notified only a left knee x-ray study had been completed at the emergency department. The physician reported at that time, on 05/03/17, a physician's orders [REDACTED]. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported at that time he/she ordered x-rays of the resident's left hip and leg. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported both the facility and the physician needed to be aware of what diagnostic studies and test results were when a resident was examined at the emergency department. On 05/18/17 at 1:30 p.m., LPN #1 was interviewed. The LPN reported the physician had discussed with the facility follow-up on diagnostic test ordered while at the emergency department. The LPN reported she was unsure if the transfer communication form accompanied the resident to the emergency department on 03/22/17. During the interview on 05/18/17 at 1:30 p.m., LPN #1 was asked after a resident had experienced a fall and continued to experience pain and bruising was staff expected to assess and monitor a resident. The LPN reported yes. The LPN was asked if the resident was monitored and assessed for left leg pain, bruising, and complications from a fall. The LPN reported no. During the interview on 05/18/17 at 1:30 p.m., LPN #1 was asked when a physician ordered diagnostic tests, should the facility complete those tests. The LPN reported yes. On 05/19/17 at 9:50 a.m., the ADM and corporate nurse were interviewed. The nurse was asked if the resident had been transferred properly per physician orders [REDACTED]. The nurse reported the facility was in the process of educating staff on following physician orders [REDACTED]. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked when a physician ordered diagnostic tests to be performed was the facility staff to ensure testing was completed as ordered. The nurse report yes. The nurse reported the facility was working to ensure test were completed as ordered by a physician. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked after a resident experienced a fall and continued to have pain, swelling, bruising, and restlessness was staff expected to assess and monitor the injury. The corporate nurse reported yes. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked if the increase of [MEDICATION NAME] 50 mg twice daily was appropriate when a resident continued to experience, swelling, restlessness, and unable to sleep. The nurse reported no. The nurse reported education would be conducted with the nursing staff.

Based on observation, record review, and interview, it was determined the facility failed to transfer one (#2) of three residents reviewed for transfers in a safe manner to prevent injury. Resident #2 experienced increased, prolonged pain and a left femur fracture. The MDS coordinator reported 54 residents who resided at the facility required one or two person assistance for transfers. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 06/06/16, documented, TRANSFER BY MECHANICAL LIFT FROM BED TO CHAIR & CHAIR TO BED. MAY USE 2 ASSIST FROM CHAIR TO TOILET & TOILET TO CHAIR. A quarterly assessment, dated 03/09/17, documented the resident was moderately impaired in cognition, was totally dependent on two or more staff members for transfers, did not ambulate, required extensive assistance of one staff member for dressing, and personal hygiene. The assessment documented the resident was impaired in both upper and lower extremities. The assessment documented the resident was always continent of bowel and bladder. A care plan, dated 03/14/17, documented, To start Hoyer lift x 2 (two person) assisted. Educated wife and (name deleted) of safety measures & not to get up any other way . A care plan, dated 03/21 (year not documented), documented, Educated family wife .on usage of Hoyer lift always each day. A care plan, dated 03/22 (year not documented), documented, Educated on usage BSC (bedside commode) x 2 staff . A nurse's note, dated 03/14/17 at 8:30 a.m., documented, CNA reported that during transfering (sic) resident to shower chair, he lost his footing & slipped-she lost control of transfer & eased him to the floor. Called for assist. & together picked resident up c (with) gait belt. Dr. (name deleted) was notified by phone. I admitted to Dr. (named deleted) we would observe bruise x 7 days for s/s (signs and symptoms) of complications. No other orders were received @ (at) this time. A nurse's note, dated 03/14/17 at 9:00 a.m., documented the resident's spouse was notified of the incident and the resident and spouse were notified the resident would need to be transferred with the use of the Hoyer lift. A nurse's note, dated 03/22/17 at 8:30 a.m., documented, The resident was on the commode. CNA stated that while he was standing holding on the bar & she was pulling his britches down & his l (left) ft. (foot) slipped back & she went to grab him & fell on top of l leg. The nurse's note documented the resident complained of pain in the left leg and was assisted by two staff members to transfer into wheelchair and returned to bed with the use of a mechanical lift. The nurse's note documented, .resident hollered out @ (at) hip site, knee site, & calf site. Called for mobile x-ray stat. A physician's orders [REDACTED]. A nurse's note, dated 03/22/17 at 9:30 a.m., documented, Mobile x-ray had not arrived & dispatch couldn't give ETA (estimated time of arrival). Mrs. (name deleted) very upset. Dr. (name deleted) notify & order received to send to ER for evaluation. A physician's orders [REDACTED]. A form titled, Nursing Home to Hospital Transfer Form, dated 03/22/17, documented the resident was transferred to the hospital after a fall and complained of left hip and leg pain. The clinical record did not document the form was sent with the resident at the time of transfer. A nurse's note, dated 03/22/17 at 11:00 a.m., documented, .called that resident was ready to be picked up. No evidence of Fx. (fracture). A nurse's note, dated 03/22/17 at 11:50 a.m., documented the resident returned to the facility from the local emergency department by the facility transport with no new orders. The clinical record did not contain hospital documentation of the treatment, diagnosis, or x-ray results. A nurse's note, dated 03/22/17 at 5:00 p.m., documented, Has remained in bed this shift c/o (complains of) pain and prn (as needed) pain med. was given. A nurse's note, dated 03/23/17 at 12:15 a.m., documented, Resting in bed, c/o (complains of) pain/soreness to LLE (left lower extremity) s/p (status [REDACTED]. States only painful when being repositioned . A nurse's note, dated 03/23/17 at 7:45 a.m., documented no injuries were noted from fall. A nurse's note, dated 03/24/17 at 7:30 a.m., documented the resident was transferred by a mechanical lift and assisted by three staff members to the bedside commode. A nurse's note, dated 03/25/17 at 9:00 a.m., documented, . extensive assist. c (with) transfer. Complete shower given tolerated well 0 acute distress. The clinical record did not contain documentation the resident's left leg was assessed. A nurse's note, dated 03/26/17 at 1:30 a.m., documented, .pain relieved d/t (due to) pain med. Norco 10 mg. was given. The clinical record, dated 03/27/17, did not contain documentation the resident's left leg was monitored and assessed. A medication administration record documented the resident received pain medication twice. A nurse's note, dated 03/28/17 at 10:00 a.m., documented the resident was being transferred by a mechanical lift and no complaints were voiced. A medication administration record, dated 03/28/16, documented the resident received pain medication twice. The March 2017 medication administration record documented the resident had received Norco 10/325 twice daily on 03/29/17, 03/30/17, 03/31/17, and 04/01/17. The clinical record did not contain documentation of the resident's left hip and left leg assessment until 04/02/17 at 9:00 a.m. The nurse's note documented the resident complained of pain to his left inner thigh. A nurse's note, dated 04/03/17 at 1:10 a.m., documented the resident used the call light every five to ten minutes. The nurse's note documented the resident was unable to state his needs. The note documented the resident would look at the nurse and CNA and say, Help me, but was unable to communicate with the staff his needs. The nurse note documented a fax was sent to the resident's doctor. A nurse's note, dated 04/03/17 at 9:00 a.m., documented, Cont to note Lg. (large) yellow bruise inside L (left) thigh. Dr. (name deleted) notified. Also reported L-ft. & leg swollen, cont. on Lasix. New order for Seroquil 50 mg. BID (twice daily). A nurse note, dated 04/04/17 at 1:40 a.m., documented, Cont. to use call light multiple times s (without) being able to state need. A nurse note, dated 04/05/17 at 5:30 a.m., documented, Resident rested this shift. Slept much better .Began Seroquel 50 mg. BID on 4-4-17. The clinical record did not contain documentation the resident's left hip/leg or bruising was assessed. The clinical record did not contain documentation the resident's left leg was assessed and monitored on 04/06/17, 04/07/17, 04/08/17, 04/09/17, 04/10/17, 04/11/17, 04/12/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/18/17, 04/19/17, 04/20/17, 04/21/17, 04/22/17, and 04/23/17. A nurse's note, dated 04/24/17 at 10:00 p.m., documented, +1 to 2 pitting edema noted in feet l (left) foot up to thigh appears larger than r (right) leg/foot .Faint yellowish discoloration noted to l (left) ^ (upper) thigh .constantly on call light today this shift . A nurse's note, dated 04/24/17 at 10:10 p.m., documented, CNAs report pain to L (left) leg when they reposition or change him. The clinical record did not contain documentation the resident's left leg was assessed and monitored. A nurse's note, dated 04/25/17 at 5:30 a.m., documented the resident had not slept until 5:15 a.m. The nurse's note documented the resident used the call light 19 times in 1.5 hours. The note documented the resident was unable to tell staff what he needed. The note documented when the call light was answered the resident stated, Help me, help me. The note documented the resident denied pain at that time. A nurse's note, dated 04/25/17 at 5:15 p.m., documented, .Screaming out 'help me' denies pain/discomfort when ask. L (left) foot 2+ pitting edema, cannot get shoe on, feet elevated this shift in recliner. Dr. (name deleted) call requesting copy of MAR (medication administration record). Communication sent yesterday to his/her office about edema to left leg et. (and) continuous being being (sic) on call-light. MARS sent to Dr. (name deleted) 0 N.O.'s (new orders) @ this time . A nurse's note, dated 04/26/17 at 5:45 a.m., documented the resident was awake all night yelling, Help me, help me, and was unable to tell staff what his needs were. The nurse's note documented the resident denied pain. Fax sent to Dr. (name deleted) & behavior sheet w (with) meds sent. A nurse's note, dated 04/26/17, documented, Dr. (name deleted) called & discussed what to do c (with) resident. received new order for psych eval. A nurse's note, dated 04/26/17 at 5:45 p.m., documented, Upon transfer res. (resident) c/o (complain of) pain upon movement of l (left) leg Conts. to have 1-2+ pitting edema. Yellowish (light) color noted to (arrow up sign) left leg. Also, besides pain to l leg, CNAs report L leg laying out et just 'flops' around. Communication sent to Dr. (name deleted). A nurse's note, dated 04/27/17 at 9:30 a.m., documented the physician called and ordered for the resident to have Lasix increased to 80 mg in the a.m. for three days and the evening dose was to remain at 40 mg. in the evening. A nurse's note, dated 04/27/17 at 7:40 p.m., documented, Cont. to monitor edema 1-2 + pitting in L leg, thigh, calf and, et. l foot. Unable to put shoe on L foot. Cont. to monitor . A nurse's note, dated 04/28/17 at 10:00 a.m., documented the resident was receiving additional Lasix and the resident continued of have 2+ non-pitting edema. A nurse's note, dated 04/29/17 at 10:00 a.m., documented the resident continued to have 2+ edema to the left leg and foot. A nurse's note, dated 04/29/17 at 5:00 p.m., documented the resident continued to have 2-3+ pitting edema to left foot and ankle. A nurse's note, dated 05/01/17 at 5:10 a.m., documented the resident continued to utilize the call light frequently. The note documented when the resident was asked what he needed, he continued to state, Help me, help me. The nurse's note documented the resident had been pain free until that moment. The note documented the resident reported he was hurting all over. Norco 10/325 was administered for pain. A radiology report with a faxed time that was stamped dated 05/02/17 at 8:11 a.m. documented a left knee x-ray had been completed on 03/22/17 at the local emergency department. The radiology report findings documented a left knee four-view x-ray was completed due to complaints of injury with left knee pain. The radiologist findings documented no acute findings. The report did not document the resident's left leg was x-rayed. The resident's left leg was not reassessed until 05/03/17. A nurse's note, dated 05/03/17 at 11:30 a.m., documented, Talked to PCP re: (regarding) continued c/o L leg-pain. Rc'd (received) order to x-ray L hip-femur-ankle & foot. Contacted (name deleted) mobile x-ray . A nurse's note, dated 05/03/17, documented the mobile x-ray had completed the resident's x-rays and the resident was diagnosed with [REDACTED]. A nurse's note, dated 05/03/17 at 1:45 p.m., documented an addendum. The note documented the resident's spouse reported she understood the resident received a left hip x-ray while at the local emergency department on 03/22/17 and the x-ray was negative for fracture. The note documented the later after the resident's spouse was notified of the left fracture, the staff asked the resident's spouse .didn't you say you thought Hosp. ER did hip x-ray. The nurse's note documented the spouse stated, I don't really remember. The resident's clinical record documented on 05/03/17 at 3:00 p.m., the resident's physician returned the telephone call. The record documented the physician requested the resident be transferred to the family's hospital of choice. The record documented at 4:45 p.m., the resident was transferred to a tertiary care facility for an orthopedic evaluation of the left femur fracture. A nurse's note, dated 05/05/17 at 5:40 p.m., documented the resident had returned from an Ardmore hospital via ambulance. The note documented the resident did not have surgical repair of the fracture. The note documented the resident remained a two-person transfer with a sling and mechanical lift. The note documented the resident's skin was intact and a stage 1 pressure wound was observed. The resident's clinical record documented the resident continued to require pain medication for leg and body pain after returning to the facility. A physician's orders [REDACTED]. On 05/16/17 at 9:15 a.m., the resident was observed in his room sitting in his wheelchair with his eyes closed. The resident was well groomed. The resident was observed to have lift sling in place and an additional sling was lying on the chair arm of the recliner. At that time, the resident's spouse was visiting. The spouse was asked how the resident was to be transferred. The resident's spouse reported after the resident had experience two falls the facility was to only transfer the resident with the use of a lift and two staff members. On 05/16/17 at 2:45 p.m., LPN #1 was interviewed. The nurse was asked how the resident was to be transferred. The LPN reported the resident was to be transferred with the use of a Hoyer lift and two staff members were to assist. During the interview on 05/16/17 at 2:45 p.m., LPN #1 reported one CNA had transferred the resident without assistance when the resident experienced a fall on 03/14/17 and again on 03/22/17. The LPN was asked how the resident was to be transferred. The LPN reported with a lift and two person assistance. The LPN reported the CNA is no longer employed at the facility. On 05/16/17 at 4:10 p.m., the ADM was interviewed. The ADM was asked if the facility was adequately staffed with CNAs. The ADM reported the facility was in the process of recruiting staff. On 05/17/17 at 9:22 a.m., the corporate nurse was asked if the resident was transferred properly to prevent injury. The nurse reported no and education was in the process of being conducted. On 05/17/17 at 10:20 a.m., the corporate nurse was asked if the staff followed the physician's orders [REDACTED].#2 on 03/14/17 and 03/22/17 for transfers. The corporate nurse reported no and staff education was in the process of being conducted. On 05/17/17 at 2:00 p.m., CNA staff interviews were conducted. Seven CNAs were interviewed. CNA #1 was asked how resident #2 was to be transferred. The CNA reported after the resident had fallen twice the resident was to be transferred with the use of a Hoyer lift and two staff members. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 was asked how staff members knew which residents required transfer assistance. The CNA reported a Daily Care Guide was utilized for resident care. The CNA reported the daily care guide documented how residents were to be transferred. The CNA reported walking rounds were also conducted at shift change and residents who had experienced changes in care were discussed. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 reported after resident #2 was transferred in the shower and the bedside commode by one CNA, which resulted in an injury to the resident, the CNAs were to only transfer resident #2 utilizing a Hoyer lift and two staff members. During the interviews on 05/17/17 at 2:00 p.m., CNA #1 reported the resident no longer goes into the bathroom or utilized a bedside commode. The CNA reported the resident was to urinate in his urinal and use a bedpan for bowel movements. The CNA reported the resident had a broken left leg and it was painful for the resident to move or be repositioned. During the interviews on 05/17/17 at 2:00 p.m., each CNA interviewed was able to explain how resident #2 was to be transferred. The CNAs reported resident #2 was injured during a fall and two staff members were to transfer the resident using the Hoyer lift. On 05/18/17 at 9:50 a.m., a copy of the emergency record for 03/22/17 was obtained. The record documented the physician's assistant documented an exam of the resident's left knee was conducted and the resident's knee was x-rayed. The record documented the physician's assistant exam documented the resident's left knee was painful and tender. The record documented the exam documented, ROM (range of motion): limited passive range of motion due to pain, in the left knee, Circulation is intact to all extremities. The record documented the emergency department nurse's note documented the resident received a pain injection while in the emergency. The nursing home clinical record contained no documentation from the emergency department of care instructions for the resident or the radiological studies conducted while at the emergency roiagnom on [DATE]. On 05/18/17 at 10:30 a.m., a telephone interview was conducted with the attending physician. The physician reported he/she was under the impression the x-rays ordered on [DATE] for the resident's left hip and left leg had been completed while in the emergency department on 03/22/17. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported the facility staff had been in contact with him/her regarding the resident's continued pain and restlessness. The physician reported staff had been asked about the x-ray results from the 03/22/17 emergency department visit. The physician reported he/she was notified only a left knee x-ray study had been completed at the emergency department. The physician reported at that time, on 05/03/17, a physician's orders [REDACTED]. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported at that time he/she ordered x-rays of the resident's left hip and leg. During the telephone interview on 05/18/17 at 10:30 a.m., the physician reported both the facility and the physician needed to be aware of what diagnostic studies and test results were when a resident was examined at the emergency department. On 05/18/17 at 1:30 p.m., LPN #1 was interviewed. The LPN reported the physician had discussed with the facility follow-up on diagnostic test ordered while at the emergency department. The LPN reported she was unsure if the transfer communication form accompanied the resident to the emergency department on 03/22/17. During the interview on 05/18/17 at 1:30 p.m., LPN #1 was asked after a resident had experienced a fall and continued to experience pain and bruising was staff expected to assess and monitor a resident. The LPN reported yes. The LPN was asked if the resident was monitored and assessed for left leg pain, bruising, and complications from a fall. The LPN reported no. The LPN was asked when a physician ordered diagnostic tests, should the facility complete those tests. The LPN reported yes. On 05/19/17 at 9:50 a.m., the ADM and corporate nurse were interviewed. The nurse was asked if the resident had been transferred properly per physician orders [REDACTED]. The nurse reported the facility was in the process of educating staff on following physician orders [REDACTED]. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked when a physician ordered diagnostic tests to be performed was the facility staff to ensure testing was completed as ordered. The nurse report yes. The nurse reported the facility was working to ensure test were completed as ordered by a physician. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked after a resident experienced a fall and continued to have pain, swelling, bruising, and restlessness was staff expected to assess and monitor the injury. The corporate nurse reported yes. During the interview on 05/19/17 at 9:50 a.m., the corporate nurse was asked if the increase of Seroquel 50 mg twice daily was appropriate when a resident continued to experience, swelling, restlessness, and unable to sleep. The nurse reported no. The nurse reported education would be conducted with the nursing staff.

Based on observation, record review, and interview, it was determined the facility failed to provide supervision to prevent accidents for one (#1) of four residents reviewed for falls. The facility failed to ensure fall prevention measures were implemented as ordered by the physician and fall analyses with interventions were conducted for resident #1. The administrator (ADM) reported 36 residents of the 80 residents, who resided in the facility, had experienced falls in the past three months. Findings: A facility clinical policy on managing falls and fall risks documented: 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .4. The staff and/or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/25/16, documented the resident required staff assistance for all activities of daily living (ADL). The care plan documented all transfers were to be assisted by the nursing staff. An undated entry documented all transfers were to be conducted with a mechanical lift. A physician's/prescriber's order, dated 06/28/16, documented, Bed Alarm to Bed (least restrictive device) DX Dementia & Parkinsons Safety. The order was signed by a nurse practitioner on 07/11/16. A care plan, initiated 07/03/16, documented the resident was at risk for further falls related to [DIAGNOSES REDACTED]. Interventions included on the care plan were for the staff to assist the resident for ambulation, for the call light was to be within reach, for a bed alarm, and for half bedrails for positioning and turning. The care plan documented the personal alarm use for wheelchair and recliner was discontinued. Interventions added to the care plan in response to the resident's falls included falling star program, keep close to nurse's station, frequent checks, and educating the family to call for assistance with resident care. A physician's/prescriber's order, dated 07/05/16, documented, Personal Alarm daily usage D/C (discontinue) Restorative Nursing Program per MD ordered to be D/Cd. The order was signed by the nurse practitioner on 07/13/16. A physician's/prescriber's order, dated 07/07/16, documented, Discontinue Personal Alarm Bed Alarm. The order contained the medical director's name in the attending physician area and contained an illegible signature. The clinical record documented the resident experienced 15 falls from 07/03/16 through 10/23/16. Nine of the falls occurred on the evening shift and six falls occurred on the day shift. A physician's orders [REDACTED]. Send MAR administration records. Place chair alarm and bed alarm. Implement geri chair, do not place pt. (patient) in wheelchair at desk. Patient is to be in direct supervision when up in chair. The order was noted by a licensed staff member. Below the physician orders [REDACTED]. Explained our facility doesn't use alarms. Requested speak (with) DON (director of nursing); explained she would be in Monday. The clinical record contained no documentation the order for alarms had been addressed or implemented. A care plan interventions, dated 10/28/16, documented to keep the resident close to the nurses' station and supervision in common areas. The clinical record documented the resident experienced a fall on 11/05/16 at 1:00 a.m. A care plan entry, dated 11/05/16, documented the resident experienced a fall with a skin tear left knee abrasion and for the resident to be checked every 15 minutes for 72 hours. A faxed physician notification, dated 11/12/16, documented, (Resident name deleted) fell in room attempted to stand up (with) wife @ side. (No) injuries . A care plan update, dated 11/12/16, documented, Fall (no) Inj (injury) Room. A nurse's note, dated 11/13/16 at 9:00 a.m., documented, Resident in room Attempted to stand up out of w/c (wheelchair) it as this nurse redirected res. (resident) to sit down. Res fell to floor beside w/c .(no) pain @ this X (time). One on one care continued . A care plan update, dated 11/13/16, documented, Fall (circled + sign) inj By (nurses') station Splint to (left) wrist hand . An undated care plan entries documented, Xray (left) = (fracture) 4th Metocaptorsal (sic). Educated wife on recliner (versus) Geri chair Multi times per Her choice likes w/c/recliner. An interdisciplinary team meeting form, dated 11/14/16 at 9:00 a.m., documented, Resident's wife came to nurses' station asking for assistance of resident back to bed. Wife stated she turned her back for a second and he fell out of chair. No injury noted. denies hitting head. Called hospice ask to have larger geri chair. A nurse's note, dated 11/14/16 at 10:50 a.m., documented, Swelling (with) bruising noted to (left) hand. PCP (primary care provided) notified. Order for x-ray received. A nurse's note, dated 11/14/16 at 11:45 a.m., documented, Order for bed alarm and Personal alarm to be placed. A physician's/prescriber's order, dated 11/14/16, documented the resident was to have an immobilizer to his left wrist/hand for eight weeks and chair and bed alarm to be used. The physician notification form for 11/12/16 was faxed to the facility on [DATE] at 3:52 p.m. with the order, Bed & chair alarm as previously ordered please. The order was noted by a licensed staff member on 11/14/16. A quarterly assessment, dated 12/15/16, documented the resident was severely impaired in cognition, exhibited no depression symptoms, and exhibited no behavioral symptoms. The assessment documented the resident required extensive assistance for transfers, dressing, eating, personal hygiene, and bathing. The assessment documented the resident had experienced two or more falls with no injury, two or more falls with injury, and one fall with major injury. A care plan entry, dated 12/15/16, documented, Quarterly Review Conts (continues) (with) recliner & w/c usage Alarms to Bed while in Bed or w/c. The care plan contained no further fall documentation after 11/13/16. The next fall documented in the clinical record was 01/03/17. On 01/04/17 at 10:00 a.m., the nurse practitioner for the resident's attending physician was interviewed. The nurse practitioner reported the facility would not follow the orders for the personal alarms. The nurse practitioner reported the resident experienced a hand injury in November and was frustrated with the facility for not following orders. On 01/04/17 at 11:30 a.m., the resident and his wife were interviewed. The resident was seated in a wheelchair with a personal alarm in place. The resident had a low speaking voice and was slow to respond to questions. The resident's wife reported the resident needed a larger geri-chair since the one provided by hospice did not fit the resident. The wife reported the resident could not sit comfortably in the geri-chair. At that time, the resident's wife reported she thought the chair alarm was helping the resident not have so many falls. The resident's wife reported the resident would sit down when the alarm sounded. During the interview, the resident was observed to attempt to stand up several times. The resident's wife would remind him to sit down. The resident did not move off the alarm pad enough to activate the alarm. The resident's wife reported the resident had worked outside most of the time and was not used to sitting around in the house. On 01/14/17 at 11:55 a.m., the ADON was asked about the orders for the personal alarms not being followed. The ADON reported the facility was a no alarm facility. The ADON was asked if the DON had spoken with the PCP about the no alarm policy, as the documentation on 10/28/16 had reported. The ADON reported she did not know if the DON spoke with the PCP. The ADON was asked if the facility could not follow the physician's orders [REDACTED]. The ADON reported the resident's wife wanted him in this facility. The ADON was informed the resident's wife thought the personal alarm was working to prevent falls. The ADON reported the resident had fallen numerous times since the personal alarm was placed. On 01/04/17 at 2:00 p.m., the corporate RN was asked for a copy of the facility's no alarm policy with the approval of the medical director. The corporate RN reported the facility did not have a written policy in regard to no personal alarms. She reported the DON had attended a seminar and evaluated the residents with alarms with the intent of eliminating the alarms in the facility. At that time, the corporate RN reported she had identified the resident's frequent falls for her QA analysis in the middle of November. The corporate RN reported the resident's falls had been addressed and the DON had reported the interventions were appropriate. The corporate RN reported fall analyses should be located in the resident's clinical record. The corporate RN was asked if the resident's frequent falls should have been addressed sooner, since the resident continued to experience falls and had experienced an injury. The corporate RN stated, Probably. On 01/04/17 at 2:15 p.m., the activities director was asked what activities of interest she provided for the resident to keep occupied to assist in preventing falls. The activities director reported she had taken the resident to the church services in the facility and the wife would remove the resident from the services to take him back to his room. The activities director was asked if she was aware the resident was accustomed to working outside daily prior to his illness. The activities director reported she was not aware of the resident's history and could do activities with him which would be to his interests. On 01/04/07 at 2:22 p.m., the social service director was asked if hospice was contacted about the resident's geri-chair replacement. The social service director reported he was not sure of the status of the geri-chair and had not spoken with hospice in a couple of weeks.

Based on record review, observation, and interview, it was determined the facility failed to assess, monitor, or intervene for a resident's decreased bowel movements and laxative ineffectiveness for one (#1) of three residents reviewed for provision of care and services. Resident #1 experienced fecal impaction, bowel obstruction, pain, and hospitalization . This had the potential to affect 88 residents who resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 12/24/10, documented the resident experienced a problem with bowel and bladder. The care plan documented the resident had a past [MEDICAL CONDITION], required frequent pain medication related to severe [MEDICAL CONDITION] arthritis, and was at risk for constipation. The care plan documented a targeted goal for the resident to achieve regular bowel movements at least every three days. Approaches listed were for the staff to provide verbal cueing, assess the resident for abdominal distention, assess for constipation and administer medication as need for constipation, evaluate nutritional interventions to support proper bowel elimination, assess bowel sounds, administer laxative or stool softener as ordered, keep fresh water at the bedside, and encourage the resident to drink fluids of her choice. A physician's orders [REDACTED]. A nurse's note, dated 08/01/16 at 9:00 a.m., documented, Resident c/o constipation, she says it has been really bad last couple of weeks. Daughter in & requested Magnesium cap c 3 caps @ HS. & Vitamin D caps-Dr. (name deleted) notified. The clinical record did not document the resident had complained of constipation or of discomfort. A nurse's note, dated 08/01/16 at 1:00 p.m., documented, Dr. (name deleted) wants lab work before ordering Vitamin D. Appointment scheduled for Thursday @ 8:00 a.m. A physician's orders [REDACTED]. The August 2016 Medication Administration Record [REDACTED] 08/06/16: MOM 30 ml (results not documented.) 08/13/16: MOM 30 ml, two doses, no results. 08/14/16: Written in entry for magnesium 400 mg four caps PO every eight hours. (The nurses' notes documented the resident received laxative and had extra large results.) 08/17/16: Magnesium 400 mg, (capsule amount and results not documented.) 08/19/16: MOM 30 ml, two doses, and magnesium 400 mg, (capsule amount of magnesium and results not documented.) 08/20/16: Magnesium 400 mg three capsules (results not documented.) 08/21/16: Magnesium 400 mg three capsules (results not documented.) 08/23/16: Magnesium 400 mg three capsules, small results. 08/24/16: Magnesium 400 mg three capsules, two doses, small results. 08/25/16: Magnesium 400 mg three capsules, two doses, small results. 08/27/16: Magnesium 400 mg three capsules, small results. 08/29/16 and 08/30/16: Magnesium 400 mg (no entry in regard to capsule amounts or results.) The MAR indicated [REDACTED]. The clinical record contained no documentation the resident was assessed for bowel sounds or abdominal pain. The clinical record contained no documentation the physician was notified of the frequency of the prn laxative use and ineffectiveness. The clinical record contained no documentation of other interventions implemented to address the resident's constipation. An annual assessment, dated 09/05/16, documented the resident was cognitively intact, required supervision with set-up for toileting, transfers, ambulation, dressing, meals, and hygiene. The assessment documented the resident required physical help in bathing and experienced decreased mobility in all extremities. The assessment documented the resident was continent of bowel and bladder. The September 2016 MAR indicated [REDACTED] 09/03/16: MOM 30 ml, no results @ 10 pm. 09/06/16: Magnesium 400 mg (no capsule amount or results documented.) 09/10/16: MOM 30 ml with xs (extra small) results, magnesium 400 mg four caps with little results. 09/11/16: MOM 30 ml, c/o constipation-xs BM hard pt. stated it hurt to go. Magnesium 400 mg four capsules, no results @ 930 pm. 09/12/16: MOM 30 ml (no documentation of time, amount, or results), magnesium 400 mg four capsules, constipation Results pending @ 10 pm. 09/13/16: Magnesium 400 mg, two doses (no capsule amount or results documented). 09/14/16: MOM 30 ml (no results documented). The MAR indicated [REDACTED]. The clinical record contained no documentation the resident was assessed for bowel sounds or abdominal pain when the resident complained of pain with bowel movements on 09/11/16. The clinical record contained no documentation the physician was notified of the frequency and ineffectiveness of the prn laxative use or of the resident having pain with bowel movements. The September 2016 CNA ADL flow sheet documented in the area for continence C in both the areas for urine and bowel movements. No size or frequency of bowel movements were documented on the flow sheet. A nurse's note, dated 09/14/16 at 2:30 p.m., documented, .bowels slow to act MOM c prune juice given at this time. The clinical record did not contain documentation the effectiveness of the laxative and prune juice. A nurse's note, dated 09/14/16 at 5:00 p.m., documented, Refused emergency RM-Dr. (name deleted) notified c N.O. (new order) to obtain Abd. x-ray stat. (Name deleted) mobile notified. BS (bowel sounds) noted in RUQ (right upper quadrant) & LUQ (left upper quadrant) c sluggish BS (bowel sounds) in lower quadrant. Resident states that she has been having slow activity until today c no activity to speak of today. Explained to resident that x-ray will be coming to make sure nothing else is wrong. A SBAR (situation, background, appearance, review) communication form, dated 09/14/16 at 5:00 p.m., documented, Situation .sluggish lower bowel sounds c Hyper upper right .treatment .MOM .she has had a colon resection d/t constipation . Background .needing to see her doctor .Resident evaluation . Abdominal/ GI Evaluation Abdominal pain, Abdominal tenderness. Constipation (date of last BM 9/13/16), Decreased/absent bowel sounds, Distended abdomen, Decreased appetite/fluid intake, Hyperactive bowel sounds upper, Resident smiling no distress noted . Appearance .alert & oriented. Speech clear, breath sounds clear, no s/sx of distress . Review And Notify .Resident does not complain or express how bad it really is. She refused to go to ER for evaluation. On 09/14/16 at 0705 (sic), a nurse's note documented the mobile x-ray had arrived for the abdominal x-ray to be completed. On 09/14/16 at 0725 (sic), a nurse's note documented, Received call from resident's daughter requested she be sent to ER for abd. pain. This nurse went & assessed resident, resident has began vomiting, white emesis. Abd. is firm & distended, resident reports intermittent severe abd. pain. 911 called, informed dtr. resident being sent to ER. A nurse's note, dated 09/14/16 at 0750 (sic), documented, Care transferred to (name deleted) EMS, x-ray results have arrived & sent c EMS. Notified Dr. (name deleted) via fax. Notified .(name deleted) R.N. unit manager. A mobile x-ray report, dated 09/14/16, documented, Findings: .Marked enlarged stool-filled colon from cecum to rectum with ascending colon spanning 9.3 cm. The distention and stool appears diffuse without gross evidence of volvulus. Pelvic phleboliths .Impression: Markedly distended stool-filled bowel suggestive of constipation . A physician's consultation report, dated 09/15/16, documented, .The patient was transferred from (hospital name deleted) last night for abdominal pain. CT scan performed there showed early signs of small bowel and large bowel blockage with concern about this being secondary to obstruction of the distal sigmoid. She has had a history of [REDACTED].She has been having nausea and vomiting for the past 3 to 4 days .PHYSICAL EXAMINATION: .Rectal: Not repeated. She was found extremely hard stool bolus in the rectum. It was guaiac-positive .ASSESSMENT : Large bowel obstruction with subsequent small bowel, most likely secondary to colonic ileus with obstipation secondary to chronic opiate use and limited activity . On 09/19/16 at 9:40 a.m., the resident was observed in her room. The resident was sitting in her wheelchair. The resident was alert and oriented. The resident reported she was taking her medicine. The resident was observed to be holding a medicine cup of white liquid. No staff member was present in the resident's room. At that time, the resident was asked how she was feeling. The resident reported she was feeling better but had to be hospitalized for [REDACTED]. On 09/19/16 at 10:15 a.m., the ADM, DON, and corporate RN provided the surveyors with documentation the problems of resident bowel movement monitoring and appointment scheduling were addressed by the quality assurance committee. The corporate RN reported the facility had in-serviced the staff and conducted audits of all the residents for bowel movements. On 09/19/16 at 11:30 a.m., CNA #1 and CNA #2 were interviewed and asked if they were given in-services on documentation and reporting residents' bowel movements. The CNAs reported they had been given in-services. The CNAs reported they were to ask the residents daily if the residents had bowel movements. On 09/19/16 at 11:40 a.m., the DON reported the facility had put interventions in place to ensure the residents' bowel movements were monitored. The DON was asked about the ADL records not having specific documentation about the residents' number and size of bowel movements. The DON reported the corporate office was to provide the facility with different ADL sheets which would have spaces for the CNAs to document more effectively. On 09/19/16 at 11:45 a.m., LPN #1 reported the resident reported having a little along when asked about her bowels, on the days prior to being hospitalized . The LPN reported the resident was in trouble when the LPN came to work on Wednesday (09/14/16) and the physician was notified. The LPN reported the resident had refused to go to the emergency room earlier the afternoon of 09/14/16. At that time, the LPN and the DON were asked if the physician was aware of the resident having increased constipation. The DON reported the resident had a physician's appointment the previous week which was missed due to the resident being transported on the wrong day. The DON reported she was not sure if the physician was notified of the resident's increased constipation and pain with bowel movements. On 09/19/16 at 12:30 p.m., CMA #1 was interviewed. The CMA was asked when a resident received a laxative for constipation should the results be documented. The CMA reported yes, at times this did not occur. The CMA was asked when a medication was administered and the medications were ineffective should the charge nurse be notified. The CMA reported yes. The CMA was asked when a charge nurse was notified the medications were ineffective where would the documentation be located. The CMA reported the documentation would be on the back page of the medication administration record. The facility provided in-service records, dated 09/16/16, documented the topics of, Nursing staff and CMA's to check ADL book at the beginning of each shift. If no reported BM for three days then initiate interventions per physician orders. Documentation of bowel movements, asking cognitive residents that are continent when last BM was. The facility provided audits of all the residents for current bowel movement status which were conducted on 09/16/16. Facility records documented: -The facility had identified areas of weakness in the procedures for documenting and monitoring of residents' bowel movements following a resident's hospitalization with a bowel obstruction from a fecal impaction. -The facility had assessed all current residents for the potential to be affected by the weakness in the system of monitoring and intervening residents. -The facility had in-serviced the staff on new procedures to prevent reoccurrence of the issues. -The facility had brought the issue to the Quality Assurance (QA) committee. The issues addressed included monitoring residents' bowel movements and providing timely interventions. The committee had instituted ongoing audits to ensure compliance.

Based on record review, observation, and interviews, it was determined the facility failed to ensure interventions were in place to prevent the decline of one identified pressure ulcer and the development of multiple pressure ulcers for one (#2) of two sampled residents who were reviewed for pressure ulcers. A sacral decubitus declined from a stage I to a stage IV. The facility failed to: a) Thoroughly assess and monitor resident #2's skin condition. b) Develop an admission care plan to address resident #2's skin condition, including a stage one pressure ulcer on the resident's coccyx. The census and condition report documented four residents with pressure ulcers. Findings: Resident #2 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing evaluation, dated 03/10/16, documented the following: #1 L ear 0.5 x 0.7 x 0.05 A (abrasion) #2 R ankle 0.3 x 1 x 0.05 A #3 Rash F (other Ulcer) #4 Rash Heel F #5 Cut 1 x 0.3 x 0.2 scabbed A #6 Stg I B (bruise). The stage I pressure ulcer was identified on a body diagram as being on the coccyx area. A Braden Scale, dated 03/10/16, documented a total score of 10. The score results documented a score of 10-12 was a high risk for pressure ulcers. An admission care plan, dated 03/10/16, did not address any problems with the resident's skin. The initial nurse's notes, dated 03/10/16, did not address any problems with the resident's skin. An admission MDS assessment, dated 03/16/16, documented the resident was at high risk for developing pressure ulcers and had one stage I pressure ulcer with [MEDICATION NAME] tissue. The assessment documented skin and ulcer treatments were to include a pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, and application or ointments/medications. The clinical record contained no documentation any of the above interventions were implemented. The clinical record contained no other documentation of the resident's skin conditions until 03/29/16. A nurse's note, dated 03/29/16 (with no time), documented, Multiple areas to RLE. area of healing ulcers. 2-open area tx c [MEDICATION NAME] Drsg- p (post) cleanse c NS QD @ 6a-6p. Reminder to staff to float heels @ all x's while in bed. A nurse's note, dated 03/30/16 at 1:00 p.m., documented, .Multiple bruising & large blister on L-heel- Dr (Name deleted) notified. Foot board removed from bed, d/t resident to long for bed, & banging ft on ft board. Enc staff to keep foot of bed elevated. Keep socks & heel protectors @ all times . A nurse's note, dated 03/30/16 at 3:30 p.m., documented, Dr (Name deleted) in & informed him of wounds on R-ft- In agreement c ADON c skin prep to dry closed wounds, & apply medhony to inside ankle. Start zinc & vitamin c & arginade-Dr (Name deleted) seen resident & was in full agreement. The weekly wound documentation, dated 03/30/16, documented the following: Exterior midside R ft Unstageable L 1.0 cm W 1.5 cm Drainage/Odor None Wound Edges Dry Treatment Vitamin Supplement Protein Supplement. Above R-outside Ankle Unstageable L 1.0 cm W 0.3 cm Drainage/Odor None Wound Edges Dry. R-Heel Unstageable L 6 cm W 5 cm blood blister Drainage/Odor None Wound Edges Dry Vitamin Supplement Protein Supplement. Exterior side of R-Heel Unstageable L 3 cm W 3 cm Drainage/Odor None Wound Edges Dry Vitamin Supplement Protein Supplement. A nurse's note, dated 04/02/16 at 2:00 a.m., documented, .While cleaning buttocks noted there is a 1 cm black area both c irregular borders. Cleansed c NSS, patted dry; applied 2x2 Dermafoam; covered c 4x4 and taped in place . A nurse's note, dated 04/03/16 at 10:00 a.m., documented, Pt c multiple wounds TX done per tx order. Has wound to coccyx c dark areas noted .Res c appt for wound care 4-4-16. The weekly wound documentation, dated 04/04/16, documented, Buttocks fold Unstageable L 6 cm W 4 cm D 0.2 cm 75 % eschar(.) Drainage/Odor scant Type Serous Odor None(.) Wound Edges Macerated(.) Treatment Vitamin Supplement Protein Supplement(.) Sacral Unstageable L 5 cm W 3 cm D 0.1 cm 75 % eschar(.) Drainage/Odor scant Type Serous Odor None(.) Wound Edges Macerated [DIAGNOSES REDACTED](.) Treatment Vitamin Supplement Protein Supplement. A nurse's note, dated 04/08/16 at 12:30 a.m., documented, .Escar area on inner buttocks popped c bloody drainage noted. Dr (Name deleted) notified c orders to use-med honey & obtain wound consult. The weekly wound documentation, dated 04/08/16, documented: Sacral Unstageable L 5 cm W 4 cm D 1.0 cm 75 % eschar(.) Drainage/Odor heavy Type Serosanguineous other Bloody Odor Present(.) Wound Edges Macerated [DIAGNOSES REDACTED] Treatment Vitamin Supplement Protein Supplement. A nurse's note, dated 04/10/16, at 10:00 a.m., documented, . Dressing (change sign) to wound on coccyx done(.) Moderate drainage c foul odor noted. tol well air mattress in place . The clinical record contained no documentation the resident was seen by the wound clinic until 04/13/16. A wound clinic physician procedure note, dated 04/13/16 at 10:30 a.m., documented the following: .OBJECTIVE FINDINGS Multi ulcers- sacrum- large ulcer tunnels about total 10 cm from 12 to 5 oclock. WOUND/ULCER DEBRIDEMENT #1 coccyx 2.0 x 1.0 x 2.6 Wound Grade/Stage IV Character of Wound/Ulcer New Indication for Debridement Abnormal Wound Base bloody c no pressure . #2 Right lateral ankles 1.5 x 1.0 x 0.2 Wound Grade/Stage II III. #3 Right Heel 5.0 x 1.0 x 0.2 Wound Grade/Stage eschar. unstage. Character of Wound/Ulcer Necrotic. The nurses' notes, dated 04/16/16 at 4:30 a.m., documented the resident was found unresponsive to verbal or tactile stimulation and was sent to the hospital. The clinical record contained no description or measurements of the resident's pressure ulcers before being sent to the hospital. The resident was admitted to the hospital with [REDACTED]. A nurse's note, dated 04/22/16 at 2:00 a.m., documented the resident had returned to the facility. The clinical record did not contain any descriptions or measurements of the resident's pressure ulcers upon readmission to the facility. On 04/26/16 at 11:05 a.m., wound care was observed for the resident. The sacral pressure ulcer was observed with red brown drainage which had leaked onto the incontinent pad. The wound was odorous when it was exposed to room air. RN #1 provided the wound care then measured the pressure ulcers. The right inner ankle measured 1.1 cm x 0.8 cm. The area was not open. The right lateral heel measured 2.8 cm x 1.9 cm. The area was covered with eschar. The coccyx pressure ulcer measured 3.8 cm x 5.0 cm x 6.5 cm tunneling from 12 o'clock to 5 o'clock. On 04/26/16 at 9:45 a.m., the DON was asked if the pressure ulcers had been measured before and after admission to the hospital. The DON reported she would check. At 2:30 p.m., LPN #2 reported she had measured the wounds on 04/25/16 when she had returned to work. LPN #2 presented a napkin which had been in a drawer in the nursing office. The napkin was not dated. Measurements written on the napkin were as follows. Coccx (sic) 3 x 5 (tunneling) 5 1/2 cm @12 - 3.0 cm @9- R-inside ankle 2 x 0.6 R outside ankle 2 x 2.5 R Heel 2.5 x 1.5. On 04/26/16 at 2:45 p.m., the DON was notified of the lack of documentation of any of the skin problems identified upon admission until the decline in condition of the coccyx, heels, and ankles. The DON was asked if the facility should have monitored the areas closer. The DON reported the areas should have been monitored upon admission and at least weekly after admission. The DON was asked if interventions to prevent the decline in the pressure ulcers should have been put in place upon identification of the skin problems when the resident was admitted to the facility. The DON reported measures should have been put in place sooner.

Based on record review and interviews, it was determined the facility failed to assess, monitor, and implement necessary care and services to ensure residents' highest levels of well-being for one (#2) of three sampled residents reviewed for well-being, including falls. The facility failed to provide timely care for a resident who experienced a fall with fractured ribs, a pneumothorax, and the insertion of a chest tube. The DON reported 82 residents resided in the facility. Findings: Resident #2 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, updated on 09/30/15, documented the resident had a potential for falls. Interventions included for the resident to have the call light within reach, to instruct the resident to ask for assistance when needed, to encourage the resident to take rest periods, and to encourage and remind the resident of safety precautions. A physician's orders [REDACTED]. A quarterly assessment, dated 12/07/15, documented the resident was cognitively impaired with severely impaired decision making skills, required extensive assistance in all ADLs, had impairments in both upper and lower extremities, and was occasionally incontinent of bowel and bladder. A nurse's note, dated 01/18/16 at 10:00 p.m., documented, Resident was in bed, found in floor by the nurse sitting up next to bed. Alarm was still attached to resident. Was on Fall mat. denies hitting head. O (no) notable injuries. Does C/O L (left) side pain on palpation to (arrow down sign) rib area. Is able to raise arm. Resident states stomach hurts. Dr. notified order received to X-Ray ribs shoulder & wrist on L side. Family aware. The January 2016 MAR documented the resident had been administered Tylenol #3 for pain on 01/18/16. The narcotic record for the Tylenol #3 had been crossed through, indicating the medication had not been administered. A respiratory record for 01/18/16 was blank with no O2 sats recorded. An incident report, dated 01/18/16 at 10:00 p.m., documented, Resident was in bed then was sitting on floor next to bed, had alarm Attached to her . The incident report documented the physician and family had been notified on 01/19/16 at 11:30 a.m. A physician's telephone order, dated 01/18/16, documented, X-Ray to L breast area & rib, shoulder, wrist Dx pain. A nurse's note, dated 01/18/16 with no time documented, Resident (up sign) W.C C/O L breast and rib area. New order received for X-Ray. A nurse's note, dated 01/18/16 at 10:00 p.m., documented, Spoke to mobile X-Ray will be here in the AM. Assessments, including the resident's vital signs, respiratory status, and/or pain status, had not been documented. A nurse's note, dated 01/19/16 with a time of 10/6, documented, Urine culture faxed to Documentation that the resident had been assessed and monitored for her respiratory status, pain status, and/or a change in condition after the fall was not found in the resident's clinical record. There was no documentation pain medication had been administered to the resident during the night. There was no documentation the resident had been assessed and monitored for vital signs, respiratory status, pain, or a change in condition on the day shift before the resident was x-rayed. There was no documentation pain medication had been administered to the resident. A nurse's note, dated 01/19/16 at 10:00 a.m., documented, (mobile X-Ray name deleted) here to do X-ray of rib area d/t C.O pain. Resident states she is tired Assisted into bed. A nurse's note, dated 01/19/16 at 10:30 a.m., documented, Rec'd x-ray results of Fracture of posterior left seventh et eighth ribs Left pneumothorax c effusion versus blood in the left base. Notified (ADON name deleted) Resident to be sent to ER. The x-ray results, faxed to the facility on [DATE] at 10:30 a.m., documented, Findings: Left pneumothorax. Soft tissue gas along the lateral left [MEDICATION NAME] base Impression Left pneumothorax, with effusion versus blood in the left base. Fractures of posterior left seventh and eighth ribs. A physician's telephone order, dated 01/19/16, documented, May Send to ER for eval & tx. A nurse's note, dated 01/19/16 at 11:00 a.m., documented, EMSA here to transfer resident to ER States Lab out of order at (Hospital name deleted) will transfer resident to (Hospital name deleted.) At 11:30 a.m., a nurse's note documented, (Resident's family member name deleted) residents daughter in law notified of occurrence. (Dr's name deleted) notified. A Discharge Summary from the hospital, dated 01/25/16, documented, admitted [DATE] .(Resident's name deleted) fell at the nursing home and was admitted to (Hospital name deleted) Emergency Department. She had left-sided chest pain and shortness of breath, CT confirmed 2 rib fractures and the left-sided pneumothorax. A chest tube was placed in the ER . On 01/28/16 at 9:50 a.m., a family member was interviewed. The family member reported the family was not aware of what had happened to the resident until the staff called them to tell them the resident was being sent to the hospital. The family member reported they were unaware the resident had fallen and had not been notified of the incident occurring the night before. On 01/28/16 at 2:15 p.m., the CMA, who had been working the night of the incident, was asked if he had administered any pain medication to the resident. The CMA reviewed the MAR and reported no pain medication had been administered. The CMA reported the resident had been complaining of pain the next morning before the x-ray. On 01/28/16 at 2:45 p.m., LPN #2, who had completed the incident report, was interviewed. The LPN reported she had been sick on the night of the incident and did not remember much of the incident. She reported the resident was found sitting on the floor with the alarm on her. LPN #2 reported the resident was complaining of pain. She was asked if she had obtained vital signs at the time of the incident. She reported she could not remember. She was asked if she had administered pain medication to the resident. She reported she could not remember, but thought she had given the resident a pain medication. At 3:30 p.m., the DON was notified of the lack of assessing and monitoring for the resident after a fall. The DON reported the staff should have monitored the resident more closely and obtained vital signs. At 4:00 p.m., the ADM, corporate nurse, and the DON were notified of the lack of assessing and monitoring of the resident after the fall for thirteen hours before being sent to the hospital. The DON stated, They just didn't do it.

Based on record review and staff interviews, it was determined the facility failed to assess, monitor and intervene in a timely manner when a resident experienced nausea and vomiting, which resulted in actual harm for one (#2) of four sampled residents. This had the potential to affect all 72 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/18/13, documented the resident had GERD, as a problem. A goal was for the resident to have decreased episodes of stomach pain. Approaches listed were for the staff to monitor the resident for complaints of GI problems: upset stomach, loose stools, emesis and heartburn. A quarterly assessment, dated 11/15/14, documented the resident was severely impaired with cognition, required extensive assistance of one staff member for transfer, bed mobility, dressing, hygiene and bathing. The resident required limited assistance of one staff member with eating. The resident was always incontinent of bowel and bladder. A 24 hour report, dated 01/23/15, documented the resident had nausea and vomiting during the a.m. The nurses' notes were reviewed for 01/23/15. There was no documentation regarding the episodes of vomiting. There was no documentation the physician had been notified during the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift concerning the vomiting episodes. A nurse's note, dated 01/24/15 at 3:15 a.m., documented, "0245 (2:45 a.m.) CNA reported resident had vomited. On observation resident had projectile coffee emisis (sic) on wall, chest, pillow. T 99.7 skin pale called physician (Name deleted) on call for physician (Name deleted) c report, orders to transfer to ER for evaluation. Resident cleaned up in shower. 0300 (3:00 a.m.) EMS c two attendants here. Transferred resident to gurny (sic). Report called into hospital (Name deleted) at 0305 (3:05 a.m.)." The clinical record contained no documentation a family member had been notified the resident had been sent to the hospital. A Notice Of Corrective Action, dated 01/24/15, documented, "...(nurse's name deleted)...Termination of Employment...01/24/15 (resident name deleted) c N/V, o note, o med given, Dr. nor Family notified....Immediate..." An In-Service/Training Sign In Sheet, dated 01/24/15, documented, "...Summary of Subjects Covered: Approx Times to Notify Family: Send out to Hospital Med Change any change in condition, Dr. appt's, Falls, Skin Tears and Documentation..." A hospital physician's progress note, dated 01/24/15, documented, "...History of Present Illness: (resident name deleted)...presented to the emergency room via EMS, with nursing home reporting coffee-ground emesis there at the nursing home facility. They stated that last evening, she had a stool that smelled very suspicious of [DIAGNOSES REDACTED]icile to them, then she began this, what they refer to as, 'projectile vomiting' with coffee-ground emesis just prior to sending her here to the emergency department..." A hospital discharge summary, dated 01/24/15 at 2020 (8:20 p.m.), documented, "...Admit Diagnoses: [REDACTED]. 1.[MEDICAL CONDITION] 2. Right-sided pneumonia 3. Urinary tract infection 4. [MEDICAL CONDITION] 5. Dehydration 6. Influenza B. 7. [MEDICAL CONDITION] 8. Secondary Parkinsonism 9. Hypertension Discharge Diagnosis: [REDACTED]. Discharge Disposition: The patient succumbed to her multiple comorbid illnesses, namely cause of death,[MEDICAL CONDITION]" On 02/18/15 at 1:20 p.m., CNA #1 was questioned in regard to the resident having nausea and vomiting during the shift she had worked on 01/23/15. The CNA reported the resident had vomited at least three times during her 6:00 a.m. to 2:00 p.m. shift. The CNA reported the first episode of vomiting occurred while the resident was in the dining room for breakfast. The second episode occurred after lunch and the last episode at approximately 1:30 p.m. before the CNA went home. The CNA reported LPN #1 was present when the resident first vomited in the dining room. The CNA reported she had informed LPN #1 of the next two episodes of vomiting. At 3:05 p.m., a telephone interview was conducted with RN #1 who was DON at the time of the incident. RN #1 was questioned in regard to LPN #1's termination. The RN reported the LPN was terminated due to two previous write ups and the latest incident concerning the resident. The RN then reported the LPN had documented the resident had nausea and vomiting on the 24 hour report 20 hours prior to being sent to the ER. The LPN had not documented in the clinical record concerning the nausea and vomiting. The RN reported she had spoken with a couple of CNAs who reported the resident had vomited three times during the 6:00 a.m. to 2:00 p.m. shift. CNA #1 reported she had informed LPN #1 of the resident's continual vomiting. CNA #2 had reported the resident had vomited two or three times during the 2:00 p.m. to 10:00 p.m shift but she did not tell her charge nurse because she thought the charge nurse was aware of the resident's condition. The RN reported CNA #2 had been verbally counseled for not reporting to the charge nurse. The RN also reported she had spoken with LPN #2. The LPN had reported she had not been made aware the resident had any problems. RN #1 was then asked if the physician should have been notified in a more timely manner. The RN stated, "Yes." The RN was asked if the family should have been notified when the resident was sent to the hospital. The RN stated, "Yes." The RN was asked if the resident should have been assessed, monitored and interventions implemented. The RN stated, "Yes, it should have been. Something should have been done on our part." At 4:20 p.m., the current DON and the corporate DON were asked if the physician should have been notified in a timely manner. No comment was made. They were both asked if the family should have been notified when the resident was sent to the hospital. They both nodded. The DON and Corporate DON were asked if the resident should have been assessed and monitored. They reported the previous DON could answer those questions. At 5:20 p.m., a telephone interview was conducted with LPN #2. The LPN was questioned in regard to the resident's condition. The LPN reported she had received report the resident had vomited once during the previous shift. The LPN reported CNA #2 had not notified her of the resident's vomiting on her shift. The LPN stated, "I didn't chart on her because there wasn't anything to chart."

Based on record review and staff interviews, it was determined the facility failed to notify: a) The physician in a timely manner of a resident's nausea and vomiting which resulted in actual harm for one (#2) of one sampled resident who experienced nausea and vomiting. b) A family member when the resident was transported to the hospital for one (#2) of two sampled residents who were transported to the hospital in the last month. This had the potential to affect all 72 residents who resided in the facility. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/18/13, documented the resident had GERD, as a problem. A goal was for the resident to have decreased episodes of stomach pain. Approaches listed were for the staff to monitor the resident for complaints of GI problems: upset stomach, loose stools, emesis and heartburn. A quarterly assessment, dated 11/15/14, documented the resident was severely impaired with cognition, required extensive assistance of one staff member for transfer, bed mobility, dressing, hygiene and bathing. The resident required limited assistance of one staff member with eating. The resident was always incontinent of bowel and bladder. A 24 hour report, dated 01/23/15, documented the resident had nausea and vomiting during the a.m. The nurses' notes were reviewed for 01/23/15. There was no documentation regarding the episodes of vomiting. There was no documentation the physician had been notified during the 6:00 a.m. to 2:00 p.m. shift or the 2:00 p.m. to 10:00 p.m. shift concerning the vomiting episodes. A nurse's note, dated 01/24/15 at 3:15 a.m., documented, "0245 (2:45 a.m.) CNA reported resident had vomited. On observation resident had projectile coffee emisis (sic) on wall, chest, pillow. T 99.7 skin pale called physician (Name deleted) on call for physician (Name deleted) c report, orders to transfer to ER for evaluation. Resident cleaned up in shower. 0300 (3:00 a.m.) EMS c two attendants here. Transferred resident to gurny (sic). Report called into hospital (Name deleted) at 0305 (3:05 a.m.)." The clinical record contained no documentation a family member had been notified the resident had been sent to the hospital. A Notice Of Corrective Action, dated 01/24/15, documented, "...(nurse's name deleted)...Termination of Employment...01/24/15 (resident name deleted) c N/V, o note, o med given, Dr. nor Family notified....Immediate..." An In-Service/Training Sign In Sheet, dated 01/24/15, documented, "...Summary of Subjects Covered: Approx Times to Notify Family: Send out to Hospital Med Change any change in condition, Dr. appt's, Falls, Skin Tears and Documentation..." A hospital physician's progress note, dated 01/24/15, documented, "...History of Present Illness: (resident name deleted)...presented to the emergency room via EMS, with nursing home reporting coffee-ground emesis there at the nursing home facility. They stated that last evening, she had a stool that smelled very suspicious of [DIAGNOSES REDACTED]icile to them, then she began this, what they refer to as, 'projectile vomiting' with coffee-ground emesis just prior to sending her here to the emergency department..." A hospital discharge summary, dated 01/24/15 at 2020 (8:20 p.m.), documented, "...Admit Diagnoses: [REDACTED]. 1.[MEDICAL CONDITION] 2. Right-sided pneumonia 3. Urinary tract infection 4. [MEDICAL CONDITION] 5. Dehydration 6. Influenza B. 7. [MEDICAL CONDITION] 8. Secondary Parkinsonism 9. Hypertension Discharge Diagnosis: [REDACTED]. Discharge Disposition: The patient succumbed to her multiple comorbid illnesses, namely cause of death,[MEDICAL CONDITION]" On 02/18/15 at 1:20 p.m., CNA #1 was questioned in regard to the resident having nausea and vomiting during the shift she had worked on 01/23/15. The CNA reported the resident had vomited at least three times during her 6:00 a.m. to 2:00 p.m. shift. The CNA reported the first episode of vomiting occurred while the resident was in the dining room for breakfast. The second episode occurred after lunch and the last episode at approximately 1:30 p.m. before the CNA went home. The CNA reported LPN #1 was present when the resident first vomited in the dining room. The CNA reported she had informed LPN #1 of the next two episodes of vomiting. At 3:05 p.m., a telephone interview was conducted with RN #1 who was DON at the time of the incident. RN #1 was questioned in regard to LPN #1's termination. The RN reported the LPN was terminated due to two previous write ups and the latest incident concerning the resident. The RN then reported the LPN had documented the resident had nausea and vomiting on the 24 hour report 20 hours prior to being sent to the ER. The LPN had not documented in the clinical record concerning the nausea and vomiting. The RN reported she had spoken with a couple of CNAs who reported the resident had vomited three times during the 6:00 a.m. to 2:00 p.m. shift. CNA #1 reported she had informed LPN #1 of the resident's continual vomiting. CNA #2 had reported the resident had vomited two or three times during the 2:00 p.m. to 10:00 p.m shift but she did not tell her charge nurse because she thought the charge nurse was aware of the resident's condition. The RN reported CNA #2 had been verbally counseled for not reporting to the charge nurse. The RN also reported she had spoken with LPN #2. The LPN had reported she had not been made aware the resident had any problems. RN #1 was then asked if the physician should have been notified in a more timely manner. The RN stated, "Yes." The RN was asked if the family should have been notified when the resident was sent to the hospital. The RN stated, "Yes." The RN was asked if the resident should have been assessed, monitored and interventions implemented. The RN stated, "Yes, it should have been. Something should have been done on our part." At 4:20 p.m., the current DON and the corporate DON were asked if the physician should have been notified in a timely manner. No comment was made. They were both asked if the family should have been notified when the resident was sent to the hospital. They both nodded. At 5:20 p.m., a telephone interview was conducted with LPN #2. The LPN was questioned in regard to the resident's condition. The LPN reported she had received report the resident had vomited once during the previous shift. The LPN reported CNA #2 had not notified her of the resident's vomiting on her shift. The LPN stated, "I didn't chart on her because there wasn't anything to chart."

On 09/03/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure the physician was notified of numerous falls, increased signs and symptoms of pain, discomfort and a decline in the condition of one resident (#2) who had experienced a [MEDICAL CONDITION]. The Oklahoma State Department of Health was notified and verified the existence of the immediate jeopardy situation. On 09/03/14 at 5:15 p.m., the ADM, DON and Corporate Nurse were notified of the IJ situation involving the lack of physician notification. At 6:30 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Plan of Removal of Immediate Jeopardy 1. Affected resident was sent to hospital on [DATE]. 2. 100% of current residents will be re-evaluated for fall risk by 9/5/14. Care Plans will be updated to reflect current resident risk factors and interventions by 9/5/14. Additionally, CNA Communication Forms will be updated to include current fall reduction interventions by 9/5/14. 3. Staff to be re-educated on facility's policy regarding post-fall assessment and physician notification by 9/5/14. Staff to be re-educated on the facility's policy regarding pain management, assessment and identification of both verbal and non-verbal pain by 9/5/14. Staff to be educated recognizing changes in condition from the resident's base line and to notify physician and family of those changes by 9/5/14. A quality assurance meeting will be held on 9/4/14 to review and approve the corrective actions taken. Facility Medical Director was notified on 9/3/14 at 0630 PM regarding the immediate jeopardy. 4. DON or Designee will review falls daily with clinical team to ensure appropriate assessment has been completed; physician notification is appropriate; root cause analysis has been completed and documented in the medical record; and interventions have been put in place to minimize risk of recurrence." On 09/04/14 at 9:30 a.m., the immediate jeopardy was removed when it was determined the facility staff had been in-serviced and were proficient in procedures put in place by the plan of removal. The deficiency remained at actual harm at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to to ensure the physician was notified of numerous falls, increased signs and symptoms of pain, discomfort and a decline in the condition of one (#2) of three sampled resident's who had experienced falls. This resulted in harm to resident #2. This had the potential to affect all 85 residents who resided in the facility. Findings: A facility Policy and Procedure titled, "Policy: Pain Evaluation and Management: Chronic" documented the following: "Policy: Pain Evaluation and Management of Chronic pain Purpose: Identify potential causes of chronic pain... Process: I. Review interdisciplinary evaluations for pain indicators. Indicators may include, but are not limited to: A. Change in mood B. Decrease in functional ability C. Family or significant other express concern about change in condition... E. Withdrawal II. Complete and review the Pain Evaluation form. Review for the following: ...B. Cognitively impaired: Review for self-report of pain or resident's family or others who are close to the resident to report of any pain C. Origin of pain D. Length of time experiencing pain... VIII. Provide staff training on interventions... X. Evaluate and document effectiveness of interventions... XI. Notify the physician if interventions are not effective...." Resident #2 had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A care plan, dated 07/21/14, documented a problem of the resident being at high risk for falls. Approaches included for the staff to monitor for changes in the resident's condition that may warrant increased supervision/assistance and notify physician. Another problem was an alteration in comfort related to pain. Approaches included for the staff to evaluate the location, frequency, duration and intensity of pain, document the evaluation and report the increased pain trend to the physician. A nurse's note, dated 07/21/14 at 9:50 p.m., documented, "RSD (resident) admitted to nursing facility on Skilled Services d/t [MEDICAL CONDITION] PT/OT for gait & balance training & strengthening. Transported via ambulance arrived @ 1630 (4:30 p.m.) VS WNL, rsd noted calm & cooperative @ that x. Speech clear, hearing adequate...@ 1930 (7:30 p.m.) RSD found in floor by other nurse on duty, RSD noted to have skin tears to (L) upper ext. & shoulder & (L) knee has superficial scratches. areas cleansed & Tx'd as ordered...Dr. (name deleted) aware of RSD arrival & fall c injury. RSD moves all ext. WNL. RSD has bed & chair alarm in place & working properly. Unable to use call light..." At that time, the facility obtained orders for a chair alarm, bed alarm and fall mat at the side of the bed. A nurse's note, dated 07/22/14 at 1:50 p.m., documented, "...found on floor next to W/C on buttocks (no) injury noted, Denies hitting head (no) head trama noted. conts on neuro's from fall on 07/21/14. Neuro (checks) WNL. Family notified...Dr (name deleted) notified." A nurse's note, dated 07/24/14 at 8:15 p.m., documented, "...RSD noted to fall in hallway from W/C @ 1445 (2:45 p.m.) witnessed by this nurse, alarm on & working properly. RSD noted trying to stand-up to ambulate to exit doors, & foot caught on W/C leg rest. this nurse too for down hall to prevent fall, rsd didn't hit head, (no) injury noted. Dr. (name deleted) on call for DR. (name deleted primary physician) notified, family... notified of fall...PRN meds for agitation & sleep as ordered..." A five day assessment, dated 07/28/14, documented the resident was cognitively impaired with moderately impaired decision making, required supervision with eating, required limited assistance with transfers, dressing, hygiene and bathing and did not ambulate. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was unsteady when moving from seated to standing position, moving on and off toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident used a wheel chair for mobility. The resident had a fall before admission and had experienced two falls with injuries since admission A nurse's note, dated 07/30/14 at 8:00 p.m., documented, "...RSD placed in recliner in room by CNAs on duty this nurse called to RSD room by CNA, upon entering room RSD noted on (L) side in floor by door & sink & back to recliner noted broken & all the way to floor, fall unwitnessed, CNA on duty heard fall & yell along c sounding alarm stated it sounded like he hit his head. (no) visible injury to head, skin tears to inner forearm (no) other injury noted. Neuro WNL @ this x. VS WNL... Dr. (name deleted) on call for DR. (name deleted primary physician) notified earlier (name deleted) RSDs' wife notified of fall & recliner malfunction... 2200 (10:00 p.m.) ...unable to obtain BP DT resident was shaking...Assisted c total change & incontinent care, resident was completely unable to assist, L arm was extremely stiff...resident leans to when up in chair, (no) injury noted from fall..." A nurse's note, dated 07/31/14 at 8:00 p.m., documented, "...RSD noted c unsteady gait, & stooped posture...RSD noted confused & agitated, family in room to visit..." A nurse's note, dated 08/01/14 at 5:30 p.m., documented, "RSD rec'vd in bed this shift. responds to V/T (verbal tactile) stimuli, C/O pain to (L) hip. CMA aware PRN given as ordered...Increased weakness & had difficulty standing c x2 assist into W/C..." A Neurological Assessment Flowsheet, dated 08/01/14 2/10 shift, documented, "C/O (L) hip pain." The August 2014 MAR indicated [REDACTED]. [MEDICATION NAME] 15 mg 1 cap had been administered to the resident on 08/01/14. There was no documentation of the resident's left hip being assessed for the cause of pain voiced by the resident. There was no documentation the physician was notified of the resident complaining of left hip pain. A nurse's note, dated 08/01/14 at 11:30 p.m., documented, "...Limited to max assist c ADLs." A nurse's note, dated 08/03/14 at 1:30 a.m., documented, "RSD rec'vd in bed c eyes closed this shift @ 2430 (12:30 a.m.) RSD became restless/anxious, moaning out loud & talking loudly, this nurse toileted RSD, noted to have weakness d/t pain in LLE (left lower extremities) RSD rated 5/10, unsure if he knew what I was asking though...RSD cont to show NON-verbal cues for discomfort & seemed really restless to the point of self harm. PRNs utilized as ordered & noted effective..." The August 2014 MAR indicated [REDACTED]. [MEDICATION NAME] 15 mg 1 cap had been administered to the resident on 08/03/14. There was no documentation of the resident's left lower extremity being assessed for the cause of pain. There was no documentation the physician was notified of pain in the LLE. A nurse's note, dated 08/03/14 at 10:00 a.m., documented, "Continued to slide to edge of W/C. transferred pt into gerichair c assist on transfer." A nurse's note, dated 08/04/14 at 1:45 p.m., documented, "PT/OT staff brought resident to nurses station wouldn't wake up enough to perform therapy...resident goes to sleep, begins moaning..." There was no documentation the physician was notified of the change in the resident's condition. A fourteen day assessment, dated 08/04/14, documented the resident was cognitively impaired with severely impaired decision making, required limited assistance with eating, required extensive assistance with transfers, dressing, hygiene, bathing and did not ambulate. The resident was always incontinent of bladder and bowel. The resident was unsteady when moving from seated to standing position, moving on and off toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident used a wheel chair for mobility. A nurse's note, dated 08/06/14 at 8:00 p.m., documented, "@ 1400 (2:00 p.m.) CNA on duty reported N/V c emesis x1 @ that x. Dr (name deleted) notified N/O's received... 2230 (10:30 p.m.) ...unable to obtain B/P resident shaking/jerking, pulling @ diaper, talking unknown persons, gave [MEDICATION NAME] for restlessness [MEDICATION NAME] for anxiety & Tylenol for s/s of pain... 2300 (11:30 p.m.) Continues to twist & turn & speak out to someone, very restless & confused." There was no documentation the physician was notified of the change in the resident's condition. A physician's note, dated 08/07/14, documented, "Mr. (resident's name deleted) is really confused and disoriented. The patient's dementia seems to be worsening. The patient is in a Ger-Chair at this time. He is cooperative with what I ask him to do, however...The patient has movement of all extremities. However, he is totally disabled with dementia. He is very weak and cannot stand or walk very well at this point..." A nurse's note, dated 08/08/14 at 10:00 p.m., documented, "RSD in bed very restless, can't stay still, yelling out, PRNs for anxiety & [MEDICAL CONDITION] given @ this x..." There was no documentation the physician was notified of the resident's increased restlessness. "RSD noted (up) in Ger-Chair this shift, alert to self only...RSD noted anxious & restless @ x's this shift. CMA made aware, PRNs utilized this shift...RSD stayed @ rest c moans noted... 2230 (10:30 p.m.) "Continue to show s/s of declining state physically..." There was no documentation the physician was notified of the resident's increased restlessness, moaning at rest or his declining physical condition. A nurse's note, dated 08/10/14 at 10:30 p.m., documented, "Increased s/s of confusion resident more rigid c movement, is not walking on this shift but can bear wt a little if held from falling, resident will push against someone holding resident from falling making any transfer severely extensive assist, may take one or two persons..." There was no documentation the physician was notified of rigid movements or decline in ability to transfer. The August 2014 MAR indicated [REDACTED]. No other pain medication had been administered for pain. A nurse's note, dated 08/13/14 at 3:00 p.m., documented, "Order Pt leg thigh lower extremities x-ray per family request... 1700 (5:00 p.m.) (name deleted) mobile x-ray in house to obtain x-ray... 2130 (9:30 p.m.) "...received fax. Dr. (name deleted) is on call awaiting call back d/t (L) femur fracture...therapist never reported any changes in ROM to this nurse, last fall noted on 7/30/14 c notable weakness to LLE, (no) bruising noted to LLE, seemed to be transferring better according to staff..." A nurse's note, dated 08/14/14 at 1:00 a.m., documented, "RC'd call from Dr (name deleted) RC'd order to send pt to (hospital name deleted) D/T (no) ortho 2 (name of hospital deleted) 0135 (1:35 a.m.) Transported to (hospital name deleted) via...EMS." An x-ray report, dated 08/13/14, documented, "FINDINGS: Acute mildly superiorly displaced left femoral neck fracture with mild varus angulation. Diffuse osteopenia. IMPRESSION: Acute mildly displaced and angulated left femoral neck fracture." On 09/03/14 at 9:10 a.m., an interview with a family member was conducted. The family member reported on 07/26/14, he/she had noted the resident was wincing when the staff moved him. He/she reported the family expressed concern and the CNA reported he would tell the nurse. He/she reported the next week he had voiced his concerns with the nurse. He/she reported the nurse stated the resident was ok. He reported at that time he asked them to get an x-ray of the resident's hip if the staff observed any expressions of pain. He/she reported on 08/10/14, the resident was being transferred by a lift onto the bedpan. He/she reported the resident screamed with pain. He/she reported the CNAs said that was normal behavior. He/she on 08/13/14 reported the family had met with the administrator and the facility then obtained an x-ray. On 09/03/14 at 2:30 p.m., the PTA (physical therapy aide), who had been doing the physical therapy, was asked how she thought the resident could participate in PT with a [MEDICAL CONDITION]. She reported when she first started doing therapy with him, when he was admitted , he did fine. She reported in the last week of therapy he was not able to participate. She reported she thought it was a cognitive issue and not a physical one, in that he could not follow commands. On 09/03/14 at 4:20 p.m., the attending physician was interviewed via telephone. He was asked if the facility had notified him of the resident's complaints of pain in the left hip and left lower extremities. He reported he had signed the admission orders [REDACTED]. He was asked if the facility had notified him of the multiple falls the resident had experienced. He reported the facility had not notified him of the falls. He was asked about the progress note for the resident, written on 08/07/14, while in the nursing facility. He reported he did not remember anything about the visit. He reported the resident was gone from the facility with a [MEDICAL CONDITION] at his last visit. On 09/03/14 at 4:50 p.m., the DON was notified of the staff documentation and the resident's reports of pain, increasing agitation, moaning and decline in condition. She reported she had reviewed the chart but had not seen the complaints of pain in the left hip and LLE. She stated, "We missed the signs." She was asked why the physician had reported he was unaware of the resident's falls. She reported there were five physicians who took turns being on call and whoever was on call took the messages from the facility. She reported the staff was supposed to call the attending physician when he was available. On 09/04/14 at 9:30 a.m., the attending physician, who was in the facility at the time, was asked if he had anymore information about what happened to the resident. He stated, "There was a major lack of communication between the home and myself. I did not know any of this was going on." He reported he had signed the admission orders [REDACTED]. He reported the procedure of notifying the physician on call might have to be changed since the physicians did not always share the information with each other.

On 09/03/14, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure a resident's condition was assessed and monitored for numerous falls, increased signs and symptoms of pain, discomfort and a decline in the condition of the resident (#2) who had experienced a [MEDICAL CONDITION]. The Oklahoma State Department of Health was notified and verified the existence of the immediate jeopardy situation. At 5:15 p.m., the ADM, DON and Corporate Nurse were notified of the IJ situation involving the lack of physician notification. At 6:30 p.m., an acceptable plan of removal was presented to the survey team. The facility's plan of removal was as follows: "Plan of Removal of Immediate Jeopardy 1. Affected resident was sent to hospital on [DATE]. 2. 100% of current residents will be re-evaluated for fall risk by 9/5/14. Care Plans will be updated to reflect current resident risk factors and interventions by 9/5/14. Additionally, CNA Communication Forms will be updated to include current fall reduction interventions by 9/5/14. 3. Staff to be re-educated on facility's policy regarding post-fall assessment and physician notification by 9/5/14. Staff to be re-educated on the facility's policy regarding pain management, assessment and identification of both verbal and non-verbal pain by 9/5/14. Staff to be educated recognizing changes in condition from the resident's base line and to notify physician and family of those changes by 9/5/14. A quality assurance meeting will be held on 9/4/14 to review and approve the corrective actions taken. Facility Medical Director was notified on 9/3/14 at 0630 PM regarding the immediate jeopardy. 4. DON or Designee will review falls daily with clinical team to ensure appropriate assessment has been completed; physician notification is appropriate; root cause analysis has been completed and documented in the medical record; and interventions have been put in place to minimize risk of recurrence." On 09/04/14 at 9:30 a.m., the immediate jeopardy was removed when it was determined the facility staff had been in-serviced and were proficient in procedures put in place by the plan of removal The deficiency remained at actual harm at a pattern. Based on observation, record review and staff interviews, it was determined the facility failed to ensure a resident's condition was assessed and monitored for numerous falls, increased signs and symptoms of pain, discomfort and a decline in condition for one (#2) of three sampled residents who had experienced falls. This resulted in harm to resident (#2). This had the potential to affect all 85 residents who resided in the facility. Findings: A facility Policy and Procedure titled, "Policy: Pain Evaluation and Management: Chronic" documented the following: "Policy: Pain Evaluation and Management of Chronic pain Purpose: Identify potential causes of chronic pain... Process: I. Review interdisciplinary evaluations for pain indicators. Indicators may include, but are not limited to: A. Change in mood B. Decrease in functional ability C. Family or significant other express concern about change in condition... E. Withdrawal II. Complete and review the Pain Evaluation form. Review for the following: ...B. Cognitively impaired: Review for self-report of pain or resident's family or others who are close to the resident to report of any pain C. Origin of pain D. Length of time experiencing pain... VIII. Provide staff training on interventions... X. Evaluate and document effectiveness of interventions... XI. Notify the physician if interventions are not effective...." Resident #2 had been admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A care plan, dated 07/21/14, documented a problem of the resident being at high risk for falls. Approaches included for the staff to monitor for changes in the resident's condition that may warrant increased supervision/assistance and notify physician. Another problem was an alteration in comfort related to pain. Approaches included for the staff to evaluate the location, frequency, duration and intensity of pain, document the evaluation and report the increased pain trend to the physician. A nurse's note, dated 07/21/14 at 9:50 p.m., documented, "RSD (resident) admitted to nursing facility on Skilled Services d/t [MEDICAL CONDITION] PT/OT for gait & balance training & strengthening. Transported via ambulance arrived @ 1630 (4:30 p.m.) VS WNL, rsd noted calm & cooperative @ that x. Speech clear, hearing adequate...@ 1930 (7:30 p.m.) RSD found in floor by other nurse on duty, RSD noted to have skin tears to (L) upper ext. & shoulder & (L) knee has superficial scratches. areas cleansed & Tx'd as ordered...Dr. (name deleted) aware of RSD arrival & fall c injury. RSD moves all ext. WNL. RSD has bed & chair alarm in place & working properly. Unable to use call light..." At that time, the facility obtained orders for a chair alarm, bed alarm and fall mat at the side of the bed. A nurse's note, dated 07/22/14 at 1:50 p.m., documented, "...found on floor next to W/C on buttocks (no) injury noted, Denies hitting head (no) head trama noted. conts on neuro's from fall on 07/21/14. Neuro (checks) WNL. Family notified...Dr (name deleted) notified." A nurse's note, dated 07/24/14 at 8:15 p.m., documented, "...RSD noted to fall in hallway from W/C @ 1445 (2:45 p.m.) witnessed by this nurse, alarm on & working properly. RSD noted trying to stand-up to ambulate to exit doors, & foot caught on W/C leg rest. this nurse too for down hall to prevent fall, rsd didn't hit head, (no) injury noted. Dr.(name deleted) on call for DR. (name deleted primary physician) notified, family... notified of fall...PRN meds for agitation & sleep as ordered..." A five day assessment, dated 07/28/14, documented the resident was cognitively impaired with moderately impaired decision making, required supervision with eating, required limited assistance with transfers, dressing, hygiene and bathing and did not ambulate. The resident was always incontinent of bladder and frequently incontinent of bowel. The resident was unsteady when moving from seated to standing position, moving on and off toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident used a wheel chair for mobility. The resident had a fall before admission and had experienced two falls since admission with injuries. A nurse's note, dated 07/30/14 at 8:00 p.m., documented, "...RSD placed in recliner in room by CNAs on duty this nurse called to RSD room by CNA, upon entering room RSD noted on (L) side in floor by door & sink & back to recliner noted broken & all the way to floor, fall unwitnessed, CNA on duty heard fall & yell along c sounding alarm stated it sounded like he hit his head. (no) visible injury to head, skin tears to inner forearm (no) other injury noted. Neuro WNL @ this x. VS WNL... Dr. (name deleted) on call for DR. (name deleted primary physician) notified earlier (name deleted) RSDs' wife notified of fall & recliner malfunction... 2200 (10:00 p.m.)...unable to obtain BP DT resident was shaking...Assisted c total change & incontinent care, resident was completely unable to assist, L arm was extremely stiff...resident leans to when up in chair, (no) injury noted from fall..." A nurse's note, dated 07/31/14 at 8:00 p.m., documented, "...RSD noted c unsteady gait, & stooped posture...RSD noted confused & agitated, family in room to visit..." A nurse's note, dated 08/01/14 at 5:30 p.m., documented, "RSD rec'vd in bed this shift. responds to V/T (verbal tactile) stimuli, C/O pain to (L) hip. CMA aware PRN given as ordered...Increased weakness & had difficulty standing c x2 assist into NW/C..." A Neurological Assessment Flowsheet, dated 08/01/14 2/10 shift, documented, "C/O (L) hip pain." The August 2014 MAR indicated [REDACTED]. [MEDICATION NAME] 15 mg 1 cap had been administered to the resident on 08/01/14. There was no documentation of the resident's left hip being assessed for the cause of pain voiced by the resident. A nurse's note, dated 08/01/14 at 11:30 p.m., documented, "...Limited to max assist c ADLs." A nurse's note, dated 08/03/14 at 1:30 a.m., documented, "RSD rec'vd in bed c eyes closed this shift @ 2430 (12:30 a.m.) RSD became restless/anxious, moaning out loud & talking loudly, this nurse toileted RSD, noted to have weakness d/t pain in LLE (left lower extremities) RSD rated 5/10, unsure if he knew what I was asking though...RSD cont to show NON-verbal cues for discomfort & seemed really restless to the point of self harm. PRNs utilized as ordered & noted effective..." The August 2014 MAR indicated [REDACTED]. [MEDICATION NAME] 15 mg 1 cap had been administered to the resident on 08/03/14. There was no documentation of the resident's left lower extremity being assessed and monitored for the cause of pain. A nurse's note, dated 08/03/14 at 10:00 a.m., documented, "Continued to slide to edge of NW/C. transferred pt into gerichair c assist on transfer." A nurse's note, dated 08/04/14 at 1:45 p.m., documented, "PT/OT staff brought resident to nurses station wouldn't wake up enough to perform therapy...resident goes to sleep, begins moaning..." There was no documentation the resident had been assessed and monitored for the change in the resident's condition. A fourteen day assessment, dated 08/04/14, documented the resident was cognitively impaired with severely impaired decision making, required limited assistance with eating, required extensive assistance with transfers, dressing, hygiene, bathing and did not ambulate. The resident was always incontinent of bladder and bowel. The resident was unsteady when moving from seated to standing position, moving on and off toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident used a wheel chair for mobility. A nurse's note, dated 08/06/14 at 8:00 p.m., documented, "@ 1400 (2:00 p.m.) CNA on duty reported N/V c emesis x1 @ that x. Dr (name deleted) notified N/O's received... 2230 (10:30 p.m.)...unable to obtain B/P resident shaking/jerking, pulling @ diaper, talking unknown persons, gave [MEDICATION NAME] for restlessness [MEDICATION NAME] for anxiety & Tylenol for s/s of pain... 2300 (11:30 p.m.) Continues to twist & turn & speak out to someone, very restless & confused." There was no documentation the change in condition of the resident had been assessed and monitored. A physician's note, dated 08/07/14, documented, "Mr. (resident's name deleted) is really confused and disoriented. The patient's dementia seems to be worsening. The patient is in a Ger-Chair at this time. He is cooperative with what I ask him to do, however...The patient has movement of all extremities. However, he is totally disabled with dementia. He is very weak and cannot stand or walk very well at this point..." A nurse's note, dated 08/08/14 at 10:00 p.m., documented, "RSD in bed very restless, can't stay still, yelling out, PRNs for anxiety & [MEDICAL CONDITION] given @ this x..." There was no documentation the resident's increased restlessness had been assessed and monitored. "RSD noted (up) in Ger-Chair this shift, alert to self only...RSD noted anxious & restless @ x's this shift. CMA made aware, PRNs utilized this shift...RSD stayed @ rest c moans noted... 2230 (10:30 p.m.) Continue to show s/s of declining state physically..." There was no documentation of the resident's increased restlessness, moaning at rest or his declining physical condition being assessed and monitored. A nurse's note, dated 08/10/14 at 10:30 p.m., documented, "Increased s/s of confusion resident more rigid c movement, is not walking on this shift but can bear wt a little if held from falling, resident will push against someone holding resident from falling making any transfer severely extensive assist, may take one or two persons..." There was no documentation of the resident's rigid movements or decline in ability to transfer being assessed and monitored. The August 2014 MAR indicated [REDACTED]. No other pain medication had been administered for pain. A nurse's note, dated 08/13/14 at 3:00 p.m., documented, "Order Pt leg thigh lower extremities x-ray per family request... 1700 (5:00 p.m.) (name deleted) mobile x-ray in house to obtain x-ray... 2130 (9:30 p.m.)...received fax. Dr. (name deleted) is on call awaiting call back d/t (L) femur fracture...therapist never reported any changes in ROM to this nurse, last fall noted on 7/30/14 c notable weakness to LLE, (no) bruising noted to LLE, seemed to be transferring better according to staff..." A nurse's note, dated 08/14/14 at 1:00 a.m., documented, "RC'd call from Dr (name deleted) RC'd order to send pt to (hospital name deleted) D/T (no) ortho 2 (name of hospital deleted) 0135 (1:35 a.m.) Transported to (hospital name deleted) via...EMS." An x-ray report, dated 08/13/14, documented, "FINDINGS: Acute mildly superiorly displaced left femoral neck fracture with mild varus angulation. Diffuse osteopenia. IMPRESSION: Acute mildly displaced and angulated left femoral neck fracture." On 09/03/14 at 9:10 a.m., an interview with a family member was conducted. The family member reported on 07/26/14, he/she had noted the resident was wincing when the staff moved him. He/she reported the family expressed concern and the CNA reported he would tell the nurse. He/she reported the next week he had voiced his concerns with the nurse. He/she reported the nurse stated the resident was ok. He reported at that time he asked them to get an x-ray of the resident's hip if the staff observed any expressions of pain. He/she reported on 08/10/14, the resident was being transferred by a lift onto the bedpan. He/she reported the resident screamed with pain. He/she reported the CNAs said that was normal behavior. He/she on 08/13/14 reported the family had met with the administrator and the facility then obtained an x-ray. On 09/03/14 at 2:30 p.m., the PTA (physical therapy aide), who had been doing the physical therapy, was asked how she thought the resident could participate in PT with a [MEDICAL CONDITION]. She reported when she first started doing therapy with him, when he was admitted , he did fine. She reported in the last week of therapy he was not able to participate. She reported she thought it was a cognitive issue and not a physical one, in that he could not follow commands. On 09/03/14 at 4:20 p.m., the attending physician was interviewed via telephone. He was asked if the facility had notified him of the resident's complaints of pain in the left hip and left lower extremities. He reported he had signed the admission orders [REDACTED]. He was asked if the facility had notified him of the multiple falls the resident had experienced. He reported the facility had not notified him of the falls. He was asked about the progress note for the resident, written on 08/07/14, while in the nursing facility. He reported he did not remember anything about the visit. He reported the resident was gone from the facility with a [MEDICAL CONDITION] at his last visit. On 09/03/14 at 4:50 p.m., the DON was notified of the staff documentation and the resident's reports of pain, increasing agitation, moaning and decline in condition. She reported she had reviewed the chart but had not seen the complaints of pain in the left hip and LLE. She stated, "We missed the signs." She was asked why the physician had reported he was unaware of the resident's falls. She reported there were five physicians who took turns being on call and whoever was on call took the messages from the facility. She reported the staff was supposed to call the attending physician when he was available. On 09/04/14 at 9:30 a.m., the attending physician, who was in the facility at the time, was asked if he had anymore information about what happened to the resident. He stated, "There was a major lack of communication between the home and myself. I did not know any of this was going on." He reported he had signed the admission orders [REDACTED]. He reported the procedure of notifying the physician on call might have to be changed since the physicians did not always share the information with each other.

Based on record review and staff interview, it was determined the facility failed to notify the physician when an antibiotic medication was not obtained from the pharmacy and not administered in a timely manner for one (#24) of two sampled residents. This had the potential to affect all 69 residents who resided in the facility. Findings: Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A nurse's note, dated 12/05/14 at 10:00 a.m., documented the pharmacy had been notified of the [MEDICATION NAME] order. A nurse's note, dated 12/06/14 at 3:00 a.m., documented, "(New order) recv'd for [MEDICATION NAME] 1 gm however med has not been delivered as of yet. Will begin as soon as recvd." The clinical record contained no documentation the physician was notified the antibiotic medication was not available and had not been administered. At 9:00 a.m., a nurse's note documented, "...have not received [MEDICATION NAME] at this time..." At 9:00 p.m., a nurse's note documented,"...have not received antibiotic..." The clinical record contained no documentation the physician was notified the antibiotic medication was not available and had not been administered. On 12/07/14 at 1:00 a.m., a nurse's note documented, "...cont. to wait on atb's (antibiotic) to begin initial dose." The clinical record contained no documentation the physician was notified the antibiotic medication was not available and had not been administered. At 3:30 p.m., a nurse's note documented, "...received [MEDICATION NAME] for injection will begin daily dose at 8 p.m. tonight." On 12/18/14 at 1:30 p.m., the DON was asked if the physician should have been notified the medication had not been administered on the day the medication was ordered. The DON reported she did not know why the physician was not notified but would check on it. The DON was asked if she expected the nursing staff to notify the physician when there was a delay in administering an antibiotic medication. The DON reported yes, she expected the nursing staff to notify the physician.

Based on record review and staff interviews, it was determined the facility failed to assess, monitor and intervene for a surgical wound, which resulted in harm, for one (#7) of two sampled residents who experienced falls with fractures in the past three months. This had the potential to affect five residents, identified by the DON, who experienced falls with fractures in the past three months. Findings: Resident #7 was admitted with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/19/14, documented the resident was moderately impaired in cognition with disorganized thinking, exhibited no depression symptoms and exhibited verbal behavioral symptoms toward others and rejection of care for one to three days of the look back period. The resident required extensive assistance for transfers, dressing, personal hygiene and bathing. The resident had impairment on one side for both upper and lower extremities. The resident was frequently incontinent of bowel and bladder. The quarterly assessment documented the resident had experienced three falls since the prior assessment. A nurse's note, dated 12/02/14 at 9:40 a.m., documented the resident experienced a fall. A nurse's note, at 11:30 a.m., documented the x-ray results showed the resident had a right femoral fracture. The resident was transferred to the hospital via ambulance at 12:25 p.m. A nurse's note, dated 12/05/14 at 9:45 p.m., documented, "Resident arrived...Dressing et (and) ace bandage on (right) leg intact. Rec'd report from (name deleted) at (hospital initials deleted) that Dressing not to be changed until 12-6-14..." A physician's orders [REDACTED]. A form titled, "RETURN TO FACILITY BODY CHECK," dated 12/05/14, documented, "...ACE wrap from groin to ankle to RLE left intact...ABD (abdominal) pad covering incision to Rt outer hip..." A care plan update for skin/wound problems, dated 12/05/14, documented the resident returned with an incision to his right hip. The intervention documented for the staff to observe for signs and symptoms of infection. The nurses' notes for 12/06/14 contain no documentation the dressing was removed from the resident's right hip. The clinical record contained no documentation of the appearance of the surgical wound site. A form titled, "OTHER SKIN CONDITION WEEKLY STATUS REPORT," dated December 1-6, documented the resident had a surgical wound with 9 staples and no odor or drainage was present. The form contained only the entry about the resident with no other residents listed. No information about the resident's right arm area was included on the document. No other residents' information was documented on the form. A nurse's note, dated 12/07/14 at 12:30 a.m., documented the dressing was intact to the resident's right upper extremity and right lower extremity. A physician's orders [REDACTED]. A care plan update, dated 12/07/14, documented, "(Resident's name deleted) observed scratching at incision site." An intervention, "Maintain trim short fingernails," was check marked on the standardized care plan. A nurse's note, dated 12/08/14 at 9:00 a.m., documented the dressing to the resident's right hip was CDI (clean, dry and intact). A Body Audit Form, dated 12/09/14 for the 6-2 shift, documented on the body diagram the areas with the notations the resident had a scab on his upper right arm and an incision with staples on his right hip. In the area "Comments," the nurse documented, "Surgical incision @ R hip (with) 9 staples c/d bruising (with) yellow/blue scab @ R elbow." A nurse's note, dated 12/09/14 at 4:45 p.m., documented, "...staples @ R hip c/d dressing (changed) per orders..." The entry contained no documentation on the appearance of the surgical wound. A nurse's note, dated 12/13/14 at 1:15 p.m., documented, "Pt in bed (with) (no) dressing to (right) hip area. Patient has 9 staples to upper (right) hip area followed by 6 staples and 5 staples to upper (right) hip area above knee. Sites are red in color and warm to touch (with) thin yellow colored drainage noted from sites...Pt reports pain to (right) hip area (physician's name deleted) notified via phone. Awaiting return call @ this time." A nurse's note, dated 12/14/14 at 1:00 a.m., documented the resident's right hip incision site continued with redness with no drainage. A nurse's note, at 2:50 p.m., documented, "Patient has 20 staples to the (right) upper leg from a recent ORIF. There is redness to Sites (with) thin yellow drainage. Sites are warm to touch. Patient has been removing dressing to surgical site. (Physician's name deleted) requests patient be seen @ (name deleted) for evaluation..." A nurse's note, at 4:00 p.m., documented, "Resident is admitted to hospital in (name deleted)...dx was not revealed by receiving nurse." A form titled, "OTHER SKIN CONDITION WEEKLY STATUS REPORT," dated 12/15/14, documented the resident had two surgical sites, one was six cm in size and the other site was seven cm in size. The form documented the resident had no odor or drainage from the sites. The form documented the resident had staples removed from the six cm site on 12/15/14 and the dressing was changed on the seven cm site. The resident was still in the hospital at the time of the completion of this form. On 12/18/14 at 2:00 p.m., the corporate nurse was asked if the resident was still in the hospital, at this time. The corporate nurse reported the resident was still in the hospital. At that time, the corporate nurse was asked if the resident's dressing should have been removed and the incision site should have been assessed when the resident was readmitted from the hospital. The corporate nurse stated, "Yes."

Based on record review, observation and staff interviews, it was determined the facility failed to provide CPR for one (#1) of one sampled resident who was found without a pulse and respirations and did not have a DNR (Do Not Resuscitate) order. This resulted in actual harm. The resident expired on [DATE]. Findings: This had the potential to affect 39 residents, identified by the facility, with full code status. The facility's policy, dated [DATE], documented the following: "Do Not Resuscitate Guidelines If resident is found or becomes unresponsive follow the following steps. 1. Call for assistance, direct staff to obtain crash cart and chart, check DNR located in the advance directive section of the chart on gold/yellow paper. 2. If resident has a DNR, notify physician and family. 3. If resident does not have a DNR, start CPR until directed otherwise by EMS, notify physician and family and document." Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The admitting physician's orders [REDACTED]. "1. Admit to Skilled Nursing 2. V.S. routine 3. Diet: No concentrated sugars 4. FSBS BID 5. Low Dose Sliding Scale 6. 02 at 2 l (liters)/min (minute) NC (nasal cannula) at night and prn (as needed) during daytime 7. Keep legs elevated 8. Wound care to legs... 9. PT (physical therapy) and OT (occupational therapy) evaluate and treat 10. [MEDICATION NAME] INR q week." There was no code status documented on the admitting orders. On [DATE], the nurses' notes documented the following: "1830 Sitting up in wheel chair. Complained of not being able to eat, nausea, don't feel right and more anxious...Informed son I was going to send pt (patient) to hospital for increased anxiety and increased shortness of breath and patient requests to go to ER (emergency room ). Called Dr (Name deleted) received new order to send to (Name deleted) ER. for further eval (evaluation) and treatment. 1850 Transferred to hospital via BNC van. Sent portable 02. 2030 Back to BNC from ER with new order for [MEDICATION NAME] anxiety..." The ER records dated [DATE], documented, "Chief complaint anxious...Clinical impression Anxiety." The nurses' notes documented the following: "2045 Assisted to bed due to seemed groggy [MEDICATION NAME] 0.5 mg was given at ER. 2 person max (maximum) assist...raised head of bed due to patient could breathe better... 2100 Resting quietly with head of bed elevated and eyes closed..." A 5-day Medicare assessment dated [DATE], identified the resident as cognitively intact, with little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired or having little energy nearly every day, requiring extensive assistance with bed mobility, transfers, walking in room, walking in corridor, dressing, toilet use, personal hygiene and bathing, required supervision with eating and had impairment on both sides of lower extremities and was frequently incontinent of urine. A temporary, undated, care plan did not document the resident's code status. On [DATE], the nurses' notes documented the following: "Resident laying quietly in bed...no signs or symptoms of distress at this time." There was no time documented for the above nurse's note. The nurses' notes documented the following: "0500 Went to room to provide care and do FSBS and found resident very cyanotic. Did check of vitals found no heart rate and no pulse and resident was cool to touch. Call was made to on call doctor and awaiting return call. I have tried to contact family at all three listed contacts and unable to speak with anyone. Left a message to call as soon as they get message. 0510 Contacted Administrator to advise her of resident's passing 0550 Dr (Name deleted) returned call and was given report and said may release body to funeral home." On [DATE], a record review was begun. No record was found to indicate the resident's code status. At 3:00 p.m., the DON was asked for a copy of the resident's code status. She reported she was having a hard time locating the resident's code status. She reported she thought the resident was a DNR and was trying to contact the hospital to see if they had accidently kept the resident's code status when the resident had been sent to theER on [DATE]. On [DATE] at 8:30 a.m., the DON was asked if she had been able to locate the DNR paperwork for the resident. The DON reported she could not find anywhere in the medical record the resident was a DNR. At that time, she was asked if the resident had received CPR when he was found in the room with no pulse or respirations. She stated, "No." She was then asked what the facility's policy was when a staff found a resident with no pulse or respirations. She reported the staff should determine their code status and if they couldn't find a DNR status, CPR should be started. At 8:50 a.m., LPN #1 was interviewed. He was the charge nurse on [DATE], who found the resident non responsive. He reported he had not initiated CPR on the resident because he thought the resident was a DNR. At 11:00 a.m., the ADM reported she had a CNA, who had been working with the resident on the shift when he expired to write a statement on [DATE]. The statement documented the following: "The night that (Resident's name deleted) passed away. When I start my shift I always make rounds to be sure everyone is OK, as I approach Mr. (Resident's name deleted) room, (LPN's name deleted) said do not go into his room for anything that he had been to the hospital and was medicated and needed to sleep hadn't slept in three days, and that he wasn't going to vital signs until he woke up, at aprox 4:30 in AM. I told (CNA's name deleted) and (LPN's name deleted) we were going to have to go and check on him. (LPN's name deleted) said he had been in and checked on him earlier. When we went in that when we found Mr. (Resident's name deleted) dead. (LPN's name deleted) said "unknown" old hell I'm in trouble. He check him and went to the office to place some phone calls. I was following nurse orders." The other CNA, who was working with the resident on the night of [DATE] was called several times with no answer. She was unable to be interviewed by the surveyor.