Every finding on record at Cherokee County Nursing Center

Based on observation and interview, the facility failed to ensure enteral feeding bags were properly labeled for 1 (#60) of 1 resident reviewed for enteral feeding. The DON identified two residents who had enteral tube feedings. Findings: On 07/02/25 at 9:01 a.m., a tube feeding bag filled with tan liquid and a bag filled with clear liquid were infusing per feeding pump at 52cc/hr. The bag was observed to have the date, time and initials written on it. On 07/02/25 at 9:08 a.m., LPN #2 stated they could not tell what formula was in the feeding bag or what resident it was intended for because the feeding bag was not labeled correctly. LPN #2 stated the bag should be labeled with the resident's name, the date, the time it was hung, what formula was in the bag, what the infusion rate should be and the initials of the person that hung the bag. LPN #2 stated without the information, a resident could get the wrong feeding formula

Based on observation and interview, the facility failed to ensure medications were secure for 1 of 2 medication/treatment carts on the South hall. The administrator identified 99 residents resided in the facility. Findings: On 07/02/25 at 10:50 a.m., LPN #1 was observed to draw up insulin to administer to a resident. LPN #1 locked the medication cart leaving the insulin on top of the cart and walked away. On 07/02/25 at 10:52 a.m., LPN #1 stated it was the policy of the facility to lock any medications not being used in the medication cart to prevent other residents, staff or visitors from obtaining the medication. On 07/02/25 at 12:30 p.m., the DON stated it was the facility policy to lock all medications in the medication cart when they were not being given.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed during resident care for 1 (#9) of 3 sampled residents reviewed for PEG tube care. The infection preventionist identified three residents in the facility had PEG tubes. Findings: On 03/04/25 at 9:11 a.m., CMA #4 was observed providing medication administration to Res #9. During the care CMA #4 made contact with multiple items that would be considered dirty without changing their gloves. After entering the resident's room, CMA #4 did the following in order written: a. cleaned their hands in the resident's sink; b. dried their hands with a fabric towel that had been stored in the open air in the resident's room; c. refolded and placed the used towel in a container with other clean towels; d. put on exam gloves; e. put on a protective gown; f. disconnected and removed feeding and water containers from an IV pole; g. pulled down the stained bedding that covered the resident; h. readjusted a stained towel that was on top of the resident and under the bedding; i. disconnected the PEG tubing and rubbed the ends with their fingers as if removing something; j. rummaged through supplies that were next to the resident's sink and found new water and feeding solution bottles; k. filled the feeding solution container; l. filled the water container with water from the resident's sink where they had washed their hands; m. hung the new water and feeding solution containers on an IV pole; n. administered Flonase spray into the resident's nose; o. rummaged through the supplies located next to the resident's sink and removed a syringe from its package; p. connected the syringe to the PEG tube and administered the resident's medication; and q. CMA #4 then removed their gloves and gown then washed their hands. A facilty policy and procedure titled Enteral Feedings, Administration via Gastrostomy, dated 11/22/16, showed the use of hand washing and glove changes were required between steps of the care. Res #9 had diagnoses which included encounter for attention to gastrostomy and fistula of stomach and duodenum. On 03/04/25 at 9:48 a.m., CMA #4 stated they thought they had changed their gloves once during the care. They stated they should have changed their gloves after touching items that would be considered to be dirty. ON 03/04/25 at 10:23 a.m., the DON stated CMA #4 should have changed gloves after touching the dirty items. They stated they should not have used the fabric towel in the room since they were not covered. They stated they felt it was appropriate to use the sink water for the PEG tube water container.

Based on record review and interview, the facility failed to investigate an injury of unknown origin for 1 (#6) of 5 sampled residents reviewed for abuse. The DON reported 97 residents resided at the facility. Findings: A facility policy titled Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting Policy, dated 10/18/22, read in part, The Administrator or Administrative Designee will conduct an immediate investigation of all incidents of alleged, witnessed or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of residents. Res #6 had diagnoses which included dementia and down syndrome. A progress note titled, Nsg [nursing]-Admission Summary, dated 08/17/24 at 8:03 p.m., showed Res #6 had been readmitted to the facility from a hospital stay. The note showed LPN #3 had written the note. The note did not include observations of a bruise on the resident. On 03/04/25 at 2:01 p.m., the DON stated they had been told by the administrator about a family member's report of bruising on Res #6. They stated they were told on either 08/29/24 or 08/30/24, but was unable to be more exact. On 03/04/25 at 2:09 p.m., family member #1 stated they had observed a bruise on Res #6's face during a visit on 08/17/24. They stated they had visited the resident at a hospital on 08/16/25 and had not seen any bruises then. They stated they informed the administrator via text about the bruising, but could not recall the exact date. On 03/04/25 at 2:45 p.m., the DON stated on the day the facility administrator had informed them of the report of bruising on Res #6 they had asked various staff if they were aware of the bruising. The DON stated they did not write down what they had asked, who they asked, or their responses. They stated they had not interviewed any residents. They stated they had not located any investigative material regarding the bruising on Res #6.

Based on record review and interview, the facility failed to report an injury of unknown origin to the OSDH for 1 (#6) of 5 sampled residents reviewed for abuse. The DON reported 97 residents resided at the facility. Findings: A facility policy titled Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting Policy, dated 10/18/22, read in part, All facility personnel, including all employees and any physician, the owner and the Administrator, must immediately report all incidents of alleged, witnessed or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of resident to the Administrator or Administrator's Designee, who will report events as required by State law or regulation. Res #6 had diagnoses which included dementia and down syndrome. On 03/04/25 at 2:09 p.m., the DON stated they had been informed by the administrator of a report by a family member of Res #6 the resident had bruising on their face. They stated they believed they were told of the report on either 08/29/24 or 08/30/24. On 03/05/25 at 8:49. a.m., LPN #3 stated they had conducted an assessment of Res #6 when they had returned to the facility on [DATE]. They stated there was no documentation of bruising in their note that day because they had not observed any bruising. They stated about two days later they had been told by someone of bruises on Res #6. They stated they could not recall who had told them. They stated they then went a looked at the resident and did see a purple colored bruise on the resident's left cheek. They stated the bruise was such that anyone would have noticed it if they saw it. They stated after witnessing the bruise they had not reported what they saw to administration because the felt they already knew, but they did pass it on to the next crew during the next shift change. On 03/05/25 at 9:12 a.m., the DON stated they had not reported the bruising on Res #6 to OSDH or anyone else because they felt the injuries had occurred when the resident was under the care of others. They stated LPN #3 had conducted an assessment of the resident when they had returned from a hospital, but they did not document the assessment. They stated they had not conducted a formal investigation into the origin of the bruises when they had become aware of them. They stated the did ask some staff about it, but did not document those discussions.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5% for two (#27 and #75) of four sampled residents observed during medication pass. A total of 25 opportunities were observed with four errors. Total error rate was 16%. The DON identified 99 residents resided in the facility. Findings: A Medications, Errors procedure, dated 11/22/16, read in parts, .A medication error is a discrepancy between what the physician orders are and what is administered. Medication errors include .wrong dose .Any medication error must immediately be reported to the resident's attending physician, Charge Nurse, or DON . 1. Res #27's physician orders, dated 02/13/24, documented to administer calcium carbonate-vit-D oral tablet 600-800 mg unit (calcium carbonate-vitamin D with minerals) for a diagnosis of iron deficiency anemia. CMA #1 administered one tablet of calcium carbonate 600 mg without vitamin D to Res #27; administer 250 mg tablet of magnesium by mouth one time daily. CMA #1 administered one 400 mg tablet of magnesium oxide to Res #27; administer one tablet of Vitamin D3 125 mcg (5,000(IU) give one tablet by mouth one time a day related to Vitamin D deficiency. CMA #1 administered one tablet of vitamin D3 25 mcg (1,000 IU) to Res #27. On 02/13/24 at 09:35 a.m., CMA #1 reported they administered one tablet of each of the physician ordered medications listed above to Res #27. On 02/13/24 at 10:50 a.m., the DON obtained the calcium carbonate, magnesium oxide, and Vitamin D3 from the medication cart and stated they did not match Res #27's physician orders. 2. Res #75's physician orders, dated 02/13/24, documented to administer Allegra Allergy Children's oral tablet disintegrating 30 mg (Fexofenadine HCL) give 2 tablets by mouth one time a day related to allergic rhinitis. CMA #1 administered one 10 mg allergy pill (Loratadine) to Res #75. On 02/13/24 at 9:35 a.m., CMA #1 stated they administered one allergy pill to Res #75 and it was not the children's tablets. On 02/13/24 at 10:45 a.m., the DON obtained the allergy medication off of the medication cart and stated the allergy pill was 10 mg and did not match Res #75's physician orders.

Based on observation, record review, and interview, the facility failed to ensure residents were safe to self-administer medications for two (#34 and #66) of two sampled residents reviewed for self-administration of medications. The DON identified 99 residents resided in the facility. Findings: A Self-Administration of Medications policy, revised 11/22/16, read in parts, .A resident may be permitted to administer or retain medication in his/her room under the following conditions .Assessment .Order is obtained from the resident's physician . 1. Res #34 had diagnoses which included pain, type 2 diabetes mellitus, insomnia, HTN, CHF, depression, hyperlipidemia, and GERD. A quarterly resident assessment, dated 11/21/23, documented the resident's cognition was intact. On 02/23/24 at 8:34 a.m., the resident was observed with two white pills and one yellow pill in a clear pill cup on their over the bed table. The resident was asked about the pills in the cup on their over the bed table. The resident stated they guessed they did not take all of their pills and picked up the pill cup and was observed swallowing them. There was no documentation the resident was assessed or an order obtained from the resident's physician to self-administer medications. 2. Res #66 had diagnoses which included allergic rhinitis and SOB. A quarterly resident assessment, dated 12/23/23, documented the resident's cognition was intact. A physician order, dated 02/12/24, documented albuterol sulfate (broncodilator) inhalation nebulizer solution 0.63 mg/3 ml. One vial inhale orally via nebulizer every six hours as needed. On 02/13/24 at 11:47 a.m., the resident was observed in their bed holding a hand held nebulizer in their mouth receiving a breathing treatment. There was no staff present in the resident's room or at their door. On 02/13/24 at 11:57 a.m., CNA #2 entered the resident's room. They asked the resident if they were finished with their breathing treatment and turned off their nebulizer machine. There was no documentation the resident was assessed or an order obtained from the resident's physician to self-administer the broncodilator. On 02/13/24 at 12:05 p.m., CMA #2 was asked if there were any residents who self-administered their medications. They stated, No, not really. They stated they watched all of the residents take their medications. They were made aware Res #34 was observed with three pills in a pill cup in their room. They stated they did not know they did not swallow all of their medication. They were asked if they were supposed to remain with the resident while a breathing treatment was administered. They stated they should. They were made aware Res #66 was observed receiving a breathing treatment without staff present. They stated they did not stay with the resident. On 02/13/24 at 12:09 p.m., the DON was asked what was the protocol for administering medications. They stated staff were to watch the residents swallow their medications. They stated all of the residents who received breathing treatments had face masks. They stated staff were able to leave and come back. They were asked if there were any residents who self-administered their medications. They stated there were not. They were made aware Res #34 and Res #66 were observed self-administering medications. On 02/13/24 at 2:02 p.m., the DON stated Res #34 and Res #66 should have been assessed and there should have been a physician order to self-administer medications.

Based on record review and interview, the facility failed to assess a resident for an infection using standardized tools and criteria for the initiation of an antibiotic for one (#58) of five sampled residents reviewed for unnecessary medications. The DON identified 99 residents resided in the facility. Findings: An Antibiotic Stewardship Program policy, dated 10/2019, read in parts, .It is the policy .to implement an Antibiotic Stewardship Program .which will promote appropriate use of antibiotics while optimizing the treatment of infections .Facility may consider protocols to address .Improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected if having an infection. McGeer criteria will be utilized . Res #31 had diagnoses which included an urinary tract infection. A physician order, dated 01/19/24, documented amoxicillin-potassium clavulante (an antibiotic) oral tablet 250-125 mg. Give one tablet by mouth three times a day until 01/27/24. There was no documentation the resident was assessed related to their infection and the initiation of an antibiotic. On 02/14/24 at 2:03 p.m., the IP was asked to provide documentation the resident was assessed related to their infection and the initiation of the antibiotic ordered. They stated they used McGeer criteria and an assessment was not completed.

Based on record review, observation, and interview, the facility failed to provide needed care and services in accordance with professional standards of practice for two (#36 and #87) of four residents reviewed for skin issues. The facility failed to: a. assess and monitor skin issues for Res #36. b. accurately measure wounds for Res #87. The Resident Census and Conditions of Residents form documented 99 residents resided in the facility. Findings: 1. A Pressure Injury, Prevention and Management policy revised 11/22/16, read in part .6. The treatment nurse will assess all pressure injuries weekly. Assessment will include measurement of length, width and depth, drainage (type, amount and odor), description of wound bed and peri wound areas . Res #87 had diagnoses which included peripheral vascular disease, surgical aftercare following surgery on the circulatory system, and diabetes mellitus. A physician order, dated 01/12/23, documented to cleanse left front toes with wound cleanse, pat dry, apply iodine, cover with 4x4s, and wrap with roll gauze. An admission assessment, dated 01/14/23, documented the resident was moderately impaired with cognition and required extensive assistance with most ADLs and had an infection of the foot. A nursing wound note, dated 01/24/23, documented the patient continued with dry gangrene to great hallux 1st and 3rd digits with eschar on tips of toes, stable, hard, and no openings. A care plan, dated 02/01/23, documented Res #87 had PVD and to encourage the resident to elevate her legs. The care plan documented the resident had diabetes mellitus and to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. The care plan documented Res #87 had chronic pain related to neuropathy and PVD with ischemic left toes. The care plan documented Res #87 had been admitted with ischemic ulcers on some of her toes of her left foot and had the potential for other areas to develop. The care plan documented the facility was to document measurements including a measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate, and any other notable changes or observations. On 02/06/23 at 12:22 p.m., Res #87 stated she was not sure if she had a pressure ulcer or a diabetic ulcer but she had them when she came into the facility. At that time, the resident's left foot was observed to be wrapped and the bandage was dated 02/06/23. A skin assessment, dated 02/07/23, documented dry gangrene to left toes measuring length 2.0 cm, width 4.0 cm, and no depth. On 02/09/23 at 9:10 a.m., Res #87 was observed in the bed with her left leg on a pillow, her foot was hanging off the pillow not touching the bed. The foot was wrapped and dated. Wound care was observed at that time. The resident was observed to have dark eschar present on the top and under the great toe, on the top of the 2nd digit, and the top of the 4th digit. On 02/09/23 at 12:31 p.m., the DON stated the wound care nurse was under the impression if there was less than one inch of intact tissue it should be measured as one wound. She stated however standards of care would dictate that each toe should have been measured as a separate wound. 34945 2. Res #36 had diagnoses which included diabetes, protein calorie malnutrition, and chronic embolism and thrombosis of unspecified vein. An admission assessment, dated 10/31/22, documented Res #36 was moderately impaired in cognition and required limited assistance with most ADLs. A care plan, dated 11/04/22, documented Res #36 goal was to have intact skin, free of redness, blisters, or discoloration, through the review date. On 02/02/23 at 11:51 a.m., Res #36 was observed lying on his bed. The resident's lower legs were visible below his pant's legs and dry, red, scaly patches were observed. The resident stated his legs itched when he bathed. A skin assessment, dated 02/07/23, documented the resident had no skin issues and was receiving moisturizer and skin protectant. On 02/09/23 at 11:26 a.m., the DON and ADON observed Res #36's legs and confirmed his legs were extremely dry and could have cracked open if not addressed. The DON stated she would check with the wound care nurse to see if there was anything ordered. On 02/09/23 at 2:30 p.m., the ADON stated the wound nurse assessed the resident's legs and would contact the PCP for a treatment.

Based on record review, observation and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight (#13, 30, 36, 38, 57, 71, 92, and #93) of eight resident reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 99 residents who lived in the facility. Findings: 1. Res #57 had diagnoses which included dementia and schizoaffective disorder bipolar type. A physician order, dated 06/21/22, documented may use positioning rails. A quarterly assessment, dated 01/04/23, documented the resident was severely impaired with cognition and required extensive to total assistance with ADLs. A care plan, last reviewed 01/27/23, documented may use positioning rails as needed. The care plan documented Res #57 had left sided weakness and required extensive assistance with bed mobility, locomotion, dressing, toileting, and personal hygiene. The EHR for Res #57 did not contain a bed rail assessment or consent for bed rails. On 02/06/23 at 1:11 p.m., Res #57 was observed lying on an air bolster mattress with quarter rails in the up position at the head of the bed. The bed was off the ground in a high position. The resident was moving her right leg off the bed stating she wanted out of the airplane. On 02/09/23 at 8:43 a.m., Res #57 was observed in bed with eyes closed on an air mattress, quarter bed rails were observed in the up position at the head of the bed, and the head of bed was raised. 34945 2. Res #36 had diagnoses which included dementia, muscle wasting and atrophy, weakness, and lack of coordination. An admission/Medicare assessment, dated 10/31/22, documented Res #36 was moderately impaired in cognition and required limited assistance with ADLs. A care plan, dated 11/04/22, documented the resident had a self care performance deficit related to confusion, dementia, and limited mobility and required limited assistance with bed mobility. The care plan documented the resident may use positioning rails as needed for repositioning. On 02/06/23 at 1:53 p.m., Res #36 was observed lying on his bed in his room. Quarter bed rails were observed in the up position on both sides at the head of the bed. A review of Res #36's EHR did not reveal an assessment or consent for the use of bed rails. 3. Res #38 had diagnoses which including Alzheimer's disease, dementia severe with agitation, and anxiety disorder. A significant change assessment, dated 12/18/22, documented Res #38 was severely impaired in daily decision making, had behaviors, and required extensive assistance with ADLs. The assessment documented the resident had fallen. On 02/07/23 at 9:38 a.m., Res #38 was observed sitting in a Broda chair with a fall alarm in place. He was unable to be interviewed. On 02/09/23 at 8:37 a.m., Res #38 was observed sitting in a Broda chair and was observed to attempt to stand up several times. On 02/09/23 at 8:43 a.m., Res #38's bed was observed to have quarter bed rails up on both sides of the head of the bed. Res #38 EHR documentation did not reveal an informed consent, assessment, or physician order for the use of bed rails. 4. Res #92 had diagnoses which included cerebral infarction and anxiety disorder. A quarterly assessment, dated 01/12/23, documented Res #92 was severely impaired in daily decision making and was independent to requiring supervision with most ADLs. A care plan, dated 01/29/23, documented the resident was independent with bed mobility and may use positioning rails as needed for repositioning. On 02/07/23 at 4:06 p.m., Res #92 was observed walking near the nursing station. She was unable to be interviewed. On 02/09/23 at 8:30 a.m., Res #92 was observed standing near the side of the bed and quarter rails were observed in the up position on both sides of the head of the bed. Res #92's EHR was reviewed and did not reveal an assessment documenting the need for bed rails or an informed consent. 46387 5. Res #71 had diagnoses which included dementia with behavioral disturbance, osteoarthritis, and seizures. A quarterly MDS, dated [DATE], documented Res #71 was severely cognitively impaired and required extensive to total assistance with ADLs. A care plan, reviewed 01/24/23, documented Res #71 may use positioning rails as needed. A bed rail assessment, dated 02/07/23 documented positioning rails removed resident unable to utilize at this time. On 02/09/23 at 8:45 a.m., Res #71 was observed in bed with quarter rails raised on the head of the bed. 6. Res #93 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and epilepsy. An annual MDS, dated [DATE], documented the resident was moderately cognitively impaired and required limited to extensive assistance with ADLs. On 02/09/23 at 10:24 a.m., Res #93 was observed with bilateral bed rails up at the head of the bed. There was no assessment for bed rail use documented in Res #93's chart. 46909 7. Res #13's quarterly assessment, dated 12/28/22, documented the resident's cognition was moderately impaired, required extensive assistance with bed mobility and transfers, and did not walk. On 02/06/23 at 11:10 a.m., an observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. The EHR was reviewed and revealed no documentation related to bed rails assessments or an informed consent for bed rails. 8. Res #30's annual assessment, dated 09/23/22, documented the resident's cognition was intact and was independent with bed mobility, transfer, toileting, and ambulation. On 02/06/23 at 11:20 a.m., and observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. On 02/07/23 at 2:52 p.m., the maintenance man stated he did not perform bed maintenance or rail checks on a routine basis. He stated he only checked a bed rail if a staff member or resident reported having a problem with the bed rails.

Based on observation and interview the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents form documented 99 residents who lived in the facility. Findings: An initial kitchen tour was conducted on 02/06/23 at 10:37 a.m. The DM was observed with a hair net on but it was not being worn properly to cover all of her hair in the front. On 02/06/23 at 10:49 a.m., the ice machine was wiped at the ice drop with a clean white cloth. A black substances was observed on the white cloth. At 10:50 a.m., the DM stated the ice machines were cleaned by an external company and the assistant DM stated she did not know what the black substance was. The DM stated she thought they had been in to clean the ice machines but the only record she could locate was when it had been cleaned in January 2022. On 02/06/23 at 12:23 p.m., during the first dining observation, the DM was observed with a hair net on but not worn properly. The front and sides of her hair were not covered by the hair net. The DM was receiving meal trays from the window pass, delivering the trays to residents, and going in and out of the kitchen. On 02/06/23 at 12:31 p.m., Res #13 was observed calling for help. A staff member was observed to enter the dining room to assist the resident and the staff member sat down and began assisting the resident to eat. Hand hygiene was not observed prior to touching the resident's silverware. On 02/06/23 at 12:32 p.m., a staff member was observed to touch the ear pieces of their mask before taking the resident's food items off their tray. No hand hygiene was observed. On 02/06/23 at 12:38 p.m., Res #13 was observed and stated I cant see and help. A staff member from the kitchen stated told Res #13 they were coming. The staff was observed to move their mask up & away from their face with their right hand, pick up a fork, and used it to move the resident's sandwich closer to the resident. No hand hygiene was observed. On 02/06/23 at 12:42 p.m., a staff member was observed lowering mask to talk to coworker, then using the same hand to pick up a resident's straw from drink, and place drops into the resident's mouth. The staff member was not observed to perform hand hygiene after touching mask and picking up the resident's straw. On 02/06/23 at 12:54 p.m., the DM was observed coming out of kitchen without her mask on and was observed to go to the ice machine. On 02/06/23 at 12:55 p.m., the DM was asked about wearing her hair net not covering all her hair. She stated all she had been doing was sitting in the back in her office. On 02/08/23 at 5:11 p.m., during a second dining observation, DA #2 was observed to touched his mask and hair net and continue to place food trays on the hall carts. Hand hygiene was not observed. On 02/08/23 at 5:13 p.m., three dietary staff were observed carrying items out to the residents in the dining room by the rim of the drinking glasses, soup bowls, and the dessert cups. On 02/08/23 at 5:16 p.m., DA #2 was observed to touch their face mask again and was touching containers for residents' trays by the rim. DA #2 was not observed to perform hand hygiene. On 02/08/23 at 5:19 p.m., DA #1 was observed to enter the kitchen without a hair net and did not wash her hands when entering the kitchen. DA #1 changed gloves when exiting the kitchen but was not observed to perform hand hygiene. On 02/08/23 at 5:22 p.m., DA #2 was observed to wipe up a spilled drink with paper towels on a residents' table. DA #2 was observed to have on gloves. DA #2 was observed to then go back to kitchen pass and in same gloves, made another drink, and coffee, placed food tray on hall cart without doffing the soiled gloves or performing hand hygiene. Additional staff members were observed to getting coffee from the coffee machine during meal service. On 02/08/23 at 5:27 p.m., cook #2 was observed to pick up an unwanted meal from a resident in the dining room and took it into the kitchen and brought out a sandwich. Cook #2 touched a resident in the dining room and returned to the kitchen and started the dish machine. Cook #2 was observed putting up clean pans and a rack in the oven. Cook #2 was observed to not doff her gloves or perform hand hygiene during this observation. On 02/08/23 at 5:30 p.m., DA #1 was asked if she should have on a hair net and she did not answer. She was asked if she washed her hands when she went into the kitchen she stated she did not. She said she changed her gloves after she came out of the kitchen. On 02/08/23 at 5:33 p.m., DA #1 was observed to remain without a hair net and entered the kitchen and washed her hands. On 02/08/23 at 5:36 p.m., cook #2 stated she did not wash her hands when she entered the kitchen. On 02/08/23 at 5:37 p.m., DA #2 stated he did not use hand sanitizer when serving meals. He stated he tried to wash his hands whenever he went into the kitchen. On 02/08/23 at 5:54 p.m., the DM stated the staff should have washed their hands when entering the kitchen and should wear hair nets when working in the kitchen. She stated gloves do not take the place of hand hygiene. On 02/09/23 at 10:36 a.m., the kitchen staff was asked to check the sanitizer in the bucket. At that time, cook #1 stated they checked the sanitizer in the buckets once a day. At 10:37 a.m., the DM brought out a roll of sanitizer strips from her office and handed it to the cook to check the sanitizer. Cook #1 was observed to place the strip into the sanitizer bucket and the level of sanitizer did not register on the strip. On 02/09/23 at 10:40 a.m., the DM stated the sanitizer had not been working and they had an outside company in to repair it last week. On 02/09/23 at 11:48 a.m., DA #2 was observed to touch his mask, then touch the rim of the bowls when moving them on the tray to place on the hall carts. The desserts were observed to be uncovered on the hall carts. On 02/09/23 at 11:54 p.m., cook #3 was observed making the alternate meals. She was also cooking fish in the fryer. She had on gloves and had touched the fryer baskets and a pan that contained fish she had cooked. She was observed to touch the lids to containers under a steam table. She then was observed to used the same gloved hand and reach in the lettuce container and grab the lettuce with the gloved hand. She then changed her gloves but did not perform hand hygiene before placing on a new pair of gloves and finished making the salad. On 02/09/23 at 11:56 a.m., cook #1 stated they had been using gloved hands to get the item from the salad bar. On 02/09/23 at 11:58 a.m., the assistant DM was asked about the uncovered dessert cups in the hall cart. She stated she was not sure but heard if food went in the covered cart its was ok if it was not covered. On 02/09/23 at 12:36 p.m., the repair man for the sanitizer was in the kitchen and stated the tip was clogged and it was not dispensing the sanitizer. He stated he was going to replace the dispensers. He stated he had been in the building last week and it had been working. On 02/10/23 at 12:35 p.m., the DM and the assistant DM were interviewed. The DM stated when staff were passing trays they should wash their hands if they touch anything which would contaminate their hands. The DM stated she was not aware staff could use hand sanitizer in the dining room while passing trays. The DM stated staff should not have touched their masks and should never touch the rims of the glasses while serving the residents. The DM stated she was told items going out on the hall carts did not need to be covered. She stated we generally cover everything but the desserts when it goes out to the halls. The DM stated before staff enter the kitchen a hair net should be on and worn properly. She stated when staff enter the kitchen they should have washed their hands. She stated the kitchen staff should have checked the sanitizer in the sanitizer buckets thee time a day, morning, noon, and night.

Based on record review, observation, and interview, the facility failed to ensure residents' PCP addressed irregularities documented on the MRR per facility policy for five (#12, 13, 38, 76, and #92) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 99 residents resided in the facility. Findings: A facility policy, titled IIIA2: DOCUMENTATION AND COMMUNICATION OF CONSULTANT PHARMACIST RECOMMENDATIONS, dated 01/01/15, read in part, .C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. 1) If the prescriber that does not respond is also the Medical Director, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facilitate compliance . 1. Res #38 had diagnoses which included Alzheimer's disease, anxiety disorder, and major depressive disorder. A consultant pharmacist MRR, dated 05/25/22, asked the prescriber to consider a taper for trazodone (an antidepressant medication) 50 mg, three tablets at bedtime. The prescriber response, dated 07/28/22, was to continue with the current medications as ordered due to continuing to have episodes of increased agitation and restlessness and difficulty to redirect. A consultant pharmacist MRR, dated 07/29/22, asked the prescriber to consider a reduction of Xanax (an antianxiety medication) one mg at bedtime. The prescriber response, dated 01/25/23, documented this medication was discontinued per discharge instructions from geri-psych stay. A consultant pharmacist MRR, dated 09/23/22, asked the prescriber to consider a reduction of escitalopram (an antidepressant medication) 20 mg. The prescriber response, dated 01/25/23, documented this medication had been discontinued per the discharge instruction from geri-psych stay. A review of Res #38's EHR revealed the medication had been discontinued on 11/14/22. On 02/08/23 at 3:54 p.m., the DON confirmed the prescriber's response had been late for the three MRRs. 2. Res #92 had diagnoses which included gastro-esophageal reflux disease. A consultant pharmacist MRR, dated 11/20/22, asked the prescriber to consider a taper for Protonix (a medication used to treat gastro-esophageal reflux disease) from 40 mg to 20 mg. The prescriber agreed to the taper on 01/18/23. A quarterly assessment, dated 01/12/23, documented Res #92 was severely impaired in daily decision making and was independent to requiring supervision with ADLs. A physician order, dated 01/19/23, documented to administer 20 mg of Protonix daily to Res #92. On 02/07/23 at 2:49 p.m., the DON was asked about November's MRR not being signed until the following January. She stated she would have to check with the ADON. On 02/10/23 at 12:56 p.m., during an interview with the DON, ADON, and the IP, the DON confirmed the MRR had not been addressed by the prescriber within the policy time frame. 46387 3. Res #12 had diagnoses which included Alzheimer's disease, dementia, and generalized anxiety disorder. A MRR, dated 10/26/22, documented a request to decrease Res #12's anxiety medication. The review was signed by the nurse practitioner as accepted on 01/04/23. A quarterly MDS, dated [DATE], documented Res #12 was cognitively intact and received anti-anxiety medication. A physician order, dated 01/04/23, documented to administer Buspar 5 mg two times per day for anxiety. 4. Res #76 had diagnoses which included gastro-esophageal reflux disease. A MRR, dated 09/23/22, documented a request to decrease Res #76's sedative/hypnotic medication. The physician declined the request on 01/19/23. A MRR, dated 11/21/22, documented a request to decrease Res #76's pantoprazole. The physician agreed to the request and signed the review on 01/19/23. A physician order, dated 01/20/23, documented to administer pantoprazole 20 mg one time per day. 46909 5. Res #13 was admitted to the facility on [DATE] and had diagnoses which included major depressive disorder and vascular dementia without behavioral disturbance. A physician order, dated 01/20/21, documented to administer buspirone 10 mg every morning and at bedtime related to a diagnosis of vascular dementia without behavioral disturbance. A pharmacist MRR, dated 01/26/22, recommended a gradual dose reduction of buspirone 10 mg. The MRR did not document a response from the physician until 05/20/22. On 02/08/23 at 3:53 p.m., an interview was conducted with DON and ADON and they both stated that the physician turned the MRR over to the nurse practitioner, but there was a communication break down between the physician and the nurse practitioner so the MRRs were not being looked at. Once the nurse practitioner discovered that the physician wanted the nurse practitioner to review the MRRs, she started reviewing them in a timely manner.

Based on record review, observation, and interview, the facility failed to ensure a resident received post dialysis assessments when the resident returned from dialysis for one (#60) of one resident reviewed for dialysis. The Resident Census and Conditions of Residents form documented one resident residing in the facility received dialysis. Findings: Res #60 had diagnoses which included diabetes, chronic kidney disease, and atherosclerosis of the renal artery. A care plan, initiated on 03/11/21, documented Res #60 received dialysis on Mondays, Wednesdays, and Fridays. The care plan documented the staff were to assess the resident's shunt every shift and to monitor for signs of bleeding or hemorrhage. An annual assessment, dated 09/13/22, documented the resident was intact in cognition, required extensive to total assistance with most ADLs, and received dialysis treatments. On 02/08/23 at 9:03 a.m., Res #60 was observed lying in her bed. She stated she received her medications before she was taken to dialysis and the staff provided her a lunch. She stated she took a form to the dialysis unit and brought it back to the facility when she returned. On 02/09/23 at 2:50 p.m., the IP reported the post dialysis assessment of the resident had not been documented since March of 2022 when the order fell off and was not noticed. The IP stated the order was put back in today when the surveyor asked about post dialysis assessments.

Based on record review, observation, and interview, the facility failed to ensure residents were assessed for the need of bed rails and informed consent was obtained prior to the use of quarter bed rails for eight (#13, 30, 36, 38, 57, 71, 92, and #93) of eight resident reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 99 residents who lived in the facility. Findings: 1. Res #57 had diagnoses which included dementia and schizoaffective disorder bipolar type. A physician order, dated 06/21/22, documented may use positioning rails. A quarterly assessment, dated 01/04/23, documented the resident was severely impaired with cognition and required extensive to total assistance with ADLs. A care plan, last reviewed 01/27/23, documented may use positioning rails as needed. The care plan documented Res #57 had left sided weakness and required extensive assistance with bed mobility, locomotion, dressing, toileting, and personal hygiene. The EHR for Res #57 did not contain a bed rail assessment or consent for bed rails. On 02/06/23 at 1:11 p.m., Res #57 was observed lying on an air bolster mattress with quarter rails in the up position at the head of the bed. The bed was off the ground in a high position. The resident was moving her right leg off the bed stating she wanted out of the airplane. On 02/09/23 at 8:43 a.m., Res #57 was observed in bed with eyes closed on an air mattress, quarter bed rails were observed in the up position at the head of the bed, and the head of bed was raised. 34945 2. Res #36 had diagnoses which included dementia, muscle wasting and atrophy, weakness, and lack of coordination. An admission/Medicare assessment, dated 10/31/22, documented Res #36 was moderately impaired in cognition and required limited assistance with ADLs. A care plan, dated 11/04/22, documented the resident had a self care performance deficit related to confusion, dementia, and limited mobility and required limited assistance with bed mobility. The care plan documented the resident may use positioning rails as needed for repositioning. On 02/06/23 at 1:53 p.m., Res #36 was observed lying on his bed in his room. Quarter bed rails were observed in the up position on both sides at the head of the bed. A review of Res #36's EHR did not reveal an assessment or consent for the use of bed rails. 3. Res #38 had diagnoses which including Alzheimer's disease, dementia severe with agitation, and anxiety disorder. A significant change assessment, dated 12/18/22, documented Res #38 was severely impaired in daily decision making, had behaviors, and required extensive assistance with ADLs. The assessment documented the resident had fallen. On 02/07/23 at 9:38 a.m., Res #38 was observed sitting in a Broda chair with a fall alarm in place. He was unable to be interviewed. On 02/09/23 at 8:37 a.m., Res #38 was observed sitting in a Broda chair and was observed to attempt to stand up several times. On 02/09/23 at 8:43 a.m., Res #38's bed was observed to have quarter bed rails up on both sides of the head of the bed. Res #38 EHR documentation did not reveal an informed consent, assessment, or physician order for the use of bed rails. 4. Res #92 had diagnoses which included cerebral infarction and anxiety disorder. A quarterly assessment, dated 01/12/23, documented Res #92 was severely impaired in daily decision making and was independent to requiring supervision with most ADLs. A care plan, dated 01/29/23, documented the resident was independent with bed mobility and may use positioning rails as needed for repositioning. On 02/07/23 at 4:06 p.m., Res #92 was observed walking near the nursing station. She was unable to be interviewed. On 02/09/23 at 8:30 a.m., Res #92 was observed standing near the side of the bed and quarter rails were observed in the up position on both sides of the head of the bed. Res #92's EHR was reviewed and did not reveal an assessment documenting the need for bed rails or an informed consent. 46387 5. Res #71 had diagnoses which included dementia with behavioral disturbance, osteoarthritis, and seizures. A quarterly MDS, dated [DATE], documented Res #71 was severely cognitively impaired and required extensive to total assistance with ADLs. A care plan, reviewed 01/24/23, documented Res #71 may use positioning rails as needed. A bed rail assessment, dated 02/07/23 documented positioning rails removed resident unable to utilize at this time. On 02/09/23 at 8:45 a.m., Res #71 was observed in bed with quarter rails raised on the head of the bed. 6. Res #93 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and epilepsy. An annual MDS, dated [DATE], documented the resident was moderately cognitively impaired, required limited to extensive assistance with ADLs, and did not use bed rails. On 02/09/23 at 10:24 a.m., Res #93 was observed with bilateral bed rails up at the head of the bed. There was no assessment for bed rail use documented in Res #93's chart. 46909 7. Res #13 had diagnoses which included vascular dementia and a history of transient ischemic attack and cerebral infarction. A quarterly assessment, dated 12/28/22, documented the resident's cognition was moderately impaired, required extensive assistance with bed mobility and transfer and did not walk. On 02/06/23 at 11:10 a.m., an observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. The EHR was reviewed and revealed no documentation related to a bed rail assessment or an informed consent for bed rails. 8. Res #30's annual assessment, dated 09/23/22, documented the resident's cognition was intact and was independent with bed mobility, transfer, toileting, and ambulation. On 02/06/23 at 11:20 a.m., and observation was made of the resident's bed. Bed rails were observed secured to each side of the resident's bed. On 02/07/23 at 1:41 p.m., the ADON stated the facility did not do bed rail assessments. She stated the manufacturer of the beds told them the beds they purchased for residents had positioning rails, not bed rails. She stated she could not say how long the facility had not been doing the assessments.

Based on record review, observation, and interview, the facility failed to ensure resident assessments accurately reflected residents' current status for three (#12, 57, and #60) of 24 residents whose assessments were reviewed. The facility failed to accurately code for: a. dialysis for Res #60. b. hallucinations and delusions for Res #12. c. PASRR Level II for Res #57. d. prognosis for Res #57. The Resident Census and Conditions of Residents form documented 99 residents resided in the facility. Findings: 1. Res #60 had diagnoses which included diabetes, chronic kidney disease, and atherosclerosis of the renal artery. A care plan, initiated on 03/11/21, documented the resident received hemodialysis on Mondays, Wednesdays, and Fridays. A physician order, dated 05/22/22, documented to apply a thin layer of lidocream to the left forearm 45 minutes before dialysis. An annual assessment, dated 09/13/22, documented Res #60 was receiving dialysis. A quarterly assessment, dated 12/06/22, documented Res #60 was not receiving dialysis. On 02/08/23 at 9:03 a.m., Res #60 was observed lying on her bed in her room. She stated she received dialysis on Mondays, Wednesdays, and Fridays. On 02/09/23 at 1:59 p.m., MDS coordinator #2 stated the quarterly coding for dialysis was an error as the resident had been on dialysis for a long time. 46387 2. Res #12 had diagnoses which included Alzheimer's disease, and unspecified dementia without behavioral disturbance. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had hallucinations, and delusions. On 02/07/23 at 3:24 p.m., LPN #1 was asked if Res #12 had any hallucinations or delusions. She stated Res #12 had not had hallucinations or delusions in the year she has cared for her. On 02/07/23 at 3:32 p.m., MDS coordinator #2 stated the coding of the MDS must have been a mistake since he was unaware of any hallucinations or delusions for Res #12. 3. Res #57 had diagnoses which included CHF, atrial fibrillation, dementia, schizoaffective disorder bipolar type, and malignant neoplasm of breast. A physician order, dated 07/13/22, documented to admit Res #57 to hospice related to atrial fibrillation. A significant change MDS assessment, dated 07/19/22, documented Res #57 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS documented Res #57 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. A quarterly MDS assessment, dated 01/04/23, documented Res #57 did not have a condition or chronic disease that may result in a life expectancy of less than six months. On 02/08/23 at 2:56 p.m., MDS coordinator #2 stated Res #57 had a PASRR level II. He stated it was coded in error. On 02/08/23 at 2:59 p.m., MDS coordinator #2 stated he was instructed not to code the resident as having a prognosis of less than six months unless explicit documentation was provided of the prognosis. He stated he did have access to the hospice chart and was aware of the requirements to place a resident on hospice. He stated he was unsure when or from whom he received the instruction from. He stated he agreed that if a resident was on hospice it constituted a physician statement of prognosis and would issue a correction on the MDS assessments.

Based on record review and interview, the facility failed to ensure advanced directives, including DNRs, were signed by an individual with the authority to do so for six (#36, 38, 48, 50, 57, and #71) of 33 residents whose records were reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 66 residents in the facility had an advanced directives and/or DNR. Findings: 1. Resident #36 had diagnoses which included diabetes, dementia, and weakness. An admission assessment, dated [DATE], documented the resident was moderately impaired in cognition and required limited assistance with most ADLs. An Oklahoma DNR form was present in Res #36's EHR and documented a signature different from the resident. On [DATE] at 1:00 p.m., the admissions clerk stated Res #36 did not have a health care proxy or POA for health care. 2. Res #38 had diagnoses which included Alzheimer's disease, dementia - severe with agitation, and major depressive disorder. A significant change assessment, dated [DATE], documented the resident was severely impaired in daily decision making, had behaviors, and required extensive assistance with ADLs. An Oklahoma DNR form, dated [DATE], was present in Res #38's EHR and documented a signature different from the resident. On [DATE] at 1:00 p.m., the admissions clerk stated Res #38 did not have a health care proxy or POA for health care. She stated the facility lawyer told them any family member could sign for a DNR on a resident. On [DATE] at 12:48 p.m., during an interview with the DON and ADON, they confirmed the DNR form documented only a POA for health care, a health care proxy, or a legal guardian, were documented on the form as who could sign as a resident's representative. 38495 3. Res #50 had diagnoses which included diabetes mellitus, seizures, muscle wasting and atrophy. An Oklahoma DNR form, dated [DATE], was signed by the resident's family member who was not the resident's POA. A physician order, dated [DATE], documented the resident's status was DNR. An admission assessment, dated [DATE], documented the resident was severely impaired with cognition and required extensive to total assistance with ADLs. On [DATE] at 12:15 p.m., the admission clerk confirmed the resident did not have a POA for healthcare. 4. Res #57 had diagnoses which included CHF, dementia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A Oklahoma DNR form, dated [DATE], was signed by the resident's family member whom did not have POA for the resident. A physician order, dated [DATE], documented the resident's status was DNR. A significant change assessment, dated [DATE], documented the resident was intact with cognition and required extensive to total assistance with most ADLs. A quarterly assessment, dated [DATE], documented the resident was severely impaired with cognition and required extensive to total care with most ADLs. On [DATE] at 12:15 p.m., the admission clerk confirmed this resident did not have a POA for healthcare. 46387 5. Res #48 had diagnoses which included aphasia, atrial fibrillation, congestive heart failure, and hypertension. A facility form, titled DNR/CPR INSTRUCTIONS dated [DATE], documented Res #48 did not want CPR in the event of cardiopulmonary arrest. The form was signed by a family member. A physician order, dated [DATE], documented Res #48's code status as do not resuscitate. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired and required limited assistance with ADLs. A care plan, reviewed [DATE], documented Res #48's code status as do not resuscitate and documented a signed DNR consent form was scanned into the chart. On [DATE] at 12:15 p.m., the admissions coordinator stated Res #48 did not have a power of attorney, healthcare proxy, or guardianship. On [DATE] at 9:25 a.m., the BOM stated the DNR/CPR INSTRUCTIONS form was the only one for resident. She stated there was not an Oklahoma DNR form for the resident. On [DATE] at 4:08 p.m., the DON stated was not aware Res #48 did not have a legal DNR on file. 6. Res #71 had diagnoses which included dementia with behavioral disturbance, hypertension, atherosclerotic heart disease, seizures, and diabetes. An Oklahoma DNR Consent Form, dated [DATE], was signed by a resident's family member. The representative signature line for the DNR form read in part, Signature of Representative (Limited to an attorney-in-fact for health care decisions acting under the Durable Power of Attorney Act, a health care proxy acting under the Oklahoma Rights for the Terminally Ill or Persistently Unconscious act or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act.) A physician order, dated [DATE], documented Res #71's code status as do not resuscitate. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired, had behaviors, and required extensive to total assistance with ADLs. A care plan, reviewed [DATE], documented Res #48's code status as do not resuscitate and documented a signed DNR consent form was scanned into the chart. On [DATE] at 12:15 p.m., the admissions coordinator stated Res #71 did not have a power of attorney, healthcare proxy, or guardianship. She stated the facility lawyer told them any family member could sign for a DNR on a resident. On [DATE] at 1:55 p.m., the admission clerk stated it was her understanding if a resident was unable to make a decision regarding DNR status, a family member could make the decision for the resident to be a DNR. On [DATE] at 3:58 p.m., the ADON and DON were present. The ADON stated according to the facility policy they did what they were supposed to. She stated we have talked to the attorney and there was a way for the family to be able to sign the DNR. On [DATE] at 4:08 p.m., the DON stated she was not aware the resident did not have a legal DNR on file. On [DATE] at 4:09 p.m., the ADON and DON provided a document sent to them from the facility attorney, dated 2019, which documented a family member could sign an advanced directive, including a DNR, if the resident did not have a POA for health care, proxy, or guardian. They stated they were unaware the law in Oklahoma had changed on [DATE] which documented only a POA for health care prior to [DATE], a health care proxy, or a legal guardian, could sign an advanced directives.

Based on record review and interview, the facility failed to ensure quarterly MDS assessments were completed no later than 14 days after the assessment reference date for seven, (#5, 31, 35, 36, 53, 70, and #92) of 24 residents whose MDS assessments were reviewed. The Resident Census and Condition of Residents form documented 99 residents resided in the facility. Findings: 1. A final validation report documented Res #5 had a quarterly MDS with an ARD of 01/10/23. The assessment was documented as being completed late with a signature date of 01/25/23. 2. A final validation report documented Res #31 had a quarterly MDS with an ARD of 01/11/23. The assessment was documented as being completed late with a signature date of 01/26/23. 3. A final validation report documented Res #35 had a quarterly MDS with an ARD of 01/23/23. The assessment was documented as being completed late with a signature date of 02/07/23. 4. Res #36 had a quarterly MDS with an ARD of 01/26/23. As of 02/09/23 the MDS assessment was documented as In Progress. 5. A final validation report documented Res #53 had a quarterly MDS with an ARD of 01/12/23. The assessment was documented as being completed late with a signature date of 01/29/23. 6. A final validation report documented Res #70 had a quarterly MDS with an ARD of 01/11/23. The assessment was documented as being completed late with a signature date of 01/27/23. 7. A final validation report documented Res #92 had a quarterly MDS with an ARD of 01/12/23. The assessment was documented as being completed late with a signature date of 01/29/23. On 02/08/23 at 3:05 p.m., MDS coordinator #2 stated quarterly MDS assessments should be completed 14 days after the ARD. He stated timely MDS completion had been an issue. He provided a QA sheet that documented all MDS assessments were up to date as of 01/20/23. On 02/08/23 at 5:31 p.m., MDS coordinator #1 stated she was under the impression all MDS assessments were caught up as of 01/20/23. She stated she was not aware of the additional late completed MDS assessments. She stated she was told by MDS coordinator #2 the MDS assessments were up to date and stated the facility did not conduct any ongoing monitoring to ensure assessments were kept up to date. She stated there was no system in place to ensure MDS assessments were going to continue to be completed on time.

Based on record review and interview, it was determined the facility failed to revise care plans for one (#70) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 02/06/23, documented 99 residents resided in the facility. Findings: Res #70 was admitted to the facility on [DATE] and had diagnoses which included chronic kidney disease, hyperglyceridemia, diabetes mellitus, and hypertension. A care plan, dated 08/14/19, related to pressure ulcer prevention and care, documented cares for pressure ulcer prevention. The care plan had not been updated with the resident's current status. Res #70's care plan was reviewed and revealed the most current revision and update was documented on 05/14/21. A significant change assessment, dated 10/18/22, documented the resident's cognition was intact, required extensive assistance with most ADLs, and had one stage II pressure ulcer. A physician order, dated 10/18/22, documented the facility was to cleanse the left buttock wound, pat dry, apply MediHoney to opening, and cover on Mondays, Wednesdays, and Fridays. A physician order, dated 11/03/22, documented the facility was to cleanse the left heel, pat dry, apply providone, cover, and place a dressing on Mondays, Wednesdays, and Fridays. A quarterly assessment, dated 01/01/23, documented the resident's cognition was intact, required extensive assistance with most ADLs, and had one unstageable pressure ulcer. On 02/08/23 at 3:15 p.m., MDS Coordinator #2 stated they had been working the floor a lot and had been behind with updating the care plans. MDS Coordinator #2 stated they were in the process of bringing all care plans up to date.

Based on record review and interview, the facility failed to ensure comprehensive MDS assessments were completed by the 14th calendar day after a determination of significant change was made for two (#14 and #99) of 24 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 99 residents resided in the facility. Findings: 1. Res #14 had a significant change assessment with an ARD of 01/11/23. A final validation report documented the assessment was completed late with a signature date of 01/27/23. 2. Res #99 had a significant change assessment with an ARD of 01/15/23. A final validation report documented the assessment was completed late with a signature date of 01/30/23. On 02/08/23 at 3:05 p.m., MDS coordinator #2 stated significant change MDS assessments should be completed 14 days after the ARD. He stated timely MDS completion had been an issue. He provided a QA sheet that documented all MDS assessments were up to date as of 01/20/23. On 02/08/23 at 5:31 p.m., MDS coordinator #1 stated she was under the impression all MDS assessments were caught up as of 01/20/23. She stated she was not aware of the additional late completed MDS assessments. She stated she was told by MDS coordinator #2 the MDS assessments were up to date and stated the facility did not conduct any ongoing monitoring to ensure assessments were kept up to date. She stated there was no system in place to ensure MDS assessments were going to continue to be completed on time.

Based on record review and interview, the facility failed to ensure an ABN notice was provided to a resident who was discharged from skilled services, had benefit days remaining, and remained in the facility, for one (#35) of three residents reviewed for beneficiary notices. The Resident Census and Conditions of Residents form documented 17 resident residing in the facility were receiving skilled services. Findings: An admission/Medicare 5 day assessment, dated 10/29/22, documented Res #35 was severely impaired in cognition, required extensive assistance with most ADLs, and did not walk. An end of PPS Part A Stay assessment, dated 01/03/23, documented Res #35 was discharged from skilled services. On 02/07/23 at 1:02 p.m., MDS coordinator #1 reported she had not provided Res #35 an ABN notice when she was discharged from skilled services and remained in the facility. She stated she should have provided one.

On 08/29/16, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent falls and to implement interventions to aid in the prevention of falls. Resident #13 experienced a fall on 04/16/16 that resulted in a rib fracture. The resident experienced a fall on 06/03/16 and then fell again on 06/04/16 and sustained a right hip fracture. The resident fell on [DATE] and experienced right hip pain and a small scratch on her back. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. ~Resident #3 experienced a fall on 04/21/16 and sustained bruises and a skin tear to the right elbow. The resident experienced falls on 04/30/16, 05/15/16, and 06/03/16 and then fell two hours later on 06/03/16, that resulted in a right wrist fracture. The resident fell on [DATE] and experienced an abrasion to the forehead. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. ~Resident #12 experienced a fall on 04/04/16 and sustained a quarter sized abrasion to the back of his head. The resident experienced a fall on 05/04/16 and sustained a small abrasion to the mid back, a skin tear to the right elbow, and pain to the back of the head and left shoulder. The resident experienced a fall on 06/09/16 and then fell again on 06/17/19 and sustained two skin tears to the upper left arm, a small abrasion to the scalp and blood to the left side of his mouth. The resident fell on [DATE] and sustained a laceration to the back of the head that required five staples. The resident fell [DATE] and sustained a skin tear to the left elbow and pain to lower back and hips and fell again on 08/14/16. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:09 p.m., the administrator and the DON were informed of the IJ regarding falls and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 6:31 p.m., an acceptable plan of removal was received from the administrator and the DON. The plan of removal documented: Plan of Removal For Immediate Jeopardy at CCNC 8-29 5:15 PM Interventions were discussed by DON .ADON .MDS Coordinator . All three patients will be monitored for safety one on one starting at 5:55 pm until interventions are put in place. All three patients will continue to be cared for one on one for safety and a signature sheet will be used to document observation and it will continue until noon on Tuesday 30th of August or until appropriate intervention for each resident is derived. All staff will be inserviced on CCNC Prevention of Fall Policy and Bowel and Bladder Program and where to find interventions for each resident by DON .and will be completed by 12:00pm midnight Monday August 29, 2016. A list of all employees by department has been made and each employee will sign off when they are inserviced. Any employee that was not inserviced by this time will not be allowed to return to work until inservice is completed. Inservicing will begin on Prevention of Fall Policy and Bowel and Bladder Program by DON .at 6:45 pm and will continue until all employees are inserviced. No employee be allowed to work until they are inserviced. A new fall risk assessment will be done on all residents by midnight on 8-29-16 by ADON and other licensed nurses. Any resident that is high risk will also have Bowel and bladder program assessment initiated. An addendum to the plan of removal was received on 08/30/16 at 10:19 a.m. The addendum documented, Addendum to POM The following is a list of employees that have not been inserviced and reason why. Each of these employees have been told via phone call on 8-29 that they are not allowed to work until they are inserviced . Each employee will sign and date when they get inserviced on a copy of this paper. The IJ was removed effective 08/30/16 at 3:45 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review it was determined the facility failed to: ~ provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for eight (#2, #3, #4, #10, #12, #13, #14, and #21) of 12 sampled residents who had experienced falls; and ~ ensure hazardous chemicals were stored in locked areas or compartments and were not accessible to residents. The facility identified 72 residents who were at high risk for falls. Findings: A fall policy documented, Fall, Prevention of .All residents will be assessed using the Fall Risk Assessment on admission, quarterly, and with a significant change of condition. Residents will be placed in the Fall Prevention Program when a score of 10 or greater is obtained on the Fall Risk Assessment . Fall, Occurrence of a .If a patient falls .An Incident Report will be completed for every fall . All falls will be evaluated by the interdisciplinary team and appropriate interventions will be placed on the careplan . Falls will be tracked and trended monthly by the QA committee . 1. Resident #13 had [DIAGNOSES REDACTED]. A care plan, dated 02/24/16, documented, .is at risk for falls. She walks with a walker or a cane and has a DX of weakness .She will have no falls .Encourage her to ask for and have assistance if needed .Encourage her to walk with her walker or cane .Keep her walker and her cane within easy reach while in room .answer call light promptly .do not move furniture around .PT/OT/ST to screen eval & tx as indicated . An incident report, dated 04/16/16, documented, .Alert and Oriented & confusion .called to room .resident setting on floor c her back to bed .L side of her Ribs she c/o of hurting only L Side of her Ribs .resident said I fell My side hurts .Steps to Prevent Reoccurrence: encourage resident to use call light if her roommate (sic) needs assist if things are droped (sic) on floor . A fall risk assessment, dated 04/16/16, documented the resident had not experienced any falls in the past three months and had a score of eight. This score indicated the resident was not at high risk for falls. The care plan, updated 04/16/16, documented, Observed sitting on the floor c her back to her bed. C/O leftside pain. Orders rec'd for portable XRay of ribcage XRay result positive for non-displaced left side rib fx 8-10 .minimal pain . The care plan had not been updated to address new fall interventions to be implemented to prevent further falls. The goal had not been met and a new goal had not been addressed. A physician's progress note, dated 04/25/16, documented, .c/o pain when she takes a deep breath .(increased) c pushing in L Ribs . A quarterly assessment, dated 05/06/16, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident was independent with transfers, was independent with toilet use, was continent of bowel/bladder, and had experienced one fall with a major injury since the prior assessment. A fall risk assessment, dated 05/09/16, documented the resident had not experienced any falls in the past three months and had a score of eight. This score indicated the resident was not at high risk for falls. An incident report, dated 06/03/16, documented, Called to residents (sic) room observed resident sitting in floor in front of toilet. No apparent injuries .assisted up from floor and back into bed .Ask (sic) Resident what happened She said I haven't made it there yet. Resident just returned from Hospital She is weak and in need of assistance, She forgets to use call light for Assist .Steps to Prevent Reoccurrence: Non skid socks & stand by assist . A fall risk assessment, dated 06/03/16, documented the resident had experienced one or two falls in the past three months and had a score of 14. This score indicated the resident was at high risk for falls. The care plan, updated 06/03/16, documented, Observed on floor in front of toilet. Had returned from hosp. stay less than an hour before fall. In weakened condition. Encouraged .to ask for assist while regaining her PLOF. The care plan had not been updated to address the resident was to use non-skid socks, did not address she was at high risk for falls, that she forgets to use the call light to ask for assistance, and what the stand by assistance was to be. The goal had not been met and a new goal had not been addressed. An incident report, dated 06/04/16, documented, .pt fell on way to Bathroom (without walker). fell , c/o severe pain to R hip .was in too much pain to explain how she fell .did not use c/L for assist .Steps to Prevent Reoccurrence: Q 30 minute checks and repeat instruction to use C/L for assist .EMS called Pt sent out . The care plan, updated 06/04/16, documented, fell on way to the BR. c/o severe pain in R hip. Out Via EMS .eval & tx . The care plan had not been updated to address who was to conduct the 30 minute checks and what they were to check and the resident forgets to use the call light. There were no new fall interventions addressed to be implemented to prevent further falls. The goal had not been met and a new goal had not been addressed. An incident follow-up, dated 06/06/16, documented, .Has been in the hospital since 5/20/16 with dx of Kidney stones. She returned on 6/3/16, during this time her memory has declined significantly. She was ambulatory before her admit but is not now. Will re-eval for need on return from Hospital. The care plan had not been updated to address the decline in her mental status, she was at high risk for falls, she was no longer ambulatory, and she would forget to use the call light to ask for assistance. A history and physical, dated 06/14/16, documented, .had just readmitted from hospital stay when she had a fall causing a R hip fracture. Also, had Bilateral Pleural effusion. Hip fx was repaired . A significant change assessment, dated 06/21/16, documented the resident had a BIMS score of seven. This score indicated the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, required extensive assistance with toilet use, was frequently incontinent of bladder, was continent of bowel, had a [DIAGNOSES REDACTED]. The care plan, updated 07/01/16, documented, .is at risk for falls .has impaired mobility at this time and has had a decrease in mobility ability .has had a recent hospital stay .will have no falls .encourage her to ask for and have assistance if needed .encourage her to walk with her walker or cane .answer call light promptly . The care plan had not been updated to address the decline in her mental status, she was at high risk for falls, she was no longer ambulatory, she was to wear non-skid socks, and she would forget to use the call light to ask for assistance. There were no new fall interventions addressed to be implemented to prevent further falls. The goal had not been met and a new goal had not been addressed. An incident report, dated 08/04/16, documented, .Dx: Dementia .Heard someone yelling Help me went to residents (sic) room et found her lying on R side in front of BR doorway .Resident c/o R hip pain .Resident stated, I was trying to get up to go to the bathroom. Small scratch noted to mid-back. L leg .Resident wc in front of bathroom door stated, I fell out of it. Resident only had on L sock & was not a non-skid material .Steps to Prevent Reoccurrence: Encourage resident to use call light et provide frequent reminders. Encourage use of non-skid socks c ambulation . A fall risk assessment, dated 08/04/16, documented the resident had experienced one or two falls in the past three months and had a score of 14. This score indicated the resident was at high risk for falls. The care plan, updated 08/04/16, documented, Observed lying on floor. c/o R hip pain. Sent to ER for evaluation .Will encourage resident to use non-skid footwear when ambulating and ask her to call for help prior to attempting to get up .8-4-16 Encourage use of non-skid footwear c ambulation . The care plan had not been updated to address the decline in her mental status, she was at high risk for falls, she was no longer ambulatory, and she would forget to use the call light to ask for assistance. There were no new fall interventions addressed to be implemented to prevent further falls. The goal had not been met and a new goal had not been addressed. On 08/29/16 at 11:47 a.m., the resident was observed sitting in the dining room in her wheelchair. The resident had regular socks on both feet. She was not wearing non-skid socks. At 11:50 a.m., CNA #3 was asked if the resident had any recent falls. She stated, Not that I'm aware of. She was asked if she had any recent fractures. She stated, I don't know. At 11:54 a.m., LPN #6 was asked if the resident had any recent falls. She stated, I believe she had a right hip fracture. She was asked what the fall interventions were to keep her from falling again. She stated, I'm not sure. At 12:00 p.m., CNA#5 was asked why the resident did not have non-skid socks on. She stated, She usually wears shoes. She was asked what fall interventions were in place to keep the resident from falling. She stated, She doesn't have any alarms. There is a big sign that says don't get up by yourself. At 2:15 p.m., the resident was observed sitting in her room in her wheelchair. The resident had on regular socks on both feet. She did not have on non-skid socks. At 4:00 p.m., the DON was asked if a fall assessment was conducted after each fall to determine the root cause of the fall and to determine the fall interventions. She stated, Yes, that is our policy. On the incident and accident report it explains the fall on the back what the resident said and then what caused the fall and come up with an intervention to keep the fall from happening again. The DON was asked what the stand by assist intervention was. She stated, I can't really answer that. She was asked why there were no toileting interventions when the resident had experienced numerous falls attempting to go to the bathroom. She stated, I can't answer that. It doesn't make any sense. She was asked why the care plans had not been updated with fall interventions. She stated, I don't know. On 09/01/16 at 11:20 a.m., the DON was asked if they had conducted a fall assessment after each fall to determine the root cause of the fall and to determine the fall interventions. She was asked where the documentation was. She stated, No. We don't have anything written down. Care plan coordinator #1 was asked why the care plan had not been updated with fall interventions. She stated, We didn't have an appropriate system in place. Care plan coordinator #2 stated, Maybe some miscommunication. We had three or four people working on them at the same time. When I get the incident report I put what's on the incident report on the care plan. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A bowel and bladder assessment, dated 01/15/16, documented, Bowel and Bladder assessment (to be completed on admission, quarterly and change in continence status) .Is resident continent of bowel and bladder? Yes .Interventions: Call bell within reach, prompted voiding (upon awakening, ac/pc, & hs) . A care plan, dated 01/22/16, documented, .Potential for injury r/t to falls. She has had one fall since admission resulting in a skin tear to her arm .Will be free from serious injury r/t falls over the next 90 days .Encourage (resident) to request assistance as needed .Keep pathways clean and free of clutter. Do not move furniture and objects around .Keep spills cleaned up off floors .Keep area consistently lighted .Answer call light promptly; keep call light within easy reach when she is in her room .Monitor closely when up in common areas . A quarterly assessment, dated 04/07/16, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, locomotion off the unit, dressing, toilet use, personal hygiene, and bathing, had two or more non-injury falls and one injury fall since admit or prior assessment. An incident report, dated 04/21/16, documented, .Description of incident .@2255 (10:55 p.m.) pt found sitting on floor in bedroom next to bathroom door, pt stated she fell out of bed but didn't hit her head, (No) bruises visible on pt head, pt responsive .pt stated she was going to bathroom, pt has small bruise on right shoulder right knee, top of right wrist and small bruise on right elbow with small skin break not bleeding, pt reports (no) pain or discomfort .Steps to prevent reoccurrence: Non skid socks, pt on priority charting consider bedside commode . The fall care plan, updated 04/21/16, documented, fell OOB when going to BR. Mult. minor bruises to 4 areas. Denies pain . There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 04/30/16, documented, .Description of Incident .While checking on res, observed res sitting in floor. Res denies hitting head, Res assessed and res has no bruising or injurys (sic) (and) moves all extremeties well with (no) pain. Res stated 'I was sitting on the bed (and) slide off to the floor' .Steps to prevent reoccurrence: Res needs to wear gripper socks or well fitting shoes when res gets up. Make sure matress (sic) off frame as res transfers . The fall care plan, updated 04/30/16, documented, Slid OOB to floor. No s/s of injury. No c/o discomfort voiced. There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 05/15/16, documented, .Description of Incident .While making round, heard res laughing, while checking observed res sitting on floor. Res laughing stated 'I was trying to get in my w/c (and) I slide (sic) out of bed and sat on the floor. I'm alright, I'm not hurt (and) I did not hit my head.' Res assessed (and) has no bruising or injuries noted .Steps to prevent Reoccurrence: Encourage res to use call light. Res to use gripper socks while up in w/c or proper fitting shoes . The fall care plan, updated 05/15/16, documented, Heard laughing from her room. Observed resident sitting on floor. States, 'I was trying to get to my w/c and I slid out of bed and set on floor.' No injuries noted. There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 06/03/16, documented, .Description of Incident .pt observed crawling on floor next to bathroom door, assist x2 pt into wheelchair and onto toilet, pt stated 'fell out of bed and landed on my butt.' Pt states she didn't hit her head, (no) bruises present only slight redness on pt butt, applied pressure to butt pt stated 'doesn't hurt .assisted pt back to bed .@0400 (4:00 a.m.) pt observed lying on floor on right side next to recliner, performed neuro (checks) all wnl, speech clear, pt states 'I wasn't going anywhere I was just getting up.' pt stated 'I didn't hit my head.' No bruises present, pt c/o right wrist hurting, pt able to move wrist and fingers .Additional comments: .Out to .ER @ 1400 (2:00 p.m.) .Steps to prevent reoccurrence: .0200 (2:00 a.m.) put pt in neuro (checks) for 72 hours, put pt in q 15 min (checks) for rest of shift, obtain x-ray for right wrist, obtain UA c C &S if indicated, start q 15 min (checks) @ 0400 (4:00 a.m.). A state reportable incident report, dated 06/03/16, documented, .Description of Incident .At 0400 (4:00 a.m.), the resident was observed lying on the floor of her room on her right side next to her recliner. States, 'I wasn't going anywhere, I was just getting up' .Head to toe assessment completed with no bruising noted. Resident c/o right wrist pain .New orders received to obtain a portable x-ray of her wrist and obtain a UA .X-ray called and arrived to do x-ray at approximately 0800 (8:00 a.m.). Report received back at 1100 (11:00 a.m.) showing positive for wrist fx .Part C: .returned to the facility from the hospital ER at 1545 (3:45 p.m.) on 6/3/16 with her right wrist in a splint and orders to follow up with .(orthopedic physician) . The fall care plan, updated 06/03/16, documented, Resident observed on floor @ 0200 (2:00 a.m.). No injury noted. Began q 15 min visual cks p fall. At 0400 (4:00 a.m.) resident observed on the floor again states 'I was going to the BR I didn't hit my head, but my wrist hurts.' Portable x-ray noted R wrist fx. Out via EMS to ER for eval (and) tx . There were no new fall interventions addressed or implemented to prevent further falls. The goal was not met and a new goal was not addressed. A quarterly assessment, dated 06/30/16, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers, locomotion off the unit, dressing, toilet use, personal hygiene, and bathing, had two or more non-injury falls and one major injury fall since admit or prior assessment. A fall risk assessment, dated 07/13/16, documented the resident had a total score of 19. This score indicated the resident was a high risk for falls. An incident report, dated 08/07/16, documented, .Description of incident .Resident found in her restroom on floor. Stated she is not sure how she fell . Resident snuck off to her room and attempted to get up without assist .Small abrasion that is shallow and 1 cm in length noted to middle of forehead at the hairline. Minimal amount of sanguineous drainage noted. Bleeding resolved with applied pressure .Steps to prevent reoccurrence: Q15 min checks until end of shift. Inservice training for employees to reinforce instruction to resident to ask for assist for ADL (and) transfers . The fall care plan, updated 08/07/16, documented, .observed on floor of bathroom .attempted to go to BR s assist. Received abrasion to forehead. Will observe closely while in common area . There were no new fall interventions addressed or implemented to prevent further falls. The fall care plan, updated 08/10/16, documented, .Anticipate (resident) needs and attempt to meet them before she tries to do them unassisted. On 08/25/16 at 11:45 a.m., the resident was sitting in the wheelchair in the dining room wearing shoes on her feet. On 08/29/16 at 9:41 a.m., the resident was observed in the dining room in the wheelchair wearing socks and shoes on her feet. At 2:12 p.m., the resident was observed sitting in her wheelchair at the table in the dining room working on an art project. The resident was wearing socks and shoes on her feet. On 09/01/16 at 11:24 a.m., the DON and the care plan coordinators were asked why the care plans were not updated with new interventions to prevent further falls. Care plan coordinator #1 stated, We didn't have an appropriate system in place. Part of the problem is we had two, three, or four people doing care plans. We had a miscommunication. Care plan coordinator #2 stated, I take the incident report and update the care plan per the incident report. I guess I missed it. They were asked if they performed a fall assessment after each fall to determine the root cause of the fall. The DON stated, We have not done a formal one, nothing written down. 3. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/03/16, documented the resident had a BIMS score of six. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers, walking, locomotion on and off the unit, extensive assistance with dressing, toilet use, personal hygiene, and bathing, had one injury fall since admit or prior assessment and received antipsychotic and antidepressant medications seven of the previous seven days. An incident report, dated 04/04/16, documented, Type of injury: Abrasion back of head, ST R elbow .Description of Incident .Resident was eating his breakfast in his room when he tried to get up (and) walk to the bathroom. Resident started towards the bathroom then looked back towards his food, lost his balance (and) falling in the process. Resident hit his head (back of his head) on his bedside table .Residents BP continued to increase. N/O noted to send resident to the ER . A state reportable incident report, dated 04/04/16, documented, .Description of Incident: .Resident got up to go to bathroom, turned back and looked at his food, lost his balance and fell causing him to fall backwards hitting his head on the floor. He has a quarter sized abrasion to the center back of his head. Dr. notified and states to start neuro checks and monitor .Approx 1.75hr later resident not responding as he normally would so he was sent to ER for eval and Tx .Part C: .returned from the hospital on [DATE]. His magnesium and Sodium levels where (sic) low and he had a bowel obstruction. He is now back to talking, telling jokes, walking about building, and drinking his coffee most of the day as normal. His neuro checks remain WNL and there are no changes in his LOC. There were no new fall interventions addressed or implemented to prevent further falls. A care plan, dated 04/13/16, documented, Focus: Potential for falls .Will be free from injury from falls .Monitor closely when he is given Seroquel and Remeron, Lasix, HTN medication or Narcotic pain medication .Encourage to request assistance as needed .Keep pathways clean and free of clutter. Keep spills cleaned up off floor. Keep area consistently lighted .Answer call light promptly; Keep call light and frequently used items within easy reach when he is in room .Had a fall on 4/4/16. Got (up) to go to the BR while eating breakfast. Lost his balance (and) fell hitting the back of his head was sent to ER for eval. Returned the next day c some med changes . The goal was not met and a new goal was not addressed. An incident report, dated 05/04/16, documented, .observed resident sitting on bottom under sink area. A&O to self. Small abrasion to midback et skin tear to R elbow noted. Resps c ease. c/o pain to back of head and L shoulder. Resident stated he was up to use the bathroom and hit his head during fall. ROM WNL. Assisted to bed c staff x 2. EMS notified. Neuro checks initiated et WNL at this time .Steps to prevent reoccurrence: Frequently re-orient resident to the environment. Instruct resident to request assistance c toileting et transfer . The fall care plan, updated 05/04/16, documented, .Resident observed on floor @ sink area. Water was on floor. Assess noted ST to R elbow and an abrasion to mid-back. C/O pain to back of head. Orders rec'd to send to ER for eval. Returned c no new orders. X-rays (and) CT all neg. for injury. Will remind resident freq. to ask for assist c transfers . There were no new fall interventions addressed or implemented to prevent further falls. An annual assessment, dated 05/26/16, documented the resident had a BIMS score of eight. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers, walking, locomotion on and off the unit, extensive assistance with dressing, toilet use, personal hygiene, and bathing, had two or more injury falls since admit or prior assessment and had not received antipsychotic or antidepressant medications the previous seven days. An incident report, dated 06/09/16, documented, .Description of Incident .CNA reported to this nurse that (resident) was on the left side of bed with his back against it and sitting on bottom on his floor, he denied pain he stated that the only thing that hurt was his pride, he was assisted to his w/c and then to the dining room (no) lumps, bumps, bruising or open areas in skin noted .Steps to prevent reoccurrence: Q30 minute checks . A fall risk assessment, dated 06/09/16, documented the resident had a total score of 22. This score indicated the resident was a high risk for falls. The fall care plan, updated 06/09/16, documented, .Observed on the floor - No injury . There were no new fall interventions addressed or implemented to prevent further falls. The fall care plan, updated 06/14/16, documented, .PT to screen, eval (and) tx as indicated . An incident report, dated 06/17/16, documented, .Description of incident .observed resident sitting on the floor. 2 skin tears to upper L arm, small abrasion to scalp front of head blood to L side of mouth. Cleansed skin tears c wound cleanser. Steri strips x2 to skin tear #1, TAO and band aid to second skin tear. Dentures removed and mouth cleaned. TAO to scalp. Resident able to MAEs s complaints. Resident assisted into wheelchair .Description of incident by person injured: .I was trying to get to bed .Steps to prevent reoccurrence: Assist c ambulation, use walker to ambulate . A fall risk assessment, dated 06/17/16, documented the resident had a total score of 23. This score indicated the resident was a high risk for falls. The fall care plan, updated 06/17/16, documented, Encourage (and) watch to see that he uses his walker for ambulation. An incident report, dated 06/19/16, documented, .Description of incident: .went to the table found resident on his back on floor head was under table - ck him had some blood to back to his head .son here .Steps to prevent reoccurrence: use chair alarm (and) bed alarm when he wants up have CNA ambulate resident . A state reportable incident report, dated 06/19/16, documented, .Description of Incident .was in the dining room following the evening meal. Noise was heard and another resident yelled, 'man down'. Upon entering the nurse observed resident lying on the floor on his back. Noted blood on the back of his head and floor. 911 called and resident sent out to ER for evaluation and treatment. Neuro checks initiated and found to be within normal limits for the resident .Please indicate relevant history: .is currently receiving physical therapy for s

On 08/31/16, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies. At 3:18 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:21 p.m., the administrator and the DON were informed of the IJ regarding their quality assessment and assurance committee and that a plan of removal was required. At 4:49 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Plan of Removal For IJ for Quality Assurance Team On 8-31-16 Administrator and the DON will be in-serviced via teleconference by (Name Deleted) NHA and consultant. The in-service will be to educate Administrator and DON over Quality Assessment and Assurance regulation. And, how to develop a process to bring identified concerns to the QA and A meeting. Please see attached outline of in-service. The in-service will be completed by 5:30pm on 8-31-2016. On 8-31-2016 the QA and A team at CCNC will conduct a meeting to educate the entire team on regulation and how we will be more effective at bringing identified concerns to the meeting specifically related to falls and interventions. And, how we are going to develop a process to bring concerns to meeting. This meeting will be completed by 8:00 pm on 8-31-2016. We will have a sign in sheet to document attendance with signature and time of each attendee. The IJ was removed effective 08/31/16 at 7:00 p.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, record review, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. This had the likelihood to affect all 92 residents who resided in the facility. Findings: A facility policy, titled Quality Assurance, documented, .The Quality Assurance Committee will meet at least quarterly to identify and address quality issues and implement corrective action plans as necessary. The Quality Assurance Committee will include the Administrator, DON, physician designated by the facility and at least three (3) other members of the facility's staff. A facility policy, titled Fall, Occurrence of a, documented, .Falls will be tracked and trended monthly by the QA committee . 1. The facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for eight (#2, #3, #4, #10, #12, #13, #14, and #21) of 12 sampled residents who had experienced falls. ~ Resident #13 experienced a fall on 04/16/16 that resulted in a rib fracture. The resident experienced a fall on 06/03/16 and then fell again on 06/04/16 and sustained a right [MEDICAL CONDITION]. The resident fell on [DATE] and experienced right hip pain and a small scratch on her back. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. ~ Resident #3 experienced a fall on 04/21/16 and sustained bruises and a skin tear to the right elbow. The resident experienced falls on 04/30/16, 05/15/16, and 06/03/16 and then fell two hours later on 06/03/16, that resulted in a right wrist fracture. The resident fell on [DATE] and experienced an abrasion to the forehead. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. ~Resident #12 experienced a fall on 04/04/16 and sustained a quarter sized abrasion to the back of his head. The resident experienced a fall on 05/04/16 and sustained a small abrasion to the mid back, a skin tear to the right elbow, and pain to the back of the head and left shoulder. The resident experienced a fall on 06/09/16 and then fell again on 06/17/19 and sustained two skin tears to the upper left arm, a small abrasion to the scalp and blood to the left side of his mouth. The resident fell on [DATE] and sustained a laceration to the back of the head that required five staples. The resident fell [DATE] and sustained a skin tear to the left elbow and pain to lower back and hips and fell again on 08/14/16. The facility was currently not consistently implementing the fall interventions that had been identified and had not addressed new fall interventions to prevent further falls. The facility identified 72 residents who were at high risk for falls. See F323. On 08/30/16 at 3:28 p.m., the DON was asked if they had a QA committee. She stated, Yes. She was asked how often the committee met. She stated, Quarterly. The DON was asked what systems were in place to ensure residents did not fall and fall interventions were in place to prevent falls. She stated, We had the let them sleep in program, the activity program, one on one for those who do not do well in groups, and taking to the bathroom. She was asked what systems were in place to identify residents who were at high risk for falls. She stated, We had our fall risk assessments and just observations or changes in medications. The DON was asked if the last QA meeting was on 06/23/16. She stated, Yes. The DON was asked if they had discussed falls and fall interventions at the last meeting on 06/23/16. She stated, Yes. We explained to the medical director we had an increase in falls. The DON was asked if any fall interventions were implemented. She stated, We had a huge turnover in staff and we were looking at medication reviews. The DON was asked if the systems in place were working? She stated, No. On 08/31/16 at 11:57 a.m., the DON was asked if they had discussed in the QA meeting conducted on 06/23/16, the residents that had fallen on 06/03/16, 06/04/16, and 06/19/16 in which major injuries were sustained that included rib fractures, a [MEDICAL CONDITION], a wrist fracture, and a laceration that required five staples. The DON stated, We didn't go into a deep discussion about it. She was asked if fall interventions had been addressed. She stated, Not at that time. The DON was asked if they discuss fall interventions in their QA meetings. She stated, We tell the medical director what we put in place for that incident. We talk about them in the daily stand up meetings. The DON was asked if they addressed the residents' falls and injuries and determined fall interventions to be implemented and care planned. She stated, No. She was asked if during the daily stand up meetings they addressed the residents' falls and injuries. She stated, We do not. The DON was asked if the QA meetings were effective. She stated, No.

On 08/14/12, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to protect resident #1 from accident/hazards by the use of full side rails. The resident had a history of [REDACTED]. The resident had sustained a large area of bruising measuring 9.5 cm by 14 cm on 07/13/12, and then on 08/04/12, the resident sustained [REDACTED]. The resident continued to have full side rails in use. The Oklahoma State Department of Health (OSDH) verified the existence of the Immediate Jeopardy at 2:00 p.m. At 2:03 p.m., the administrator and DON were informed of the Immediate Jeopardy and that this placed the facility in a partial extended survey. At 4:23 p.m., an acceptable plan of removal received from the DON documented, "Notified at 2:00pm on 08/14/12 of Immediate Jeopardy safety hazard concerning full bed rails and reports of patient trying to get out of bed. Steps to remove safety hazards are;1. Replace bed with new low bed with half rails; 2. place blanket rolls under air mattress to create a concave surface. Blankets will be replaced with side bolsters as soon as they arrive in the building; 3. Place bed in lowest position as possible; 4. Soft mats will be placed on floor next to bed on both sides. 5. RN-MS will educate all RN's, LPN's, CNA's, Housekeeping, and dietary staff on residents with osteoporosis and reporting issues, such as any abnormal sounds heard during transfers or care, any movements or deformities noted and report any issues to the Charge Nurse immediately. All RN's, LPN's, CNA's, Housekeeping, and Dietary staff need to report to the Charge Nurse any attempts or verbalization's (sic) of wanting to get out of bed, sliding in bed, placing extremities thru (sic) rails, or removing any safety device immediately. 7. All staff will be educated by 12:01pm on 08/15/12. 8. Resident will be reassessed for the need of side rails. 9. Care Plan will be updated by 5:00 pm 08/14/12. 10. DON will educate any staff that is not present for the education completed on 08/14/12 at 05:30 pm. Steps #1 thru 5 completed at 2:45 PM 08/14/12." On 08/16/12 at 9:40 a.m., the IJ situation was determined to be continued regarding the facility's failure to protect resident #2 from accident/hazards by the use of 1/2 side rails that were located in the middle section of the bed. The resident had previously attempted to climb out of bed by crawling over the top of the side rails at the head of the bed, which had resulted in the resident's head on the floor and her abdomen against the side rails. The OSDH verified the continued existence of the Immediate Jeopardy at 9:44 a.m. At 9:50 a.m., the administrator and DON were informed of the continuation of the immediate jeopardy.. At 12:53 p.m., an acceptable plan of removal received from the DON, documented, "A. Steps to remove safety hazards for resident #2 (name withheld) are: 1.Remove wheels from bed and place bed in lowest position. 2.Replace mattress with a concave mattress. 3.Soft mats are in place on floor next to bed on both sides as ordered. 4.Remove side rails and Charge Nurse will monitor resident every two hours, for the first forty eight hours in the resident chart, to make sure resident continues to remain in bed safely and reassess residents need to have side rails or not have side rails. Steps A. 1 thru 4 completed at 12:45 B. Steps for safety on all residents are: 1.All resident (sic) will be reassessed for need side rails or if residents have a preference for a side rail. This will be completed on 08/16/12 by 05:00pm (sic). 2.(Name deleted) RN-BSN Nursing Consultant will educate all RN's, LPN's, CNA's, (sic) Office Staff, Housekeeping, and dietary staff side rail (sic) safety issues and to report any issues noted to the Charge Nurse on duty immediately. 3.Side Rails will be positioned according to the Side Rail Assessment form that has been completed and in the residents (sic) chart. This will noted (sic) on the closet care plan located in the closet of every resident's room. 4.A Side Rail Assessment will be completed on admit, on re-admit, or there is a significant change in the resident. 5.DON, ADON, RN on Staff and/ or weekend RN's (sic) will do a daily room check to assure all rails in position as ordered. This will be in documented daily on a form and kept in a book labeled "Room Checks" and kept at the Hall 1 nurses station. Each nurse completing the form will date and sign the form and list any corrections that are made if any. 6.DON will write a policy for the above Side Rail Assessment. Policy will be completed by 04:00pm (sic). 7.All staff will be educated by 06:00 pm (sic) on 08/16/12." The IJ was removed on 08/16/12 at 7:00 p.m. when all components of both plans of removal had been completed. The deficient practice remained at an isolated level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to ensure the environment was free of accident hazards for two (#1 and #2) of six sampled residents who had side rails. Both residents had attempted to get out of bed and climb over and around side rails, or placed their extremities over or through the side rails. This resulted in an Immediate Jeopardy situation. Resident #1 sustained a large area of bruising measuring 9.5 cm by 14 cm on 07/13/12, and then on 08/04/12, the resident sustained [REDACTED]. The facility identified 66 residents with side rails. Findings: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 06/28/12, documented, "...Problem: She requires assistance with ADLS...1. Assist her with bed mobility. She can use the side rails to assist. Encourage her to do as much for herself as possible...Problem: resident #1 (name deleted) has bed rails up while in bed to prevent her from sliding off the edge of the bed on to floor...1. Bed rails up x 2 while in bed to prevent her from sliding off of edge of bed onto floor. She scoots or wiggles to the edge of the mattress placing herself at risk for sliding off the edge of the mattress onto the floor. She is not able to brace herself to prevent going over the edge of the bed..." A quarterly assessment, dated 06/29/12, documented the resident had a BIMS score of 4 which indicated the resident was severely impaired in cognitive skills for daily decision making. The resident had total dependence for transfers and was always incontinent of bowel and bladder and used bed rails daily. Monthly physician's orders [REDACTED].@ family directions..." The care plan, updated on 07/05/12, documented, "...Problem: potential for injury from falls...Full side rails while in bed - scoot/slides to the edge of the bed placing self at risk for sliding off bed onto floor..." An incident report, dated 07/13/12, documented, "...Description of incident: Nurse was called to the resident room by the CNA. Bruising noted to posterior thigh L. Resident noted c L leg between the mattress & bed rail multiple times. Continue to move resident leg back to the top of the mattress. Bruise is 9.5 cm x 14 cm long & purple in color...Steps to prevent reoccurrence: Instructed staff to apply a rail pad so the resident cannot get her leg between the rail & the bed..." An incident report, dated 08/04/12, documented, "...Incident report form: combined Initial and Final...Incident type: certain injuries...Description of incident: CNA entered room to get resident up for dinner, she was holding her left leg and she stated 'no don't touch it it hurts' CNA looked at her thigh and noted she had deformity to the mid-upper thigh. He notified the LPN and resident was sent to hospital (name deleted). Resident did not stated (sic) what may have happened to cause a fracture...corrective measures implemented to prevent recurrence: ...There have been no falls involving this resident, no injuries reported that may have cause (sic) this incident. DON and CNA's involved with resident care reenacted the way resident was found in the bed and DON feels that resident may have caught her left foot/leg into the bed rail and cause (sic) her to fracture her leg..." A QA report, attached to the incident report and sent to the OSDH, documented, "...Resident has full bed rails that the family insist upon having and resident recently had some bruising to her left outer leg; therefore, pads were placed to help prevent any further bruising or injuries. Resident will often remove these pads and either move them in her bed or kicks them onto the floor..." A hospital (name deleted) x-ray report, dated 08/04/12, documented, "...left femoral neck fracture and proximal femur diaphyseal fracture..." A hospital (name deleted) history and physical/discharge summary, dated 08/04/12, documented, "...History of present illness: The exact etiology of the fracture is unknown..." Admission/start-up physician's orders [REDACTED]. On 08/14/12 at 9:44 a.m., the resident was observed in bed with full side rails up on both sides of her bed. Padding was observed on both side rails. The padding was secured to the side rail by a hem, approximately 3 inches in length, which was located on the outside of the side rail. At 10:10 a.m., CNA #13 was asked if the resident was able to move on her own in bed. She stated, "She has moved her legs, rolled over, scooted down to the bottom of the bed, and tried to get out of bed. She has never gotten all the way out of the bed." She was asked if the resident had attempted to go over the side rails. She stated, "She has put her legs over the side rails and through the side rails." She was asked if the resident had removed the pads from the side rails. She stated, "Yes, she has ripped them off. She just pulls them off, even when they are secured with velcro." At 10:52 a.m., CNA #1 was asked if the resident had tried to get out of the bed with the side rails up. She stated, "She gets confused and has said, 'I got to go'. I've not seen her come out of the bed but she moves herself in bed, wiggles, and moves her legs. She has scooted down to the end of the bed." At 11:47 a.m., CNA #2 was asked if the resident was able to change positions by herself in bed. She stated, "Yes, she has moved her arms, legs, and she has moved onto her side." She was asked if she had observed the resident putting her legs over the side rails. She stated, "Yes." She was asked if the resident had removed the padding on the side rails. She stated, "Yes, I've seen her take them off and throw them." On 08/14/12 at 1:39 p.m., the DON was asked what interventions had been put into place when the resident had returned to the facility after her fractures. The DON stated, "She has a transfer pad under her for turning and positioning and we placed a new pad on the bed rails." She was asked if other interventions had been tried before the full side rails were placed on the resident's bed. She stated, "No." She was asked why the resident had full side rails in place upon return to the facility from the hospital with a [DIAGNOSES REDACTED]. She stated, "I did not know that." At 2:06 p.m., the DON and surveyor observed the resident in her bed. The DON was asked if the resident could remove the pads on the side rails. She stated, "Yes." At 3:30 p.m., the resident was observed in a low bed, mats on the floor on both sides of the bed and 1/2 side rails placed on both sides of the bed. The side rails were located in the middle section of the bed. They extended approximately from the resident's mid chest area to her knee area. The areas at the resident's head and lower legs were open to the edge of the bed. The DON was asked if the resident had attempted to climb over the side rail or scoot down the bed and attempt to get out of bed. She stated, "Yes." At 3:55 p.m., the DON was informed the 1/2 side rails placed at the middle of the resident's bed did not remove the accident/hazard for the resident. At 4:10 p.m., the resident was observed in bed. The bed was in the low position, mats were on the floor on each side of the bed, and 1/2 side rails were placed at the head of the resident's bed. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 06/13/12, documented the resident had a BIMS score of 4 which indicated the resident was severely impaired in cognitive skills for daily decision making, was independent for bed mobility and transfers, and was frequently incontinent of bowel and bladder. The resident had two falls since admission/entry or reentry or prior assessment without injury. A care plan, dated 06/26/12, documented, "...Problem: "(resident) has a potential for injury from falls r/t impaired mobility...6. assess for patterns to falls and if noted develop interventions to prevent them and implement...8. staff has been educated to ask her hourly if she needs to go to the bathroom and assist her to go as needed or as she allows..." The care plan did not address the side rails as a problem. A facility incident report, dated 07/16/12, documented, "...Description of incident: ...upon entering room. noted resident on buttocks on floor at end of bed...Steps to prevent reoccurrence: encouraged pt to call for help c transfers. Educated staff to check on pt as close to the hour as possible and offer toileting and ask pt if they can help her c anything..." The care plan, updated on 07/16/12, documented, "...Problem: potential for injury from falls...Discovered on floor on buttock @ end of bed...Ask pt hourly if she needs help c anything, offer toileting hourly as above..." A facility incident report, dated 08/05/12, documented, "...Description of incident: Called to pt room by CNA. Upon entering room pt was half way in bed c L side of head in (sic) floor. Pt abd against bed rail & BLE in bed. Upon assessment pt noted to have raised red area near upper L cheek...Steps to prevent reoccurrence: 1/2 SR moved from mid area of bed to HOB. Instruct staff to make rm visit as close to 30 min as possible..." A state reportable incident report, dated 08/05/12, documented, "...Combined Initial and Final...Description of incident: Resident was found with legs and most of trunk laying on the bed and her face off bed onto floor...Staff noted her 1/2 rail was positioned mostly to the middle of the bed...measures implemented to prevent recurrence: Side rail moved to head of bed, staff educated to make room checks as close to 30 minutes as possible for a few days and assist resident with all her needs...She has a pink are (sic) to the left cheek area..." The care plan was updated on 08/05/12. The care plan documented, "...Problem: potential for injury from falls...Found c head on floor abd against BR & BLE in bed...SR moved to HOB q 30 min checks..." On 08/15/12, at 2:13 p.m., the resident was observed in bed with 1/2 side rails up on both sides of the bed. The side rails were located in the middle section of the bed. They extended approximately from the resident's mid chest area to her knee area. At 3:03 p.m., the DON was asked where the documentation was for the staff inservice regarding 30 minute checks for the resident after her fall on 08/05/12. She stated, "I don't have any of that. I verbally instructed CNAs and LPNs coming on duty and told them to pass it on to other staff." She was asked if the 30 minute checks on the resident were documented. She stated, "No." The DON was asked what the resident had been doing at the time of the incident. She stated, "She was trying to climb out of bed at the top of her bed and around the side rails. She was found with her head on the floor and her body was on the bed." At 3:26 p.m., CNA #3 was asked where the resident's side rails were to be positioned. She stated, "Mid bed." At 3:28 p.m., CNA #4 was asked where the resident's side rails were to be positioned. She stated, "Mid bed." At 3:58 p.m., the resident was observed in bed on her left side with 1/2 side rails placed on both sides of the bed. The side rails were located in the middle section of the bed. They extended approximately from the resident's mid chest area to her knee area. At 4:32 p.m., LPN #3 was asked where the resident's side rails were to be positioned. She stated, " Mid bed." On 08/16/12 at 9:21 a.m., resident #2 was observed in her bed with 1/2 side rails up on both sides of the bed. The side rails were located in the middle section of the bed. They extended approximately from the resident's mid chest area to her knee area. At 9:40 a.m., the DON and surveyor went to the resident's room. The resident was observed in bed with 1/2 side rails placed on both sides of the bed. The side rails were located in the middle section of the bed. They extended approximately from the resident's mid chest area to her knee area. The DON was asked if the resident's side rails were in the same position they had been when the resident had attempted to climb out of bed by crawling over the top of the side rails. She stated, "Yes."