Every finding on record at Cimarron Nursing Center

Based on record review and interview, the facility failed to administer insulin per physician orders for two (#5 and #47) of six sampled residents whose medications were reviewed. The DON identified 10 residents received insulin. Findings: An Administering Medications policy, dated April 2010, documented medications must be administered as prescribed. 1. Resident #5 had diagnoses which included diabetes mellitus. A physician's order, dated 01/11/24, documented to administer insulin aspart 100 units/ml per sliding scale, subcutaneous, before meals and at bedtime at 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. It documented: a. if BS was less than 60 call physician, b. if BS was 151 to 200 give 2 units, c. if BS was 201 to 250 give 4 units, d. if BS was 251 to 300 give 6 units, e. if BS was 301 to 350 give 8 units, f. if BS was 351 to 400 give 10 units, g. if BS was 401 to 450 give 12 units, and h. if BS was greater than 450 call physician. A physician's order, dated 11/12/24, documented to administer Tresiba insulin 100 units/ml, 11 units; subcutaneous twice daily between 7:00 a.m. - 08:00 a.m. and 7:00 p.m. - 8:00 p.m. A December 2024 FSBS and insulin administration sheet documented the following: a. on 12/01/24 at 8:00 p.m., FSBS was 163, 2 units of insulin was ordered to be administered. There was no insulin administered, b. on 12/05/24 at 7:50 p.m., FSBS was 161, 2 units of insulin was ordered to be administered. There was no insulin administered, c. on 12/07/24 at 7:59 p.m., FSBS was 98, Tresiba 11 units was ordered to be administered. There was no insulin administered, d. on 12/08/24 at 4:00 p.m., FSBS was 302, 8 units of insulin was ordered to be administered. There was 6 units of insulin administered, e. on 12/08/24 at 8:00 p.m., FSBS was 314, 8 units of insulin was ordered to be administered. There was 4 units of insulin administered, f. on 12/16/24 at 8:12 p.m., FSBS was 186, 4 units of insulin was ordered to be administered. There was no insulin administered, and g. on 12/31/24 at 7:31 p.m., FSBS was 163, 2 units of insulin was ordered to be administered. There was no insulin administered. A January 2025 FSBS and insulin administration sheet documented on 01/28/25 at 8:42 p.m., FSBS was 162, and 2 units of insulin should have been administer. There was no insulin administered. 2. Resident #47 had diagnoses which included diabetes mellitus. A physician's order, dated 10/24/24, documented to administer insulin aspart 100 units/ml, insulin pen, per sliding scale, subcutaneous, before meals and at bedtime at 7:00 a.m., 11:00 a.m., 4:00 p.m., 8:00 p.m. It documented: a. if BS was less than 60 call physician, b. if BS was 151 to 175 give 3 units, c. if BS was 176 to 200 give 4 units, d. if BS was 201 to 225 give 6 units, e. if BS was 226 to 250 give 8 units, f. if BS was 251 to 275 give 10 units, g. if BS was 276 to 300 give 12 units, and h. if BS was greater than 300 give 14 units. A December 2024 FSBS and insulin administration sheet documented the following: a. on 12/01/24 at 11:00 a.m., FSBS was 217, 6 units of insulin was ordered to be administered. Other Comment: 4 units where administered, b. on 12/08/24 at 8:00 p.m., FSBS was 177, 4 units of insulin was ordered to be administered. There were 2 units of insulin administered, c. on 12/21/24 at 8:00 p.m., FSBS was 228, 6 units was ordered to be administered. There were 4 units of insulin administered, d. on 12/22/24 at 11:00 a.m., FSBS was 154, 3 units of insulin was ordered to be administered. There were 2 units of insulin administered, e. on 12/22/24 at 8:00 p.m., FSBS was 184, 4 units of insulin was ordered to be administered. There were 2 units of insulin administered, f. on 12/28/24 at 11:00 a.m., FSBS was 191, 4 units of insulin was ordered to be administered. There were 2 units of insulin administered, g. on 12/28/24 at 4:00 p.m., FSBS was 191, 4 units of insulin was ordered to be administered. There were 2 units of insulin administered, and h. on 12/28/24 at 8:00 p.m., FSBS was 321, 14 units of insulin was ordered to be administered. There were 8 units of insulin administered. A January 2025 FSBS and insulin administration sheet documented the following: a. on 01/03/25 at 4:00 p.m., FSBS was 286, 12 units of insulin was ordered to be administered. There were 8 units of insulin administered, b. on 01/05/25 at 4:00 p.m., FSBS was 261, 10 units of insulin was ordered to be administered. There were 8 units of insulin administered, c. on 01/18/25 at 8:00 p.m., FSBS was 209, 6 units of insulin was ordered to be administered. There were 4 units of insulin administered, and d. on 01/19/25 at 11:00 a.m., FSBS was 185, 4 units of insulin was ordered to be administered. There were 3 units of insulin administered. A February 2025 FSBS and insulin administration sheet documented the following: a. on 02/01/25 at 11:00 a.m., FSBS was 236, 8 units of insulin was ordered to be administered. There were 6 units of insulin administered, and b. on 02/02/25 at 8:00 p.m., FSBS was 227, 8 units of insulin was ordered to be administered. There were 6 units of insulin administered. On 02/02/25 at 9:37 a.m., LPN #2 stated Resident #47 received FSBS's before meals and at bedtime. LPN #2 stated Resident #47 was on a high sliding scale, so they sometimes used their own judgement on how much insulin they would administer. On 02/04/25 at 9:18 a.m., LPN #3 was asked what the policy was for insulin administration. They stated they would check the FSBS, verify the physician's order to see how much insulin was to be administered, then go administer the insulin. LPN #3 was asked what the policy was if they felt like the insulin dosage was too high. They stated they would not give the insulin if their FSBS was not much over 150 or if they had not eaten a snack. LPN #3 stated there were times they had not administered the sliding scale insulin.

Based on record review and interview, the facility failed to update and/or revise a care plan for two (#2 and #49) of fourteen sampled residents reviewed for care plans. The DON identified 53 residents resided in the facility. Findings: An undated Update and Maintain Care plans policy, read in part, with the most accurate resident preferences and needs available. 1. Resident #2 had diagnoses which included recurrent urinary tract infections and multiple sclerosis. A Physician Order, dated 05/13/24, documented Resident #2 was placed on Macrobid (antibiotic medication) 50mg daily prophylactically for diagnosis of recurrent UTI's. A Care Plan, review date 01/02/25, did not document a focus problem for recurrent UTI's or being on Macrobid prophylactic. 2. Resident #49 had diagnoses which included schizoaffective disorder (bipolar type) and dementia. A Physician Order, dated 06/08/24, documented the resident was placed on Seroquel (antipsychotic medication) 200mg at bedtime for diagnosis of schizoaffective disorder (bipolar type). A Care plan, review date 01/02/25, did not document a focus problem for use of an antipsychotic medication. On 02/03/25 at 8:58 a.m., MDS coordinator #1 was asked the facility policy for updating and revision of care plans. They stated they got information from floor staff regarding a resident and then they put it in the careplan. They stated they tried to update at that time. They were then asked to review the care plan for Resident #2 and then asked if the care plan had a focus problem for recurrent UTI's and Macrobid prophylactic. They stated, No. On 02/03/25 at 10:46 a.m., MDS coordinator #1 was asked what the steps were for adding a problem and/or focus on a care plan. They stated they looked at the admission paperwork and then placed the main problem areas on the initial care plan and then added new problems as needed. MDS Coordinator #1 was asked to review the care plan for Resident #49 and were then asked if the care plan included a problem or focus area for their antipsychotic medication use. They stated No.

Based on record review, observation, and interview, it was determined the facility failed to ensure afternoon snacks were offered/passed to two (#22 and #51) of two sampled residents reviewed for snacks. The Resident Census and Conditions of Residents report, dated 11/29/22, documented 61 residents resided in the facility. Findings: A meal and snack time form, undated, documented the snack times for the facility were 10:00 a.m., 2:00 p.m. and 7:00 p.m. 1. Resident #51 had diagnoses which included type two diabetes mellitus and GERD. On 11/29/22 at 7:58 a.m., Resident #51 was asked if they received their meals as ordered and if snacks were available. They stated not always. They stated sometimes they didn't get snacks. On 12/01/22 at 2:03 p.m., Resident #51 was observed lying in bed, eyes closed. No staff were observed on resident halls passing snacks. 2. Resident #22 had diagnoses which include anxiety disorder and GERD. On 11/29/22 at 2:13 p.m. Resident #22 was asked if meals were provided as ordered and if snacks were available. Resident #22 stated that meals were provided, snacks weren't always available or offered. On 12/01/22 from 1:45 p.m. through 3:11 p.m. observations were made of all three resident halls. No snacks were observed coming out of the kitchen and no staff were observed passing snacks on the halls to the residents. On 12/01/22 at 3:11 p.m., CNA #1 was asked what time they passed out snacks on hall 300. They stated,10 a.m. to 11 a.m. and then after supper. When asked who passed out snacks today, CNA #1 stated, CNA #2 passed snacks this morning and there has been a problem with the kitchen keeping snacks stocked. They were asked who received snacks today on their hall. They stated, I don't know for sure. On 12/01/22 at 3:15 p.m., CNA #3 was asked what time they passed out snacks on hall 400. They stated,10:30 a.m., 2:30 p.m., 7:30 p.m. When asked who passed out snacks today, CNA #3 stated, I think that the other CNA passed out snacks today. They were asked who received snacks today on their hall. They stated, I don't know. On 12/01/22 at 3:22 p.m., CNA #4 was asked what time they passed out snacks on hall 200. They stated, 10:00 a.m. after breakfast and then at 7:30 p.m. They were asked who passed out snacks today. CNA #4 stated, I passed after breakfast, but I have not passed the after-lunch snacks yet. They were asked who received snacks today. CNA #4 stated, Only two residents got snacks this morning everyone else got ice this morning. On 12/01/22 at 3:37 p.m., Dietary Aide #1 was asked who was responsible to ensure residents received their snacks. They stated, I do as the Dietary Aide. They stated snacks were stocked in the nourishment room, and the CNAs passed the snacks on the hall. On 12/01/22 at 4:14 p.m., the CDM stated there was an ongoing problem with residents not receiving their snacks and the DON was aware.

Based on observation, record review, and interview, the facility failed to provide dependent residents baths as scheduled for three (#1, 14 and #22) of three sampled residents reviewed for bathing. The Resident Census and Conditions of Residents report, dated 11/29/22, documented 61 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, revised 06/30/22, read in part, .BATHING: I AM TOTAL ASSIST OF ONE WITH SHOWERS. IT TAKES ME 45 MINUTES TO ONE HOUR FOR SHOWERS A daily shower schedule sheet, dated 11/02/22, documented a blank for the resident's shower. A daily shower schedule sheet, dated 11/14/22, documented a blank for the resident's shower. Resident #1's annual assessment, dated 11/16/22, documented the resident was total dependence on staff with one person physical assist for the task of bathing. A daily shower schedule sheet, dated 11/28/22, documented a blank for the resident's shower. There were no daily shower schedule sheets located for November 4th, 9th, 18th, or 21st. A facility shower schedule, undated, documented the resident's scheduled shower days were Mondays, Wednesdays, and Fridays. On 11/29/22 at 1:03 p.m., Resident #1 was asked if they received their bath/shower as often as they would like. They stated, No. They stated in the last month to six weeks, staff refused to give them a shower because they refuse to allow the resident to hold the shower head. Resident #1 stated they had gotten staff wet while holding the shower head and now staff mark they refuse baths because of it. They stated, I need better care here. They stated their mother told staff to give them a shower but they don't listen. Resident #1's hair was observed to be greazy in appearance. 2. Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, revised 06/29/22, read in part, .BATHING: I AM TOTAL ASSIST OF ONE WITH BATHING . A daily shower schedule sheet, dated 11/14/22, documented a blank for the resident's shower. Resident #14's annual assessment, dated 11/16/22, documented the resident was total dependence with one person physical assist for the task of bathing. There were no daily shower schedule sheets located for November 4th, 9th, 18th, or 21st. A facility shower schedule, undated, documented the resident's scheduled shower days were Mondays, Wednesdays, and Fridays. On 11/29/22 at 8:20 a.m., Resident #14 was asked if they received their bath/shower as often as they would like. They stated , No. They stated one shower aide quit and the new shower aide had a heart problem. They stated they hadn't received a shower in a couple of weeks. They were asked what type of help they required for bathing. They stated they needed staff to help them in a shower. 3. Resident #22 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22's annual assessment, dated 07/02/22, documented the resident was total assist for bathing. Shower schedules reviewed from 11/01/22 through 11/28/22 documented Resident #22 had not been bathed six out of 12 opportunities in November, 2022. A facility shower schedule, undated, documented the resident's scheduled shower days were Mondays, Wednesdays, and Fridays. On 11/29/22 at 2:13 p.m., Resident #22 stated their bath days were Monday, Wednesday, and Friday. Resident #22 stated they had not received a bath on Monday. On 12/02/22 at 10:19 a.m., the DON was asked how staff knew when a resident was supposed to be bathed. She stated staff would look at the bathing book. She stated the book documented a list of residents which were to be bathed on each date. On 12/02/22 at 10:41 a.m., the DON, ADON, and the DOO were asked what staff charted on the daily shower schedules. The ADON stated staff would document an R for refused or a D for done and then initial it. She was asked if the form was blank next to the resident's name, did that mean the bath/shower wasn't given? The ADON stated not necessarily, sometimes staff forgot to fill it in. They were asked if there was no documentation the resident received their shower or bath, how would staff know if they did. The DOO stated they would get back on that. On 12/02/22 at 10:54 a.m., CMA #2 was asked who was responsible for bathing residents. They stated any staff could assist with bathing but mostly the aides. They were asked if they were responsible for bathing residents today. They stated, Yes. They were asked what days Resident # 1 and Resident #14 were scheduled to be bathed. They stated they were both scheduled to be bathed on Mondays, Wednesdays, and Fridays. CMA #2 was asked what type of assistance Resident #14 required to bathe. They stated the resident needed help from the staff. They stated the resident would do as much as they could, but staff would washed the resident's body and shaved the resident as needed. CMA #2 was asked what type of assistance Resident #1 required to bathe. They stated the resident was full total care. They were asked where staff charted baths/showers. They stated there was a form at the nurses' station where staff charted them. They were asked what staff were instructed to chart. They stated staff would initial the ones they completed. CMA #2 was asked if there was no documentation next to the resident's name what did that mean. They stated, That it didn't get done. On 12/02/22 at 11:04 a.m., the DON was asked to explain the blanks in documentation on the shower schedule forms. She stated the facility had a shower aide who quit last week. She stated when the facility had a shower aide, they would document on the form. She stated, since they no longer had a shower aide, the CNAs on the floor were responsible for showers. She stated the CNAs were to document the showers electronically and on the form. She stated if a resident refused a shower, staff were to notify the nurse. The DON was asked if all November shower forms should be in the book. She stated, Yes ma'am. She was asked to review the shower book and confirm there was no shower schedule form for 11/04, 11/09, 11/18, and 11/21/22. She stated, Correct. The DON was shown the daily shower schedules for 11/02, 11/07, 11/11, 11/14, 11/23, 11/28/22 and ask if Resident #22 had a shower on any of those days. The DON stated no, she did not.

Based on observation, record review, and interview the facility failed to ensure the correct urinary catheter was utilized as ordered to prevent leakage for one (#7) of two sampled residents reviewed for urinary catheters. The Resident Census and Conditions of Residents report, dated 11/29/22, documented 6 residents with indwelling or external catheters resided in the facility. Findings: 1. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Order, dated 07/15/22, read in part, S/P CATHETER 18F, WITH 10CC BULB, TO BE CHANGED MONTHLY BETWEEN THE 14TH AND THE 16TH. DX: [CONDITION(S)] BLADDER MAY FLUSH WITH 60 CC STERILE WATER AS NEEDED TO PREVENT OBSTRUCTION . A Nursing Note, dated 11/11/22 at 12:07 a.m., read in part, .SP Catheter changed - Resident had urinated requiring complete change. Catheter would not flush. Attempted to flush and aspirate multiple times. 8.5cc of liquid removed from the bulb. 18F 30cc catheter removed. Upon pulling the cath, a large amount of urine drained from SP site .New lubed 18Fr 30cc catheter inserted to resistance. Bulb filled with 10cc NS . A Nursing Note, dated 11/15/22 at 10:53 a.m., read in part, .Resident's SP catheter reported leaking this morning . A Nursing Note, dated 11/20/22 at 7:01 a.m., read in part, .SP Catheter changed with sterile technique .New lubed 18F 30cc catheter inserted to resistance .Bulb filled with 15cc NS . A Nursing Note, dated 11/24/22 at 3:39 p.m., read in part, .S/P [INDWELLING URINARY CATHETER] BULB BUSTED NOTED [INDWELLING URINARY CATHETER] LAYING BESIDE HIM IN BED . On 11/29/22 at 10:09 a.m., Resident #7 was asked if they had a urinary catheter. They stated they did have a urinary catheter. They stated it would get clogged from sediment. They stated something was wrong with it. They stated they spoke to staff about it approximately a month ago. On 12/01/22 at 2:50 p.m., LPN #1 was asked how staff knew what catheter to use for the resident. They stated the orders documented the size of the catheter as well as how much saline to use to fill the bulb. They stated the package that contained the urinary catheter also documented the size of the catheter and how much saline to use in the bulb. LPN #1 was asked what size urinary catheter and bulb the resident had. They stated the resident used an 18 fr 30 cc bulb. The resident's catheter was observed to be an 18fr with a 30cc bulb. They were asked what the purpose of the bulb was. They stated the bulb was used to block urine from coming out of the insertion site. They stated if there wasn't enough saline in the bulb, it could cause leakage around the insertion site. On 12/01/22 at 4:00 p.m., LPN #1 was asked to review the resident's catheter order. They were asked if the order documented 18fr 10cc bulb. They stated it did. They stated the order needed to be updated. They stated the resident's catheter would leak if they used anything less than a 30cc bulb. On 12/01/22 at 5:44 p.m., the DON was asked to explain the facility policy related to suprapubic catheters. She stated the catheters and dressings were to be changed per physicians orders. She was asked how staff knew what size of catheter to use. She stated, It's in the order. She was asked how staff knew how much fluid to put in the bulb of the catheter. She stated when staff looked at the catheter, it would tell them how much to use. She stated it was also in the orders. The DON was asked what the purpose was for the catheter bulb. She stated it was used to keep the catheter in place in the bladder. The DON was asked if the nursing note dated 11/11/22 at 12:07 a.m. documented an 18fr 30cc catheter was inserted to resistance and the bulb was filled with 10 cc of normal saline. She stated, Yes ma'am. She was asked if she could explain the reason the bulb was filled with 10cc of fluid. She stated she would need to review the order. She was asked if the nursing note dated 11/15/22 at 10:53 a.m. documented the resident's suprapubic catheter was leaking. She stated, Yes ma'am. The DON stated the order was for 18fr suprapubic catheter with 10 cc bulb. She was asked if the nursing note dated 11/20/22 at 7:01 a.m. documented an 18fr 30cc catheter was inserted and filled with 15 cc ns. She stated, Yes. She was asked if she could explain the reason 15cc was used to fill the 30cc bulb. She stated, No ma'am, I cannot. The DON was asked if the nursing note dated 11/24/22 at 3:39 p.m. documented the bulb had busted and the catheter was laying next to the resident. She stated, Yes ma'am it does. She was asked if not filling the catheter bulb to the manufacturer's recommended amount could result in the catheter leaking. She stated, No ma'am. She stated the reason was because the nurse had just called her into the resident's room due to the catheter leaking. She stated the bulb was filled to the maximum and it was still leaking.

Based on record review and interview, the facility failed to ensure a resident's Advance Directive was part of clinical record for one (#1) of one sampled resident reviewed for Advance Directives. The Resident Census and Conditions of Residents report, dated 11/29/22, documented 61 residents resided in the facility. Findings: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Advance Directive Acknowledgement record, dated 11/15/11, documented the resident had executed an Advance Directive. No documentation of the resident's advance directive was located in the clinical record. On 11/30/22 at 10:19 a.m., the DON was asked to locate the resident's advance directive. On 11/30/22 at 10:25 a.m., the DON returned stating the advanced directive acknowledgement form was not from the facility. She stated it was from the facility the resident previously resided in. She stated the document was scanned in. She stated she believed the form was inaccurate as the facility did not locate a copy of the resident's advance directive. On 11/30/22 at 10:33 a.m., Resident #1 was asked if they had an advance directive. They stated, Yes. They stated they completed it a long time ago at a previous facility and it should be in their records. On 12/01/22 at 11:34 a.m., the DON was asked what the facility policy was for obtaining information related to a resident's advance directive. The DON stated the facility requested that information on admission. She stated staff would request a copy from the resident or family prior to admission. She was asked if the facility was able to locate Resident #1's advance directive. She stated, No. She stated unfortunately the home the resident previously lived in was no longer in service.

Based on observation and staff interviews, it was determined the facility failed to ensure staff wore appropriate personal protective equipment (PPE) according to the Centers for Medicare & Medicaid Services (CMS) guidelines to prevent the development and transmission of COVID-19. The facility identified 67 residents who resided in the facility. Findings: On 09/03/21 at 8:45 a.m., licensed practical nurse (LPN) #1 was observed performing COVID-19 testing on the residents. She was observed to wear a surgical mask and gloves only. She donned gloves, opened the testing card and placed drops of reagent on the card. She gathered the card and the swab and took them into room [ROOM NUMBER]. She was observed to come out of the resident's room with the swab in the card and the card was sealed. She used alcohol based hand sanitizer and proceeded to repeat the process for room [ROOM NUMBER]. At 9:20 a.m., LPN #2 was observed performing COVID-19 testing on the residents. She opened and removed the testing card, placed drops of reagent on the card, donned gloves and went into room [ROOM NUMBER] with a swab. She came back out and put the swab into the card, doffed gloves, sealed the card and used alcohol based hand sanitizer. She was observed to wear a surgical mask and gloves only. At 10:02 a.m., LPN #1 stated they usually don't do the COVID-19 testing. She stated she wasn't aware they had to wear the full PPE. She was asked what PPE should be worn when performing the tests. She stated a facemask, face shield, gown and gloves. She was asked who told her what PPE she should have worn. She stated, The director. At 11:05 a.m., the interim administrator was asked what PPE the staff wore to perform COVID-19 tests. She stated, What I saw this morning or what they're suppose to wear. She was asked what were they suppose to wear. She stated, Supposed to be gown, gloves, mask and shield.

Based on record review, and family and staff interviews, it was determined the facility failed to notify the physician and family of a change in the resident's condition for three (#53, 54 and #164) of three sampled residents reviewed for notification. Resident #164 had an incident and the physician and family were not notified until four days later. The resident had a fractured tibia and fibula. The facility identified 65 residents resided in the facility. Findings: 1. Resident #164 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/01/20, documented, .Transfer using overhead lift and assist of 2 person to reduce risk for falls . The resident's quarterly assessment, dated 10/12/20, documented the resident's cognition was intact and she was totally dependent on two persons for transfers. An initial state incident report, faxed on 10/14/20, documented, Incident date 10/10/20 .incident location .residents room .incident type .certain injuries .allegations of abuse/mistreatment .physical harm .Description of incident .Resident in bed c/o [complained of] Lt [left] leg pain upon assessment Lt leg had obvious deformity, with equal pedal pulses bilaterally with minimal bruising. Resident stated They tried to stand me up without the lift and hurt my leg. [Licensed practical nurse (LPN) #1] to order STAT X-ray of LT leg in order to r/o [rule out] fx [fracture]. Upon X-ray residents Tibia and Fibula was fractured. Resident was given PO [by mouth] pain medication in addition to sent to local ER for eval and tx of Lt leg. Agency Staff member was removed from this facility in addition to removed from Agency Staff, reported to Oklahoma State Health Department and police report was filed with [local] PD [police department] . There wasn't any documentation of an incident in the resident's medical record from 10/10/20 to 10/14/20. There wasn't any documentation the physician or resident's family had been notified. A nurse's progress note, dated 10/14/20 at 11:30 a.m., documented, .Observed resident's left foot d/t [due to] in report nurse stated that she had a wound. No wound observed to resident's foot. Resident's left foot is observed to be displaced. Spoke with DON [director of nursing] and she observed resident with this nurse. Resident is also observed with multiple hematomas to BUE [bilateral upper extremities]. She c/o severe pain to her left ankle. [Physician] notified with order to obtain X-Ray to left ankle. [Family] is called and notified. [X-ray company] is called and notified of order. A nurse's progress note, dated 10/14/20 at 1:54 p.m., documented, .[X-ray company] staff at facility to obtain x-ray of left ankle .Resident's tibia and fibula are fractured. [Physician] notified with order obtained to send to ER . Resident aware of results and [family] is called with results and order . There was no documentation the resident's pain was assessed from 10/10/20 to 10/14/20. On 08/12/21 at 10:21 a.m., a phone interview was conducted with LPN #2. She was asked to describe what happened on 10/10/20. She stated an agency staff member reported there was blood in the resident's room. She stated she went and didn't see any blood. She stated the resident denied pain. She stated she had assessed the resident and there weren't any abnormal findings. She stated she was pretty sure the night shift aide tried to transfer the resident without the lift. She stated she didn't know until after the investigation was over. She was asked if she documented the incident. She stated she did not but should have. She was asked if she reported it to anyone. She stated she hadn't. On 08/13/21 at 9:49 a.m., the interim administrator [admin] was asked if the physician and family were notified of this incident in a timely manner. She was observed to look at nurses' progress notes, state reports and in the resident's electronic health record. She stated, I don't see any documentation the physician was ever notified. She was asked if the family had been notified timely. She stated, No. She stated, There isn't even a nurse's note on that day. The interim admin, admin in training, DON and ADON were made aware and acknowledged the findings. 2. Resident #53 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission assessment, dated 04/08/21, documented the resident's cognition was severely impaired. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated 05/13/21 at 11:27 a.m., documented, .PATIENT HAS AN UA [urinalysis] PENDING AT THIS TIME . A nurse's progress note, dated 05/14/21 at 1:21 a.m., documented, .Resident started ABT [antibiotic] for [CONDITION(S)], started [MEDICATION(S)] 1 tab po twice daily x 10 days . There was no documentation the resident's representative had been notified of the [CONDITION(S)] or [NAME]. A nurse's progress note, dated 08/04/21 at 6:07 p.m., documented, .Resident had foul urine smell in shower [UA was completed] .She has an [CONDITION(S)] and n/o [new order] received [MEDICATION(S)] 100mg bid [twice a day for 3 days] until c&s [culture and sensitivity] comes back. Med [medication] in facility and will be started tonight . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated 08/06/21 at 3:12 a.m., documented, .Continues on ABT for [CONDITION(S)] with no s/sx [signs of symptoms] of adverse reaction noted . There was no documentation the resident's representative had been notified of [CONDITION(S)] or [NAME]. On 08/09/21 at 1:45 p.m., a phone interview was conducted with the resident's husband. He stated he wasn't notified when there were medication changes. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated 08/10/21 at 11:49 p.m., documented, .[MEDICATION(S)] MONO-MCR 100MG 1 PO BID X 7 DAYS FOR [CONDITION(S)] ARRIVED AND FIRST DOSE WAS GIVEN THIS EVENING WITH NO S/S [signs or symptoms] OF ADVERSE REACTIONS NOTED . On 08/16/21 at 9:57 a.m., the DON was asked when staff were to notify the resident's representative. She stated, If the resident has an issue. She stated to notify right then. She stated if it happened in the middle of the night and it wasn't an emergency, then they were notified first thing in the morning. She was asked to review the nursing notes in May. She was asked if the family had been notified of the [CONDITION(S)] and new order for medication. She stated, I don't see that it's documented here. She was asked to review the nursing notes from August. She was asked if the family was notified of the [CONDITION(S)] and medication. She stated, I don't see they put anything. The DON was made aware of the above and acknowledged the findings. 3. Resident #54 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 10/13/2020, documented the resident was cognitively intact for daily decision making skills; was independent for bed mobility, transfers, ambulation, eating, toileting, and hygiene. The resident required supervision for bathing. A nurse's note dated 10/20/2020 at 9:20 a.m., documented, .update on resident. resident has brain bleed. A nurse note dated 10/20/2020 at 9:30 a.m., documented, .8:20 [a.m.] Upon entering resident room, resident is observed sitting in chair .right side of face is drooping .unable to answer and staring off into another direction. Unable to follow simple commands .unable to squeeze nurses hands .right sided weakness . A nurse's note dated 10/21/2020 at 12:28 a.m., documented, .late entry from 10/20/2020 at 4:19 a.m., .fell coming out of the restroom, trying to get back in bed .denies pain and no injury noted .148/104 [blood pressure] .remains in isolation . A five day skilled assessment, dated 10/31/2020, documented: the resident refused to participate in interviews; he required extensive assistance with bed mobility, transfers, dressing, eating, toileting, hygiene and bathing; and he did not walk. The clinical record did not document the physician, oncoming staff for day shift, or resident's family had been notified of a fall or elevated blood pressure that occurred on 10/20/2020 at 4:19 a.m. A nurse's note dated 10/30/2020 documented, .[blood pressure] 168/96 . There was no documentation the physician was notified of the elevated blood pressure. A nurse's note, dated 12/29/2020 at 3:33 p.m., documented, .'not feeling well' .temp 100.4 . A nurse's note at 6:00 p.m., documented, new orders were received for an antibiotic to be initiated and to monitor for further symptoms. The physician was to be notified immediately for additional symptoms. The clinical record did not contain documentation the family had been notified for a medical change of condition of the resident. A nurse's note, dated 01/23/21 at 10:22 a.m., documented, .was bleeding .skin tears on his right arm .left leg . The clinical record did not document the physician or resident's family were notified of injuries of unknown origin. A nurse's note dated 02/17/21 at 6:25 a.m., documented, .just fell .got dizzy .[blood pressure] 152/76 . The clinical record did not document the physician or resident's family were notified of a fall or elevated blood pressure. A nurse's note, dated 02/25/21 at 3:56 p.m., documented, .states he is not sleeping well . A new order was obtained from the physician. The clinical record did not document the resident's family had been notified of a medication change. A nurse's note, dated 03/01/21 at 5:07 p.m., documented the resident was .confused, not making sense when speaking . The clinical record did not document the resident's family had been notified of the change of condition. A nurse's note, dated 03/26/21 at 9:06 a.m., documented, .reported to Dr .increased episodes of confusion .more foggy and confused . A new order was received for [MEDICATION(S)] transdermal patch due to resident having a history of smoking. The clinical record did not contain documentation the resident's family were notified of the reported changes of condition or of the new medication orders. A nurse's note dated 04/14/21 at 4:26 p.m., documented, .wondering in room without any clothes on and no walker. Confused and anxious .[new order] [MEDICATION(S)] . The clinical record did not document the resident's family had been notified of the behavioral changes or the new medication orders. A nurse's note, dated 06/14/21 at 4:31 a.m., documented, .vomited x2 a thin bile colored emesis .nausea medication given and instructed to call if he vomits again . A nurse's note at 1:56 p.m., documented, .acute [MEDICATION(S)] with hematuria .blood noted in urine at this time . A nurse's note at 8:57 p.m., documented, .find resident half sitting leaning on right forearm on the floor in between recliner and bed .[doctor] notified and order received for skin tear [treatment] as noted. No other orders. Will continue to monitor. A nurse's note at 11:43 p.m., documented, Resident sent out .[status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Son notified . The clinical record did not document the physician had been notified of changes of condition beginning on 6/14/21 at 4:31 a.m., until 6/14/21 at 8:57 p.m. The clinical record did not document the resident's family had been notified of 06/14/21 events beginning at 4:31 a.m., until 11:43 p.m. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to obtain and record blood pressure. If the systolic blood pressure was less than 100 or diastolic blood pressure less than 80, the medication was to be held. If the medication was held 3 consecutive events, the physician was to be notified. This order was renewed on 01/31/2021, and continued as current orders. The orders did not reflect how high the blood pressure would be allowed prior to notification to the physician. The American Heart Association documents a normal blood pressure would be 120/80. The resident's blood pressure was out of range one time in February, 10 times in March, 21 times in April, 14 times in May, six times in June, nine times in July and two times in August. There was no documentation the physician had been notified of the elevated blood pressures. On 8/17/21 at 12:45 p.m., LPN #3 was asked who is responsible for obtaining the resident's vital signs. She stated the blood pressures are obtained by the medication aides due to they administer the medication. LPN #3 was asked how parameters were set for guidance of notification of change. She stated the physicians are supposed to provide the parameters in the orders. LPN #3 was asked what protocol/steps were initiated if the blood pressures were out of parameters. She stated the blood pressure should be retaken, usually at noon, and if remained high the physician should be notified. At 1:00 p.m., in the presence of the regional nurse consultant, the administrator was asked to review the above documentation in nurse's notes and blood pressure logs. The administrator was asked how the facility established blood pressure parameters. She stated the physician is supposed to put the parameters in the orders. The administrator was asked if there were no parameters or partial parameters, what was the acceptable blood pressure range. She stated according to the American Heart Association, a good range for blood pressure is 130/80. The administrator was asked if the physician and/or resident's family had been notified of changes of condition, falls, medication orders, and/or elevated blood pressures. As she reviewed the documentation, she stated the facility had not made notifications of changes.

Based on record review and staff interviews, it was determined the facility failed to ensure: ~ residents were assessed/monitored after an accident. This affected two (#54, and #164) of three sampled residents who were reviewed for falls/accidents; This resulted in resident #164 sustaining a tibia/fibula fracture. ~residents were assessed/monitored and interventions placed for residents with hypertension, change of condition and notification. This affected one (#54) of three sampled residents whose clinical records were reviewed for changes of condition; ~a resident's venous wound was monitored and treatment provided as ordered for one (#214) of three sampled residents reviewed for wounds; and ~assess/monitor and intervene for finger stick blood sugars for one (#114) of five sampled residents reviewed for medications. The facility identified 65 residents resided in the facility. Findings: The facility's Fall Prevention and Management policy documented: .In the event of a resident fall, nursing documentation of what occurred will be completed .and all nursing actions .implement the following fall risk plan of care and prevention interventions .Potential Head Injury from Fall Residents who are taking anticoagulants or who are on aspirin therapy and at increased risk of subdural hematoma if they experience head trauma. Any resident that has a fall unwitnessed must complete neuro checks every 15 minutes x 1 hour, every 1-hour x4, then every 4 hours x24 hours. If a resident falls and hits their head must be evaluated and start neuro checks immediately .Notify the Physician with any changes from the resident's baseline condition . 1. Resident #164 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/01/20, documented, .Transfer using overhead lift and assist of 2 person to reduce risk for falls . The resident's quarterly assessment, dated 10/12/20, documented the resident's cognition was intact and she was totally dependent with two person assist for transfer. An initial State incident report, faxed on 10/14/20, documented an incident occurred on 10/10/20 which resulted in the resident sustaining a fractured tibia and fibula. There was no documentation the resident had been assessed or monitored at the time of the incident until four days later. A nurse's note, dated 10/14/20 at 11:30 a.m., documented, .Observed resident's left foot d/t [due to] in report nurse stated that she had a wound. No wound observed to resident's foot. Resident's left foot is observed to be displaced. Spoke with DON [director of nursing] and she observed resident with this nurse. Resident is also observed with multiple hematomas to BUE [bilateral upper extremities]. She c/o severe pain to her left ankle. [Physician] notified with order to obtain X-Ray to left ankle. Son [name deleted] is called and notified. [X-ray company] is called and notified of order. A nurse's note, dated 10/14/20 at 1:54 p.m., documented, .[X-ray company] staff at facility to obtain x-ray of left ankle .Resident's tibia and fibula are fractured . On 08/10/21 at 3:04 p.m., LPN #1 was asked to describe the incident from 10/10/20. She stated when she came back from her days off, she was told the resident had a wound on her foot. She went and assessed the resident. She stated the resident's left foot was dangling. She called the doctor and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital. LPN #1 was asked how the fractures occured. She stated the facility had agency CNAs in the building. One agency CNA transferred the resident without the lift, even though the resident told the agency CNA she required a lift. LPN #1 stated there was a hoyer lift in the resident's room that had been provided by hospice. She stated she went straight to the previous DON. She stated the incident had been reported to an agency nurse who failed to follow up on it. On 08/12/21 at 10:21 a.m., a phone interview was conducted with LPN #2. She was asked to describe what happened on 10/10/20. She stated an agency staff member reported there was blood in the resident's room. She stated she went and didn't see any blood. She stated the resident denied pain. She stated she had assessed the resident and there weren't any abnormal findings. She stated she was pretty sure the night shift aide tried to transfer the resident without the lift. She stated she didn't know until after the investigation was over. She was asked if she documented the incident. She stated she did not but should have. She was asked if she reported it to anyone. She stated she hadn't. On 08/13/21 at 9:49 a.m., the interim administrator [admin] was asked if the resident was assessed in a timely manner. She stated, I heard it was not. She was observed to look at nurses' progress notes, state reports, and in the residents electronic health record. She stated, There isn't even a nurse's note on that day. The interim admin, admin in training, DON and ADON were made aware and acknowledged the findings. 2. Resident #214 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 06/04/20, documented the resident had no skin breakdown. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .paste; 100 [percent] .1. cleanse site and pat dry 2. apply thin layer of [MEDICATION(S)] to site 3. cover c [with] border gauze and change BID [twice daily] and PRN [as needed] until healed . A progress note, dated 07/07/20 at 4:11 p.m., documented, Pt [patient] noted with open area to RLL [right lower leg], red/warm to touch. [Doctor name deleted] notified and new orders obtained for [MEDICATION(S)] 875mg [milligrams] 1 tab po [by mouth] BID [twice daily] x 7 days. Pt informed and ok with new orders. A wound evaluation note, dated 07/14/20, documented the resident had [CONDITION(S)] of the right lower leg and a venous wound to the right upper lateral ankle. The wound measured 3x2.4x0.2cm [centimeters], had heavy serous exudate and 100 percent slough. There was no treatment administration record [TAR] located for July 2020. There was no documentation twice daily wound care had been provided. A wound evaluation note, dated 08/03/20, documented the wound to the right lateral upper ankle measured 4x3.3x 0.2cm with moderate serous drainage. It documented a treatment plan of alginate calcium once daily for 10 days and Santyl once daily for 30 days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Santyl .ointment; 250 unit/gram; topical Special Instructions: Cleanse wound to right ankle with NSS [normal sterile saline], pat dry, apply thin layer of santyl, and cover with dry dressing . A wound evaluation note, dated 08/18/20, documented the wound measured 4.4x4x0.4cm with moderate serous exudate. It documented the wound had deteriorated due to generalized decline of peripheral arterial disease. A wound evaluation note, dated 08/25/20, documented the wound measured 5.4x5x 0.4cm and had deteriorated. There was no TAR located for August 2020. There was no documentation daily wound care had been provided. A resident assessment, dated 09/02/20, documented no skin breakdown. A wound evaluation note, dated 09/3/20, documented the wound measured 5x4.6x0.4 cm. It documented the wound had improved. A wound evaluation note, dated 09/21/20, documented the wound meaured 5x4x0.5 cm. There was no TAR located for September 2020. There was no documentation daily wound care had been provided. A wound evaluation note, date 10/2/20, documented the wound measured 4.4x6x0.3 cm. A wound evaluation, dated 10/16/20, documented the wound measured 4x4x0.2 cm. A wound evaluation note, dated 10/23/20, documented the wound measured 4.1x5x0.2 cm. A wound evaluation note, dated 10/30/20, documented the wound measured 4.1x5x0.2 cm. There was no TAR located for October 2020. There was no documentation daily wound care had been provided. A wound evaluation note, dated 11/06/20, documented the wound measured 4.6x5x0.2 cm. A wound evaluation note, dated 11/13/20, documented the wound measured 5x5x0.2 cm. A wound evaluation note, dated 11/24/20, documented the wound measured 5.1x5x0.2 and had improved. It documented the resident had an angiogram showing severe blockage. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .ointment; 250 unit/gram; topical Twice A Day . There was no TAR located for November 2020. There was no documentation twice daily wound care had been provided. A wound evaluation note, dated 12/08/20, documented the wound measured 5.1x 5x0.2 cm. There were no weekly skin assessment or wound measurements located from 12/08/20 to 12/28/20. A wound evaluation note, dated 12/29/20, documented the wound measured 6x5.8x0.2 cm and had improved. It documented the resident had undergone revascularization surgery. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A December 2020 TAR documented fourteen of 56 opportunities for the treatment were blank for the Santyl treatment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .S., FILL WOUND BED WITH COLLAGEN SPRINKLES TO SKIN LEVEL, APPLY SILVER CLCIUM ALGINATE, COVER WOUND BED WITH 2X2 FOAM DRSG [DRESSING], COVER ALL WITH FOAM AND SECURE WITH TAPE VERTICALLY ONCE DAILY . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no January 2021 weekly skin assessments or wound measurements located. A January 2021 TAR documented one of seven opportunities for the treatment were blank for the collagen and silver calcium alginate treatment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation weekly skin assessment or wound measurements from 02/11/21 to 02/24/21 had been conducted. A wound evaluation noted, dated 02/25/21, documented the resident had a wound to the right, outer calf. The assistant director of nursing verified that this is the same wound as the right lateral upper ankle. It measured 4.4x5.3x unable to determine. There was no TAR located for February 2021. There was no documentation of daily wound care had been provided. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .C. [wound cleanser], APPLY SANTYL NICKEL THICK TO ENTIRE WOUND BED, APPLY CALCIUM ALGINATE, COVER WITH ABD, WRAP WITH BULKEE GAUZE AND SECURE WITH TAPE DAILY . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .ointment; 250 unit/gram; topical .APPLY NICKEL SIZE TO WOUND BEDS ON RIGHT LOWER EXTREMITY DAILY . A wound evaluation note, dated 03/26/21, documented the wound measured 4x4x unable to determine. This was the only weekly skin assessment with wound measurements for the month of March. A March '21 TAR documented a blank for the Santyl treatment on 03/28/21. A wound evaluation note, dated 04/22/21, the wound measured 4x5.7x0.2 cm. This was the only weekly skin assessment with wound measurements for April. An April '21 TAR documented blanks for the Santyl treatment on 04/03, 04/04, 04/10 and 04/11/21. A May '21 TAR documented a blank for the Santyl treatment on 05/02/21. On 08/16/21 at 12:50 p.m., the interim administrator (ADM) was asked to provide TARs for July-November 2020 and February 2021. At 1:50 p.m., the interim ADM stated she could not find anymore TARs. On 08/17/2 at 12:07 p.m., the interim ADM was shown the December 2020 TAR blanks on 12/28/20, 12/01 -12/06, 12/08, 12/10-12/13, 12/19 and 12/22/20. She was asked if the treatment had been provided. She stated if it's blank staff didn't initial it. She was asked to look at the progress notes to see if the treatments had been provided. She stated there was no documentation in the progress notes that the treatment had been provided. At 4:56 p.m., the interim ADM was asked how staff were instructed to monitor skin. She stated staff were to do skin assessments weekly. She was asked where that was documented. She was observed to look in the electronic medical record. She stated there were no weekly skin assessments for January or February. She stated there were two in March 2021. She was shown the above blanks on the TARs and the missing weekly skin assessments. She acknowledged the findings. 3. Resident #54 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 10/13/2020, documented the resident was cognitively intact for daily decision making skills; was independent for bed mobility, transfers, ambulation, eating, toileting, hygiene. The resident required supervision for bathing. A nurse's note dated 10/14/2020, at 9:45 a.m., documented, .fall [with] injury x3 skin tears to left outer elbow .laceration to back left of head .ER to be evaluated . The resident's care plan for falls, updated on 10/14/20, documented approach/interventions, Fall with injury - call to res [resident's] room r/t [related to] fall has 3 skin tears to left outer elbow - laceration to back of left of head. Sent out to ER and returned. Encourage [resident] to ask for assistance. The facility did not document neurological assessments had been conducted post head injury per facility policy. A nurse's note, dated 10/20/2020 at 9:30 a.m., documented, .8:20 [a.m.] Upon entering resident room, resident is observed sitting in chair .right side of face is drooping .unable to answer and staring off into another direction. Unable to follow simple commands .unable to squeeze nurses hands .right sided weakness . A nurse's note, dated 10/20/2020 at 9:20 a.m., documented, .update on resident. resident has brain bleed. The resident's care plan, updated on 10/20/20, documented approach/intervention for falls, Fall without injury - Res [resident] fell coming out of the restroom, trying to get back in bed. No injury. Encourage [resident] to use call light when going to bathroom. A nurse's note, dated 10/21/2020 at 12:28 a.m., documented, .late entry from 10/20/2020 at 4:19 a.m fell coming out of the restroom, trying to get back in bed .denies pain and no injury noted. 148/104 [blood pressure] .remains in isolation . The clinical record did not document the resident had been assessed/monitored or interventions placed at the time of a fall with injury until four hours later and there was no documentation the facility followed up on the elevated blood pressure. It did not document the physician, oncoming staff for the day shift or the resident's family had been notified of the fall or elevated blood pressure. A nurse's note, dated 10/30/2020, documented, .[blood pressure] 168/96 . A five day skilled assessment, dated 10/31/2020, documented the resident refused to participate with the interviews; staff reported resident has a long term and short term memory deficits; he required extensive assistance with bed mobility, transfers, dressing, eating, toileting, hygiene and bathing; and he did not walk. A nurse's note, dated 12/29/2020 at 3:33 p.m., documented, .'not feeling well' .temp 100.4 . The clinical record did not contain documentation the family had been notified for a medical change of condition of the resident. A nurse's note, dated 01/16/21 at 4:30 a.m., documented, Resident reported to CNA (certified nurse aide) at approx [approximately] 2:50am that he had fallen in bathroom and hit his head on the door. He was laying in his bed when he reported this. He had 2 skin tears to his right elbow, 1 to his left wrist, an abrasion to right upper back and a bruised/discolored area to right lower back. Slightly red area to top/right side of head .transferred to [local emergency department] . A nurse's note dated 01/17/21 at 3:11 a.m., documented, Notified .sending resident to [different hospital] as he has a brain bleed . A nurse's note, dated 02/17/21 at 6:25 a.m., documented, resident lying in bed and told CNA that he just fell stated he tried to stand up to go to bathroom and got dizzy and slid to floor .[blood pressure] 152/76 .Ao [alert and oriented] x2 .scab from area on left lower leg off and dried blood noted .placed call light in reach and encouraged to use when needing help or getting up . The resident's care plan for falls, updated on 02/17/21, documented approach/interventions, Fall with minor injury - Res lying in bed and told CNA that he just fell . Stated he tried to stand up to go to the bathroom and got dizzy and slid to floor .Scab area to left lower leg off and dried blood noted. Placed call light in reach and encouraged to use when needing help or getting up . The clinical record did not document the resident's elevated blood pressure was assessed/monitored or interventions placed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to obtain and record blood pressure. If the systolic blood pressure was less than 100 or diastolic blood pressure was less than 80, the medication was to be held. If the medication was held 3 consecutive events, the physician was to be notified. The orders did not reflect how high the blood pressure would be allowed prior to notification to the physician. The resident's blood pressure was out of range one time in February, 10 times in March, 21 times in April, 14 times in May, six times in June, nine times in July and two times in August. There was no documentation the resident had been assessed/monitored for elevated blood pressure or for the effectiveness of his ordered medication for elevated blood pressures. On 8/17/21 at 12:45 p.m., LPN #3 was asked who was responsible for obtaining the resident's vital signs. She stated the blood pressures were obtained by the medication aides due to they administer the medication. LPN #3 was asked how parameters are set for guidance of notification of change. She stated the physicians are supposed to provide the parameters in the orders. LPN #3 was asked what protocol/steps are initiated if the blood pressures are out of parameters. She stated the blood pressure should be retaken, usually at noon, and if remained high the physician should be notified. At 1:00 p.m., in the presence of the regional nurse consultant, the administrator was asked to review the above documentation in nurse's notes and blood pressure logs. The administrator was asked how the facility established blood pressure parameters. She stated the physician is supposed to put the parameters in the orders. The administrator was asked if the physician had not specified parameters, what was the acceptable range of a blood pressure. She stated according to the American Heart Association, a good range for blood pressure is 130/80. The administrator was asked if any new interventions were attempted when resident continued to fall. After review of the care plan, she stated, If so, they are not documented. The administrator was asked if the interventions documented in the care plan, such as encourage to call for assistance, were appropriate for a resident with advanced dementia. She stated, No. The administrator was asked if neurological checks had been completed and documented after the falls with unknown injury or known head injury. She acknowledged the neurological checks were only completed on falls occurring on 10/14/20 and 01/16/21. She stated they were initiated on 01/21/21 prior to being sent to the emergency department. She acknowledged the resident had not been assessed/monitored or appropriate interventions placed for falls. 4. Resident #114 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 101-150 give 5 units . 151-200 give 7 units . If blood sugar 401-450, give 15 units If BS (blood sugar) is greater than 450, give 0 units .call MD (medical doctor) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, updated 09/21/20 documented, .is a diabetic and is at risk for hypo/hyperglycemic episodes .my FSBS will be WNL (within normal limits) .Approach .Administer insulin as ordered .monitor effectiveness .monitor hypoglycemic: sweating, cold, clammy skin . A FSBS and insulin management flowsheet for October 2020, documented a FSBS reading of 56 on 10/01/20 at 6:30 a.m. A nurse's note, dated 10/01/20 at 6:51 a.m., documented .Res BS at 56 this am gave brownie res had in her personal fridge. Day shift notified will continue to monitor . The resident's record reviewed with no further documented assessment, monitoring or intervention for low blood sugar reading. A FSBS and insulin management flowsheet, dated 10/08/20 at 6:30 a.m., documented a FSBS reading of 61. The resident's record reviewed with no further documented assessment, monitoring or intervention for low blood sugar reading. A FSBS and insulin management flowsheet, dated 10/09/20 at 6:30 a.m., documented a FSBS reading of 58. There was no further documentation the resident had been reassessed, monitor or intervention had been put in to place after the FSBS 58. A nurse's note, dated 10/09/20 at 8:20 a.m., documented, The nurse entered patients room found her unresponsive to verbal commands and nursing physical touch. Resident moaning was able to drink 4 oz. (ounce) of orange juice. Still unresponsive to verbal commands notified . family and doctor .FSBS 58 .sent to [named] hospital. A nurse's note, dated 10/09/20 edited at 12:00 p.m., documented, res return to facility . The resident's record was reviewed with no documentation of further assessment and monitoring upon resident's return from the hospital for evening or night shift of 10/09/20 and day and evening shift of 10/10/20. On 08/17/21 at 3:42 p.m., LPN #1 was asked what the facility's protocol was when a resident is exhibiting a hypoglycemic episode. She stated try orange juice, milk or a snack. She further stated she would administer [MEDICATION(S)] IM (intramuscular) for blood sugar reading below 60 or if showing symptoms. At 4:08 p.m., the interim administrator was asked to review the resident's record for the noted entry of FSBS low readings, transfer to hospital and return. She was asked if the facility assessed, monitored and intervened for changes in resident's condition. She stated, The staff should monitor resident every shift for at least 72 hours after return from hospital. She stated, No, she was not assessed and not monitored.

Based on record review and resident and staff interviews, it was determined the facility failed to ensure residents were free from physical abuse and neglect. This affected four (#26, 42, 54, and #164) of four sampled residents who were reviewed for abuse/neglect. Resident #42 sustained a [CONDITION(S)] during an improper transfer. This had the potential to affect 65 residents that resided in the facility. Findings: An abuse policy, revised on 01/2018, documented, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person . A facility mechanical lift transfer policy, documented, Training: All nursing staff and resident handlers will be trained on equipment upon hire. They must each be able to demonstrate proficiency with all types of lifts in the facility. Transfer Criteria .Mechanical Lift Transfers 2 = Two Person Transfers Sit to Stand Lift .Total Lift . 1. Resident #42 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 01/05/21 at 11:36 a.m., documented, At 9 am, Resident in shower with CNA (certified nurse aide), she was getting him up from shower chair using the Sit to Stand, he started leaning to his right and it [Sit to Stand lift] fell over. C/O [complains of] of right hip pain .ordered an X-Ray of Right Hip . A nurse's note at 2:00 p.m., documented, Received call from [x-ray company] with notifications .right hip x-ray. Impression: fracture base of the right femoral neck .orders obtained to Send to ER [emergency room ] . An initial incident report, dated 01/05/21, documented, .taken to shower room by the bath aide who was in the process of transferring him to the shower chair with the sit to stand and he fell to his right side. He let go of the shower bar with his right hand and the left side of the sit to stand then tilted up .the wheels slid in the water .resident who c/o some pain in his right leg .xray results .acute slightly displaced fracture . The care plan, updated on 01/05/21, documented the CNA was getting the resident out of the shower chair, using the sit to stand lift. The resident began to lean toward the right and the lift fell over. Intervention was added to utilize two CNAs when using the lift. A final incident report, dated 01/05/21, documented, .Resident returned on 1/9/21, he did not have surgery, the decision was made because he was not ambulatory prior to the incident and the Dr. felt the risks outweigh the benefits. All Staff were in-serviced on safe transfers by the therapist and the bath plan for the resident was changed and 2 staff will assist at all times and he will transfer with a bar. Maintenance installed a higher bar to accommodate him . A nurse's note dated, 01/10/21 at 12:29 p.m., documented, .resident will be returning to facility. We received him at aprox.1110 on stretcher .He tolerated the trip well but requested pain medication upon arrival to room stating pain of a 7 after transferring from stretcher to bed .Discharge status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 01/11/21 at 6:02 p.m., documented: Resident remains SNF [skilled nursing facility] for displaced intertrochanteric fracture of right femur, [CONDITION(S)] right dominant side, anxiety, depression, & dysphagia for PT/OT for balance, gait, mobility, safety awareness, & assistance with ADL's .Resident transfers with sit-to-stand lift & x2 staff assistance .episodes of bladder incontinence noted when unable to reach urinal .C/o pain to right hip . A nurse's note, dated 01/12/21 at 3:59 p.m., documented, .Resident transfers with x2 staff assistance & gait belt .episodes of bladder incontinence noted when unable to reach urinal . A nurse's note, dated 01/13/21 at 3:26 a.m., documented, .Resident remains SNF .Resident transfers with x2 staff assistance & gait belt .episodes of bladder incontinence noted when unable to reach urinal . A nurse's note, dated 01/20/21 at 4:58 a.m., documented, Resident remains SNF .Resident transfers with x2 staff assistance & gait belt .episodes of bladder incontinence noted when unable to reach urinal . A nurse's note, dated 01/20/21 at 12:29 p.m., documented, .remains SNF .Resident transfers with x2 using full body lift .episodes of bladder incontinence noted when unable to reach urinal . A nurse's note, dated 01/21/21 at 12:24 a.m., documented, .on SNF .Right leg cont [continues] to be swollen at outward hip area and turned Resident c/o pain A nurse's note, dated 01/22/21 at 03:34 a.m., documented Resident crying, c/o Right hip/leg pain . A nurse's note, dated 01/22/21 at 11:16 a.m., documented, .resident was c/o R [right] hip pain this AM and stated the aides on night shift hurt his leg and he can not move it because it hurts. he was crying and very frustrated . A nurse's note, dated 01/22/21 at 4:03 p.m., documented, x-ray shows more displaced than last x-ray, dr [name omitted] notified and he ordered for resident to go back to [previous hospital] . A nurse's note, dated 01/23/21 at 3:49 a.m., documented, resident returned from hospital at 2050 [8:50 p.m.] on 1-22-2021, via ambulance, transfer to bed with assist of 4, rt. [right] leg placed on top of pillows, swelling in rt. leg 1+pulses present, and strong. stated pain on scale of 1-10 was a 6 . A nurse's note dated, 04/25/21 at 1:17 p.m., documented, Resident came to this nurse and another nurse together to tell us that staff was getting mad every time he had to have a bowel movement. He also said that they are always sitting down and when he asks them to help they get mad because he has to use the full body lift and they have to lay him down for him to go on the bedpan. He also stated to his family member that he hadn't been changed .since the day before. We are currently awaiting word from the upper management on what actions to take towards the aides, but this nurse talked to both aides and re-educated them on the importance of checking every resident that may be incontinent. The aides expressed understanding and told nurse that the resident gets mad at them because they have to use the full body lift to transfer him and he wants to use the sit to stand. The aides were told that as far as lifts go they have to use the full body until otherwise authorized and made the resident aware as well. Resident did not bring the issue of being changed to the charge nurses, they were informed by the family member. There was no documentation an investigation of neglect had been initiated. An incident report was not located and was not provided. A nurse's note, dated 05/04/21 at 12:49 p.m., documented, .patient was up in full body lift when sling strap broke and he fell from sling to his left side hitting his left jawl [jaw] shoulder elbow and knee. The cross necklace he is wearing caused a laceration and abrasion to left of neck and clavicle region .was noted that he had bruising and swelling to his left jawl, laceration to left side of his neck and an abrasion to the left clavicle region, bruising and abrasion to left elbow and abrasion to left knee with redness .pain [greater than] 10 to his left post shoulder .called for stat X-Ray . A state initial/final incident report, dated 05/04/21, documented, .Resident was in the full body lift and the sling broke resulting in him falling to the floor hitting his [left] jaw, shoulder, arm/leg .Staff was inserviced 5/5/21 on monitoring all lift equipment and reporting any deficient equipment to supervisors .slings were checked and replaced . A facility incident/accident report, dated 05/04/21, documented, .Additional comments and/or steps taken to prevent recurrence .immediately discarded defective sling. in-serve staff on checking equipment . The in-service documentation, dated 05/05/21, documented, .ATTN [attention] all nursing staff: Going forward .preparing to use a lift on a Resident, you are expected to first inspect the equipment. This includes the actual lift and the sling you are using with it . The in-service documentation contained 10 signatures of individuals that attended the in-service/obtained the information. A nurse's note, dated 05/06/21 at 9:31 a.m., documented, .it is his shower today he was assured that we would have 3 persons present during lift transfer and that sling would be assessed prior to use. A nurse's note dated 05/20/21 at 3:40 p.m., documented, .obtained x-ray of left scapula .tech was unsure of the quality [due to] position required . No further documentation was located/provided regarding the left scapula pain or x-ray results. A quarterly assessment, dated 06/10/21, documented the resident was cognitively intact for daily decision making; had not displayed behaviors or a negative mood; did not walk; required total assistance of two staff for transfers, and toileting; required total assistance of one staff for bathing; required extensive assistance for bed mobility, dressing and hygiene. The care plan, last updated 06/25/21, documented the resident was dependent in bathing, dressing, hygiene, and transfers; required extensive assistance for bed mobility and toileting. The resident is at risk for falls due to right sided weakness, required a mechanical lift for transfers, and 1-2 person assist using a full body hoyer lift. This care plan contradicts the facility mechanical lift policy. On 08/09/21 at 2:32 p.m., the resident reported to this surveyor a girl that worked at the facility is mean to me. He was asked if the girl continued to work here. He stated Yes, it happened when she broke my leg. She was what caused the broken leg. She is the meanest. On 08/12/21 at 10:25 a.m., the director of nurses (DON) was asked to review the incident report for resident #42, dated 01/05/21. She was asked to identify the nurse aide. She stated the nurse aide involved was CNA #1. The DON was asked if CNA #1 transferred the resident by herself on 01/05/21 and did she follow the facility's protocol with mechanical lifts. She stated the CNA transferred the resident by herself and did not follow the facility's protocol. She stated the event occurred due to the nurse aide was supposed to have two people to assist with a transfer using the lift and she did not have a second person. The DON was asked if CNA #1 was provided education on transfers and facility protocol prior to her being assigned to the shower room. She stated the nurse aide had been provided education. The DON was asked to provide the information to support the nurse aide had been educated and was competent in transfers with mechanical lifts. No further information was provided. The DON was asked to review the incident report, dated 01/25/21 for resident #42. The DON was asked if abuse had been considered. She stated she did and reported the CNAs. The DON was informed the final report was not located in the information provided. She was asked if a final report had been completed with the information of the outcomes. She stated she would need to look for it. No further documentation was provided. The DON was asked asked to review the nurse note for resident #42, dated 04/25/21. The DON was asked if the event was investigated as abuse/neglect. She stated it should have been reported to some one. The DON was informed that a nurse knew and documented in the nurse notes. She was again asked if the incident should have been investigated. No information was provided. 2. Resident #54 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 07/14/2020, documented the resident was cognitively intact for daily decision making; was independent in bed mobility, transfers, ambulation, eating, toileting, and hygiene; and required set up and supervision for bathing. A quarterly/five day assessment, dated 10/13/2020, documented the resident's status remained unchanged from 07/14/2020. A nurse's note, dated 10/19/20 at 4:52 p.m., documented, .receiving Skilled Services for Covid 19 .is alert and oriented to person, place, time and situation. He is verbal and able to make needs/wants known .he is independent with all ADLs [activities of daily living] . A nurse's note, dated 10/20/2020 at 4:19 a.m., documented, [resident] fell coming out of the restroom, trying to get back in bed .[blood pressure] 148/104 .on [skilled] services and remains in isolation for positive covid-19 . A nurses note dated 10/20/2020 at 9:30 a.m., documented, 0820 [a.m.]: Upon entering residents room resident is observed sitting in his chair. Resident's right side of face is drooping. When asking resident questions resident is unable to answer and staring off into another direction. Unable to follow simple commands. Resident unable to squeeze nurses hands. Resident observed with right sided weakness .orders to send to ER [emergency room ] . A Combined Initial and Final Incident Report, dated unknown, included an attached Incident/Accident Report dated 10/20/2020. The Combined Initial and Final report documented, .Resident is currently receiving [treatment at hospital- name omitted]. The nurse that failed to report his has been reprimanded and is no longer allowed back in the facility . A follow up information report form, dated 10/20/2020, documented, .Oklahoma State Health Department called and stated that this incident needed to be reported to the Oklahoma Board of Nursing and to Adult Protective Services .she did fail to report it in off/on coming shift report. APS notified on 11/6/2020 @1504 [3:04 p.m.] .OBN notified 11/6/2020 See attached confirmation sheet . The Incident report had an attached statement, from LPN #5, which documented, .I did not tell [oncoming nurse] about .fall .His blood pressure was a little high, but I did not know his baseline .looked in on him around 5:30 . The document was signed and dated 10/21/2020. The hospital record, dated 10/21/20 at 12:53 p.m., documented, .Plan .suspect that patient's falls are related to reconditioning in the setting of acute COVID-19 infection compounded by a multifactorial toxic-metabolic [CONDITION(S)] due to decreased oral intake, acute kidney injury, [CONDITION(S)] .persistent [CONDITION(S)] is likely due to a toxic-metabolic [CONDITION(S)] due to the aforementioned reasons, now further compounded by severe traumatic brain injury with multicompartmental hemorrhages . The clinical record did not contain documentation that neurological checks had been initiated or the resident was assessed/monitored from the time of the event at 4:15 a.m., until 8:20 a.m., a four hour time frame. A five day assessment, dated 10/31/20, documented the resident refused to answer questions to participate in the assessment; staff reported the resident had short and long term memory deficits; the resident required total assistance with bed mobility, transfers, dressing, eating, toileting, hygiene, and bathing; and the resident did not ambulate. A Complaint Form, dated 11/06/2020, documented LPN #5 had been reported to the Oklahoma State Board of Nursing regarding an incident occurring on 10/20/2020 at 4:15 a.m. On 08/17/21 at 11:08 a.m., the DON was asked to provide neurological assessment documentation and hospital records from the event on 10/20/2020. At 12:01 p.m., the DON provided hospital records for the event on 10/20/2020. She stated she was still looking for the other items. No documentation of neurological assessments were provided regarding the event on 10/20/2020. On 08/17/21 at 5:35 p.m., after review of the nurse's notes and incident reports regarding resident #54 on 10/20/2020, the administrator was asked if the event that occurred at 4:15 a.m., with no assessments or notifications completed, for four hours, should this event have been investigated as neglect. The administrator stated, Yes. 3. Resident #164 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/01/20, documented, .Transfer using overhead lift and assist of 2 person to reduce risk for falls . The resident's quarterly assessment, dated 10/12/20, documented the resident's cognition was intact and she was total dependence with two person assist for transfer. A initial State incident report, dated 10/10/20, documented, .incident location .residents room .incident type .certain injuries .allegations of abuse/mistreatment .physical harm .Description of incident .Resident in bed c/o [complain of] Lt [left] leg pain upon assessment Lt leg had obvious deformity, with equal pedal pulses bilaterally with minimal bruising. Resident stated They tried to stand me up without the lift and hurt my leg. The incident was not reported or investigated until four days later on 10/14/20. A nurse's note, dated 10/14/20 at 11:30 a.m., documented, .Observed resident's left foot d/t [due to] in report nurse stated that she had a wound. No wound observed to resident's foot. Resident's left foot is observed to be displaced. Spoke with DON [director of nursing] and she observed resident with this nurse. Resident is also observed with multiple hematomas to BUE [bilateral upper extremities]. She c/o severe pain to her left ankle. [Physician] notified with order to obtain X-Ray to left ankle. Son [name deleted] is called and notified. [X-ray company] is called and notified of order. A nurse's note, dated 10/14/20 at 1:54 p.m., documented, .[X-ray company] staff at facility to obtain x-ray of left ankle .Resident's tibia and fibula are fractured . An x-ray report, dated 10/14/20 at 2:03 p.m., documented, .Left ankle x-ray .there is a fracture which involves the distal metaphysis of the tibia . On 08/10/21 at 3:04 p.m., LPN #1 was asked to describe the incident from October 2020. She stated when she came back from her days off, she was told the resident had a wound on her foot. She went and assessed the resident. She stated the resident's left foot was dangling. She called the doctor and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital. LPN #1 was asked how the fractures occurred. She stated the facility had agency CNAs in the building. One agency CNA transferred the resident without the lift, even though the resident told the agency CNA she required a lift. LPN #1 stated there was a hoyer lift in the resident's room that had been provided by hospice. She stated she went straight to the previous DON. She stated the incident had been reported to an agency nurse who failed to follow up on it. On 08/11/21 at 10:42 a.m., the DON was asked what the policy was for abuse. She stated the staff member comes to her and they start a formal investigation. She stated they conduct interviews with other residents and staff members. She stated they report to the administrator (admin) and completed state reportables. She was asked what the staff would do if a resident was injured. She stated they would assess them, contact the physician and family and look over documentation to see if anything was reported. She was asked if there was any further documentation for the incident that occurred on 10/10/20. The DON stated she didn't know for sure but she would look. The DON read the email from the previous admin that documented the facility was to conduct interviews with other residents and staff. On 08/12/21 at 10:21 a.m., a phone interview was conducted with LPN #2. She was asked to describe what happened on 10/10/20. She stated an agency staff member reported there was blood in the resident's room. She stated she went and didn't see any blood. She stated the resident denied pain. She stated she had assessed the resident and there weren't any abnormal findings. She stated she was pretty sure the night shift aide tried to transfer the resident without the lift. She stated she didn't know until after the investigation was over. She was asked if she documented the incident. She stated she did not but should have. She was asked if she reported it to anyone. She stated she hadn't. At 3:57 p.m., the admin in training and the DON was asked what was considered neglect. The DON stated not answering call lights, not assisting with changing, eating or bathing. They were asked if they would consider it neglect if a resident who required extensive assistance with ADLs, had a care plan they required a hoyer lift for transfers, had a hoyer lift in their room and was transferred by one person without the use of a lift and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A resident assessment, dated 08/24/20, documented the resident's cognition was intact. An incident report, dated 11/04/20 AM (no time), documented, .location of incident/accident .Shower Room .Resident told staff that she was afraid because on Wednesday 11-4-20 resident was getting a shower and got into an aguement [sic] [with] aide in which the resident called the aide a [expletive] so in return the aide sprayed the resident down [with] cold water .Witness was present during the time the resident stated these allocations [sic] . On 08/11/21 at 11:35 a.m., the director of nursing was asked what she considered abuse. She stated anything physical, hitting, pushing, shoving, verbal and anything neglectful. She was asked if spraying someone with cold water would be considered abuse. She stated, Yes. She was shown the incident report and asked if an abuse investigation had been conducted. She looked through the state reportable incidents and stated, I don't see anything. She was asked if an abuse investigation should have been conducted. She stated, I think so, yes. She was asked how residents were protected from further abuse if an abuse investigation had not been conducted. She stated, I feel like it should have been conducted in order to protect them from further abuse. At 12:20 p.m., the resident was asked about the incident. She stated the bath aide, certified nurse aide (CNA) #1, the same one who is here today, had sprayed her with cold water. She was asked if it was intentional. She stated, Yes. She stated the CNA was mad because she needed help washing. She stated the CNA was always rude. CNA #1's personal file documented a hire date of 12/21/20. There was no documentation that a back ground check had been conducted or abuse training had been provided to her upon hire. On 08/12/21 at 9:49 a.m., the interim administrator was asked if a background check had been conducted prior to or upon hire. She stated no and they had just completed one today. At 10:40 a.m., the interim ADM was asked the policy for conducting employee back ground checks. She stated, Before they are hired. She was asked the policy for providing abuse training. She stated, On hire.

Based on record review and staff interviews, it was determined the facility failed to ensure proper transfers were completed for three (#42, 54 and #164) of three sampled residents who were reviewed for accidents. Resident #164 was improperly transferred which resulted with the resident's tibia and fibula being fractured. The facility identified 65 residents who resided in the facility, ten residents who transferred with a Hoyer lift and three residents who transferred with a sit to stand. Findings: The facility's Fall Prevention and Management policy documented: .In the event of a resident fall, nursing documentation of what occurred will be completed .and all nursing actions .implement the following fall risk plan of care and prevention interventions when the fall score is less than 10: 1. Purposeful rounding 2. Call light within reach and personal items within reach 3. Resident and family education 4. Orient resident to surroundings .Potential Head Injury from Fall Residents who are taking anticoagulants or who are on aspirin therapy and at increased risk of subdural hematoma if they experience head trauma. Any resident that has a fall unwitnessed must complete neuro checks every 15 minutes x 1 hour, every 1-hour x4, then every 4 hours x24 hours. If a resident falls and hits their head must be evaluated and start neuro checks immediately .Notify the Physician with any changes from the resident's baseline condition . A facility mechanical lift transfer policy, documented, Training: All nursing staff and resident handlers will be trained on equipment upon hire. They must each be able to demonstrate proficiency with all types of lifts in the facility. Transfer Criteria .Mechanical Lift Transfers 2 = Two Person Transfers Sit to Stand Lift .Total Lift . 1. Resident #164 was admitted with diagnoses which included congested heart failure, [CONDITION(S)] ([CONDITION(S)]), pain, arthritis, long term use of anticoagulants and periodic limb movement disorder. A care plan, dated 05/01/20, documented, .Transfer using overhead lift and assist of 2 person to reduce risk for falls . The resident's quarterly assessment, dated 10/12/20, documented the resident's cognition was intact and she was total dependent with two person assist for transfer. Initial State incident report,faxed on 10/14/20, documented, Date of incident 10/10/20 .incident location .residents room .incident type .certain injuries .allegations of abuse/mistreatment .physical harm .Description of incident .Resident in bed c/o [complain of] Lt [left] leg pain upon assessment Lt leg had obvious deformity, with equal pedal pulses bilaterally with minimal bruising. Resident stated They tried to stand me up without the lift and hurt my leg. [Licensed practical nurse (LPN) #1] to order STAT X-ray of LT leg in order to r/o [rule out] fx [fracture]. Upon x-ray residents Tibia and Fibula was fractured . There was no documentation the resident had been assessed for pain from 10/10/20 to 10/14/20. A nurse's note, dated 10/14/20 at 11:30 a.m., documented, .Observed resident's left foot d/t [due to] in report nurse stated that she had a wound. No wound observed to resident's foot. Resident's left foot is observed to be displaced. Spoke with DON [director of nursing] and she observed resident with this nurse. Resident is also observed with multiple hematomas to BUE [bilateral upper extremities]. She c/o severe pain to her left ankle. [Physician] notified with order to obtain X-Ray to left ankle. Son [name deleted] is called and notified. [X-ray company] is called and notified of order. A nurse's note, dated 10/14/20 at 1:54 p.m., documented, .[X-ray company] staff at facility to obtain x-ray of left ankle .Resident's tibia and fibula are fractured . A typed statement from the previous DON, dated 10/16/20, documented, I was notified on Wednesday 10/14/2020 that it was stated by another CNA [certified nursing assistant] in report that [alleged perpetrator] with [staffing company] had transferred our resident . who is a full body assist without a lift. [Agency CNA #2] with [staffing agency] stated he went down to the room on Monday morning to receive report from off going CNA [alleged perpetrator] where he states he walked into resident .room to see what he states as a large puddle of blood. This is when [alleged perpetrator] told [agency CNA #2], according to [agency CNA #2]. That she [alleged perpetrator] transferred the resident without the lift from her bed into her chair and stubbed her toe, causing it to bleed. [Agency CNA #2] told [alleged perpetrator] he was going to get the nurse to look at the resident's toe. According to [agency CNA #2] this is when [alleged perpetrator] told him Do not go get the nurse we have to clean the blood up and get my story straight. [Agency CNA #2] stated he immediately left the room and told [LPN #2] what took place. [LPN #2] stated she finished report and went down to the resident's room to find a small penny size drop of blood on the floor from the residents toe and it had already stopped bleeding. [LPN #2] states she propped up the resident's feet and they looked normal to her at that time on Monday . On 10/14/2020 [LPN #1] notified me of this incident and asked me to come to look at the residents legs. She stated resident .Left ankle looked broken. I went down to assess the resident with the nurse. Her legs were positioned on a pillow where her LT ankle had an obvious deformity. She was yelling out in pain when I attempted to check pedal pulses. I instructed [LPN #1] to order a STAT X-ray of the residents LT ankle. After X-ray was performed it was confirmed that her Tibia, Fibula and ankle were all fractured. [LPN #1] consulted with the resident's doctor and family where she was instructed to send the resident to the ER. Resident returned to the facility around 8 p.m. on 10/14/2020 . On 08/10/21 at 3:04 p.m., LPN #1 was asked how the fractures occurred. She stated the facility had agency CNAs in the building. One agency CNA transferred the resident without the lift, even though the resident told the agency CNA she required a lift. LPN #1 stated there was a hoyer lift in the resident's room that had been provided by hospice. She stated she went straight to the previous DON. The interim admin, admin in training, DON and ADON were made aware and acknowledged the findings. 2. Resident #54 had diagnosis to include: nontraumatic subdural hemorrhage. The current physician order report documented, beginning 07/18/19 through 06/16/21, the resident was to be administered aspirin, delayed release 81 milligrams daily. A quarterly assessment, dated 10/13/2020, documented the resident was cognitively intact for daily decision making skills; was independent for bed mobility, transfers, ambulation, eating, toileting, hygiene. The resident required supervision for bathing. A nurse's note dated 10/14/2020, at 9:45 a.m., documented, .fall [with] injury x3 skin tears to left outer elbow .laceration to back left of head .ER to be evaluated . The resident's care plan for falls, updated on 10/14/20, documented approach/interventions, Fall with injury - call to res [sic] room r/t [sic] fall has 3 skin tears to left outer elbow - laceration to back of left of head. Sent out to ER and returned. Encourage [resident] to ask for assistance. A nurse note, dated 10/20/2020 at 9:30 a.m., documented, .8:20 [a.m.] Upon entering resident room, resident is observed sitting in chair .right side of face is drooping .unable to answer and staring off into another direction. Unable to follow simple commands .unable to squeeze nurses hands .right sided weakness . A nurse's note, dated 10/20/2020 at 9:20 a.m., documented, .update on resident. resident has brain bleed. The resident's care plan, updated on 10/20/20, documented approach/intervention for falls, Fall without injury - Res [sic] fell coming out of the restroom, trying to get back in bed. No injury. Encourage [resident] to use call light when going to bathroom. A nurse's note, dated 10/21/2020 at 00:28 a.m., documented, .late entry from 10/20/2020 at 4:19 a.m., .fell coming out of the restroom, trying to get back in bed .denies pain and no injury noted. 148/104 [blood pressure] .remains in isolation . A five day skilled assessment, dated 10/31/2020, documented: the resident refused to participate with the interviews; staff reported resident has a long term and short term memory deficits; he required extensive assistance with bed mobility, transfers, dressing, eating, toileting, hygiene and bathing; and he did not walk. The clinical record did not document the the resident had been fully assessed/monitored or interventions placed at the time of a fall with injury on either accidents. A nurse's note, dated 01/16/21 at 4:30 a.m., documented, Resident reported to CNA (certified nurse aide) at approx [approximately] 2:50am that he had fallen in bathroom and hit his head on the door. He was laying in his bed when he reported this. He had 2 skin tears to his right elbow, 1 to his left wrist, an abrasion to right upper back and a bruised/discolored area to right lower back. Slightly red area to top/right side of head .transferred to [local emergency department] . The resident's care plan for falls was not updated with any new interventions for a fall with injury. A nurse's note dated 01/17/21 at 3:11 a.m., documented, Notified .sending resident to [local hospital] as he has a brain bleed . The resident's care plan for falls, updated 02/01/21, documented approach/interventions to include: ~make sure my environment has adequate lighting and is clutter free at all times; ~Encourage me to use the handrails in the bathroom for added support and balance Remind me to use my walker/wheelchair at all times. The interventions were not appropriate for a resident with impaired cogition. The resident's care plan for falls, updated on 02/16/21, did not document any new interventions for falls. A nurse's note, dated 02/17/21 at 6:25 a.m., documented, resident lying in bed and told CNA that he just fell stated he tried to stand up to go to bathroom and got dizzy and slid to floor .[blood pressure] 152/76 .Ao [alert and oriented] x2 .scab from area on left lower leg off and dried blood noted .placed call light in reach and encouraged to use when needing help or getting up . The resident's care plan for falls, updated on 02/17/21, did not document any new interventions. A nurse's note, dated 06/14/21 at 8:57 p.m., documented, .find resident half sitting leaning on right forearm on the floor in between recliner and bed .[doctor] notified and order received for skin tear [treatment] as noted. No other orders. Will continue to monitor. A nurse's note, at 11:43 p.m., documented, Resident sent out .[status post] fall due to recent brain bleed and recent re-admission The resident's care plan for falls, updated on 06/14/21, did not document any new interventions. A nurse's note dated 06/15/21 at 6:33 a.m., documented, Report rec'd [sic] .being admitted for subdural hematoma . The clinical record did not document the resident had been monitored or neurological assessment had been completed from 8:57 p.m., thru 11:43 p.m for a resident who had a fall with a head injury. On 08/17/21 at 11:08 a.m., the DON was asked to provide all neurological assessments regarding the resident's falls with unknown injury and falls with known to have hit his head during the fall. At 12:00 p.m., requested an update regarding the documentation requested earlier. The DON provided parts of documentation but did not include the neurological assessments. At 1:00 p.m., in the presence of the regional nurse consultant, the administrator was asked if any new interventions were attempted when resident continued to fall. After review of the care plan, she stated, If so, they are not documented. The administrator was asked if the interventions documented in the care plan, such as encourage to call for assistance, were appropriate for a resident with advanced dementia. She stated, No.' The administrator was asked if neurological checks had been completed and documented after the falls with unknown injury or known head injury. She acknowledged the neurological checks were only completed on falls occurring on 10/14/20 and 1/16/21. She stated they were initiated on 1/21/21 prior to being sent to the emergency department. She acknowledged the resident had not been assessed/monitored or appropriate interventions placed for falls. 3. Resident #42 was admitted to the facility on [DATE], with diagnosis to include: [CONDITION(S)]/[CONDITION(S)] following non-traumatic intracranial hemorrhage affecting the right dominant side; lack of coordination; muscle wasting/atrophy; major depressive disorder and anxiety. A nurse's note, dated 01/05/21 at 11:36 a.m., documented, At 9 am, Resident in shower with CNA (certified nurse aide), she was getting him up from shower chair using the Sit to Stand, he started leaning to his right and it [Sit to Stand lift] fell over. C/O of right hip pain .ordered an X-Ray of Right Hip. Called [x-ray company] . A nurse's note at 2:00 p.m., documented, Received call .right hip x-ray. Impression: fracture base of the right femoral neck .orders obtained to Send to ER . An initial incident report, dated 01/05/21, documented, .taken to shower room by the bath aide who was in the process of transferring him to the shower chair with the sit to stand and he fell to his right side. He let go of the shower bar with his right hand and the left side of the sit to stand then tilted up .the wheels slid in the water .resident who c/o some pain in his right leg .xray results .acute slightly displaced fracture . The care plan was updated on 01/05/21, documented the CNA was getting the resident out of the shower chair, using the sit to stand lift. The resident began to lean toward the right and the lift fell over. Intervention was added to utilize two CNAs when using the lift. A nurse's note, dated 01/11/21 at 6:02 p.m., documented: Resident remains SNF [skilled nursing facility] for displaced intertrocanteric fracture of right femur, [CONDITION(S)] right dominant side .Resident transfers with sit-to-stand lift & x2 staff assistance C/o pain to right hip . Nurse's notes, dated 01/12/21, 01/13/21 and 01/20/21, documented, the resident had been assisted with two staff members and a gait belt. The care plan had documented the resident was to be transferred via mechanical lift with two person assist. A nurse's note, dated 01/21/21 at 00:24 a.m., documented, .on SNF .Right leg cont [continues] to be swollen at outward. hip area and turned Resident c/o pain A nurse's note, dated 01/22/21 at 03:34 a.m., documented Resident crying, c/o Right hip/leg pain . A nurse's note, dated 01/22/21 at 11:16 a.m., documented, .resident was c/o R [right] hip pain this AM and stated the aides on night shift hurt his leg and he can not move it because it hurts. he was crying and very frustrated . A nurse's note, dated 01/22/21 at 4:03 p.m., documented, x-ray shows more displaced than last x-ray, dr [name omitted] notified and he ordered for resident to go back to [previous hospital] . A nurse's note, dated 05/04/21 at 12:49 p.m., documented, .patient was up in full body lift when sling strap broke and he fell from sling to his left side hitting his left jawl [jaw] shoulder elbow and knee. The cross necklace he is wearing caused a laceration and abrasion to left of neck and clavicle region .was noted that he had bruising and swelling to his left jawl, laceration to left side of his neck and an abrasion to the left clavicle region, bruising and abrasion to left elbow and abrasion to left knee with redness .pain [greater than] 10 to his left post shoulder .called for stat X-Ray . A quarterly assessment, dated 06/10/21, documented the resident was cognitively intact for daily decision making; had not displayed behaviors or a negative mood; did not walk; required total assistance of two staff for transfers, and toileting; required total assistance of one staff for bathing; required extensive assistance for bed mobility, dressing and hygiene. The care plan, last updated 06/25/21, documented the resident was dependent in bathing, dressing, hygiene, and transfers; required extensive assistance for bed mobility and toileting. The resident is at risk for falls due to right sided weakness, required a mechanical lift for transfers, and 1-2 person assist using a fully body hoyer lift. On 08/09/21 at 2:32 p.m., the resident reported a girl that work at the facility is mean to me. He was asked if the girl continued to work here. He stated Yes. it happened when she broke my leg. She was what caused the broken leg On 08/12/21 at 10:25 a.m., the director of nurses (DON) was asked to review incident report for resident #42, dated 01/05/21. She was asked to identity the nurse aide. Stated the nurse aide involved was CNA #1. The DON was asked if CNA #1 had transferred the resident by herself on 01/05/21 and did she follow the facility protocol for mechanical lifts. She stated the CNA was in the shower room, transferring a resident by herself and the CNA did not follow the facility protocol. At 2:05 p.m., the housekeeping supervisor was asked if any of her departments assisted with the maintenance of the mechanical lifts. She stated her departments assist with small issues such as checking the batteries and obtaining prices for further maintenance and replacements. The housekeeping supervisor was asked if she was aware of any events regarding accidents with the mechanical lifts. She stated she had heard a resident had fallen from a sit to stand lift, but understood the problem was human error. The housekeeping supervisor was asked if she was aware of an event the sling straps broke during a transfer. She stated she was not really aware of any details but a few months back, she had been involved with helping price slings for the full body lifts so the facility could order new ones. She stated the administrator and DON would have the paper work for the ordered items The housekeeping supervisor was asked if the facility had recently ordered new lifts. She stated the last time new lifts were ordered was by the previous administrator. At 1:35 p.m., the DON was asked if the facility had ordered any new lifts. She stated they had not. She stated a company was here to service the lifts. She was asked if the maintenance was routine or due to concerns. She stated I think it was a routine visit. She was asked to provide a copy of the correspondence. The documented e-mail correspondence provided by the DON was dated 02/04/21 through 04/01/21. The documentation addressed routine maintenance and replacing four batteries. No new slings had been ordered after the resident's fall from the sling. At 1:46 p.m., the administrator provided the lift sling order. She was asked if any additional maintenance was required. She stated not that she was aware of.

Based on observation, record review, resident, family and staff interviews, it was determined the facility failed to ensure a resident's right to receive unrestricted visitation for seven (#12, 26, 39, 48, 49, 53 and #63) of seven residents and a confidential resident council interview reviewed for visitation. The facility identified 65 residents who resided in the facility. Findings: A visitation policy, dated 03/29/21, documented, .To allow visitation to occur between Residents and outside personnel (family, friends) in a safe manner following designated infection control manners in a controlled environment .Policy .will allow visitation to Residents of our community following the guidelines set forth by CDC [Centers for Disease Control and Prevention] and the Department of Health and Human Services (CMS) and the Oklahoma State Health Department [OSDH] .Visitation will only be allowed at the facility while it is deemed COVID-free . An OSDH nursing home visitation grid, dated 08/02/21, documented, .Outbreak .Indoor Visits Suspended .If first round of outbreak testing reveals no additional COVID-19 cases in other areas (e.g., units) of the facility, visitation can resume for residents in areas/units with no COVID-19 cases .If the first round of outbreak testing reveals one or more additional COVID-19 cases in other areas/units of the facility (e.g., new cases in two or more units), then facility should suspend visitation for residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing .Outdoor Visitation may continue .Compassionate Care visits should continue at all times . 1. On 08/09/21 at 8:43 a.m., the administrator (admin) in training was asked how the facility is allowing visitation. She stated they are not allowing visitation due to one staff member that tested positive. She stated they aren't allowing visitors of any kind. She was asked when visitation stopped. She stated 07/31/21. She stated they haven't done any window visits because no one has asked. 2. At 9:33 a.m., resident #48 was asked if she was allowed to have visitors. She stated she wasn't sure. She stated, You would have to ask them what the visitation laws or rules are. 3. On 08/09/21 at 9:52 a.m., resident #26 was asked if she was able to have visitors. She stated, Not right now, we're shut down from a COVID case. 4. At 1:45 p.m., a phone interview was conducted with resident #53's husband. He was asked when he last visited the resident. He stated August 1st. He stated he received a text saying he couldn't visit because they had a staff member test positive for COVID. He was asked when visitation would resume. He stated the text said at least seven days or more. 5. On 08/10/21 at 9:28 a.m., resident #63 was asked if he was allowed to have visitors. He stated, No, not now because someone tested positive. My mom usually visited on Saturdays. At 3:17 p.m., the admin in training was asked what the visitation policy was. She stated, Honestly, I don't know. She was asked who decided the facility was on lock down. She stated they decided in the stand up meeting. She was made aware of the visitation guidance. She acknowledged the findings 6. Resident #39 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 06/04/21, documented the resident was cognitively intact for daily decision making. On 08/09/21 at 1:52 p.m., the resident was observed in his room, resting quietly in bed. While visiting with the resident, he was asked if he is able to have visitors. He stated his wife is in a wheelchair, depended on family to bring her, and drive for more than an hour to the facility. He stated due to the hardship of travel and needed assistance, his wife can only visit every other Saturday. The resident stated his wife and son attempted to visit last Saturday and the facility staff would not let them stay. 7. Resident #49 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An annual assessment, dated 07/02/21, documented the resident was cognitively intact for daily decision making. On 08/09/21 at 2:01 p.m., the resident was asked if he is allowed to have visitors. He stated he had two visitors yesterday. Some friends came to help celebrate his birthday. He stated he was not aware they were coming to surprise him or that they had been at the front door of the building. When the staff brought a container of cupcakes and gifts to his room, he was he was informed visitors had attempted to enter the building to celebrate his birthday. The staff did not allow the visitors to enter the building, nor had the resident been offered outside/alternate options for visitation. 8. On 08/10/21 at 1:30 p.m., a group of 19 cognitive residents attended the Resident Council interview. The residents were asked if they were allowed visitors. The residents stated the facility had been on lock down for almost 2 weeks. One resident stated she had been informed today that the facility was going to be in lock down for another 2 weeks. She stated, I do not think this is fair. On 08/13/21 at 1:19 p.m., the administrator in training (AIT) was informed of the residents report of not being able to have visitation. She acknowledged the facility had been on lockdown due to a staff member testing positive for COVID. The AIT was asked about residents #39 and #49 that had reported their visitors had been turned away without options for visitation. The AIT stated she had not been aware of the issues with resident #39. The AIT stated she had been made aware of the plan for visitors to come for resident #49 to celebrate his birthday. She stated this had been discussed with department heads and cleared the visit to occur. She stated instructions of in-room visit due to private room had been provided for staff. She stated she was not aware the visitors had been refused entry and did not know why staff did not follow her directions.

Based on observation, record review and interview, it was determined the facility failed to ensure two (#9 and #56) two sampled residents were treated with dignity during assistance with meal service. The facility identified five residents who were dependent of staff for meal intake. Findings: 1. Resident #56 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 05/06/21, documented the resident had severe cognitive impairment for daily decision making; was inattentive; had disorganized thinking; and required supervision/encouragement/cueing for meals. 2. Resident #9 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly assessment, dated 07/09/21, documented the resident had severe cognitive impairment for daily decision making; required supervision/encouragement/cueing for meals. On 08/09/21 at 12:26 p.m., the noon meal service was observed in the main dining room. Residents #9 and #56 were seated next to each other at a table with two additional residents, and being assisted by staff with meal intake. The residents were seated at a horseshoe table with licensed practical nurse (LPN) #3 seated in the center of the horseshoe table, across from the residents. LPN #4 was observed to stand next to resident #56 while assisting with food intake. After providing several bites, LPN #4 left the eating utensils next to resident #56, walked around the resident and remained standing between resident #56 and resident #9. LPN #2 approached resident #56 and began to assist the resident with meal intake. LPN #2 remained standing next to/over resident #56. LPN #4 walked away from the table. LPN #2 was asked if the LPNs usually assist with meal intake for the dependent residents. She stated, Yes. LPN #2 and #3 were asked if they normally would stand or sit next to a resident that required meal assistance. LPN #3 stated, It just depends. She stated resident #56 will require assistance to start eating and then feed herself, therefore she did not plan on staying at the table very long. LPN #3 was asked if staff should sit to assist with meal intake for the dependent residents. She stated, Yes.

Based on record review and staff interviews, it was determined the facility failed to: ~ implement their abuse policy to ensure residents remained free from abuse and neglect for two (#26 and #42) of four sampled residents who were reviewed for abuse/neglect and ~ conduct pre-employment screenings for two new hires and provide abuse training upon hire for three of five employee files reviewed. This had the potential to affect 65 residents that resided in the facility. Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 01/05/21 at 11:36 a.m., documented, At 9 am, Resident in shower with CNA (certified nurse aide), she was getting him up from shower chair using the Sit to Stand, he started leaning to his right and it [Sit to Stand lift] fell over. C/O of right hip pain .ordered an X-Ray of Right Hip . A nurse's note at 2:00 p.m., documented, Received call from [x-ray company] with notifications .right hip x-ray. Impression: fracture base of the right femoral neck .orders obtained to Send to ER [emergency room ] . A state initial incident report, dated 01/05/21, documented, .taken to shower room by the bath aide who was in the process of transferring him to the shower chair with the sit to stand and he fell to his right side. He let go of the shower bar with his right hand and the left side of the sit to stand then tilted up .the wheels slid in the water .resident who c/o some pain in his right leg .xray results .acute slightly displaced fracture . The care plan was updated on 01/05/21, documented the CNA was getting the resident out of the shower chair, using the sit to stand lift. The resident began to lean toward the right and the lift fell over. Intervention was added to utilize two CNAs when using the lift. A nurse's note, dated 01/22/21 at 11:16 a.m., documented, .resident was c/o R [right] hip pain this AM and stated the aides on night shift hurt his leg and he can not move it because it hurts. he was crying and very frustrated . A nurse's note, dated 01/22/21 at 4:03 p.m., documented, x-ray shows more displaced than last x-ray, dr [name omitted] notified and he ordered for resident to go back to [previous hospital] . A nurse's note dated, 04/25/21 at 1:17 p.m., documented, Resident came to this nurse and another nurse together to tell us that staff was getting mad every time he had to have a bowel movement. He also said that they are always sitting down and when he asks them to help they get mad because he has to use the full body lift and they have to lay him down for him to go on the bedpan. He also stated to his family member that he hadn't been changed .since the day before. We are currently awaiting word from the upper management on what actions to take towards the aides, but this nurse talked to both aides and re-educated them on the importance of checking every resident that may be incontinent. The aides expressed understanding and told nurse that the resident gets mad at them because they have to use the full body lift to transfer him and he wants to use the sit to stand. The aides were told that as far as lifts go they have to use the full body until otherwise authorized and made the resident aware as well. Resident did not bring the issue of being changed to the charge nurses, they were informed by the family member. There was no documentation an investigation of neglect had been initiated. An incident report was not located and was not provided. A nurse's note, dated 05/04/21 at 12:49 p.m., documented, .patient was up in full body lift when sling strap broke and he fell from sling to his left side hitting his left jawl [jaw] shoulder elbow and knee. The cross necklace he is wearing caused a laceration and abrasion to left of neck and clavicle region .was noted that he had bruising and swelling to his left jawl, laceration to left side of his neck and an abrasion to the left clavicle region, bruising and abrasion to left elbow and abrasion to left knee with redness .pain [greater than] 10 to his left post shoulder .called for stat X-Ray . An initial/final incident report, dated 05/04/21, documented, .Resident was in the full body lift and the sling broke resulting in him falling to the floor hitting his [left] jaw, shoulder, arm/leg .Staff was inserviced 5/5/21 on monitoring all lift equipment and reporting any deficient equipment equipment to supervisors .slings were checked and replaced . A nurse's note, dated 05/06/21 at 9:31 a.m., documented, .it is his shower today he was assured that we would have 3 persons present during lift transfer and that sling would be assessed prior to use. A quarterly assessment, dated 06/10/21, documented the resident was cognitively intact for daily decision making; did not walk; required total assistance of two staff for transfers, and toileting; required total assistance of one staff for bathing; required extensive assistance for bed mobility, dressing and hygiene. The care plan, last updated 06/25/21, documented the resident was dependent in bathing, dressing, hygiene, and transfers; required extensive assistance for bed mobility and toileting. The resident was at risk for falls due to right sided weakness, required a mechanical lift for transfers, and 1-2 person assist using a fully body hoyer lift. On 08/09/21 at 2:32 p.m., the resident reported to this surveyor a girl that work at the facility is mean to me. He was asked if the girl continued to work here. He stated Yes, it happened when she broke my leg. She was what caused the broken leg. She is the meanest. On 08/12/21 at 1025 a.m., the director of nurses (DON) was asked to review the incident report for resident #42, dated 01/05/21. She was asked to identity the nurse aide. She stated the nurse aide involved was CNA #1. The DON was asked if in the situation of the event with CNA #1, on 01/05/21, did the nurse aide transfer the resident by herself and did the CNA follow the facility protocol with mechanical lifts. She stated the CNA was in the shower room, transferring a resident by herself and the CNA did not follow the facility protocol. The DON was asked if is was considered at the time of the event to address the situation as abuse and/or neglect. She stated, It was not abuse. She stated the event occurred due to the nurse aide was supposed to have two people to assist with a transfer using the lift and she did not have a second person. No further information was provided. The DON was asked asked to review the nurse note for resident #42, dated 04/25/21. The DON was asked if the event was investigated as abuse/neglect. She stated it should have been reported to some one. The DON was informed that a nurse knew and documented in the nurse notes. She was again was asked if the incident should have been investigated. No information was provided. The DON was asked to review the nurse's note for resident #42, date 05/04/21, regarding the resident fallen during a transfer in a full body lift in which the sling strap broke and the resident received minor injuries. She stated an incident was completed. The DON was asked if the incident was investigated as neglect. She did not reply. 3. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/24/20, the resident's cognition was intact. An incident report, dated 11/04/20 AM (no time), documented, .location of incident/accident .Shower Room .Resident told staff that she was afraid because on Wednesday 11-4-20 resident was getting a shower and got into an aguement [sic] [with] aide in which the resident called the aide a [expletive] so in return the aide sprayed the resident down [with] cold water .Witness was present during the time the resident stated these allocations [sic] . On 08/11/21 at 11:35 a.m., the director of nursing was asked what she considered abuse. She stated anything physical, hitting, pushing, shoving, verbal and anything neglectful. She was asked if spraying someone with cold water would be considered abuse. She stated, Yes. She was shown the incident report and asked if an abuse investigation had been conducted. She looked through the state reportable incidents and stated, I don't see anything. She was asked if an abuse investigation should have been conducted. She stated, I think so, yes. She was asked how residents were protected from further abuse if an abuse investigation was not conducted. She stated, I feel like it should have been conducted in order to protect them from further abuse. At 12:20 p.m., the resident was asked about the incident. She stated the bath aide, certified nurse aide (CNA) #1, the same one who is here today, had sprayed her with cold water. She was asked if it was intentional. She stated, Yes. She stated the CNA was mad because she needed help washing. She stated the CNA was always rude. CNA #1's personal file documented a hire date of 12/21/20. There was no documentation that a back ground check had been conducted or abuse training had been provided prior to or upon hire. On 08/12/21 at 9:49 a.m., the interim administrator was asked if a background check had been conducted prior to or upon hire. She stated no and they had just completed one today. At 10:40 a.m., the interim ADM was asked the policy for conducting employee back ground checks. She stated before they are hired. She was asked the policy for providing abuse training. She stated, On hire. 4. On 08/12/21 at 8:25 a.m., the administrator in training was asked to provide employee files. At 9:49 a.m., the interim administrator provided the employee files and stated certified nurse aide (CNA) #1 did not have a background/pre-employment screening conducted prior to hire. CNA #3's employee file had no documentation abuse training had been provided upon hire. CNA #5's employee file had no documentation pre-employment screening had been conducted or abuse training had been provided upon hire. At 10:40 a.m., the interim administrator was asked what the policy was for conducting pre-employment screenings. She stated, Before they are hired. She was asked the policy for providing abuse training. She stated, On hire. She was made aware of the above information. She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to ensure an investigation for staff/resident criminal activity was conducted for one (#1) of one sampled resident reviewed for a criminal act. The facility identified 65 residents resided in the facility. Findings: A statement located in an in-service book, dated 06/04/21, documented, Attn [attention] Nurses: Just letting you know if you haven't heard that [licensed practical nurse (LPN)#6's initials] LPN has been let go and there is a police report being done for her bringing marijuana in the building and giving it to [resident #1] to sell to the residents. We also met with [resident #1's] family and explained that we won't tolerate the marijuana in the building anymore .Thank you .Management. On 08/12/21 at 8:35 a.m., the interim administrator was asked to provide the state reportable incident and investigation related to this incident. She stated there was no reportable. She stated she had asked the director of nursing for it this morning. She was asked if the LPN had ben reported to the nursing board and the local authorities. She stated she had not seen where she had been reported to the nursing board or the local authorities. She was asked who was responsible for conducting the reporting and the investigation. She stated, The DON [director of nursing]. She was asked when the DON had been made aware of the incident. She stated, On 06/02. At 4:00 p.m., the DON was asked if a reportable incident, police report and investigation had been conducted related to the statement. She stated she would have to look through the books. On 08/13/21 at 8:35 a.m., the administrator-in training was informed there was no reportable incident, police report or report made to the nursing board regarding this incident. At 9:02 a.m., the administrator-in-training provided a state reportable incident for the above criminal act. She was asked when it had been completed. She stated, Yesterday. At 9:59 a.m., the interim administrator was asked how she had been made aware of the criminal act. She stated resident #1's family members had called her and told her. They told her that LPN #6 was bringing it to resident #1 and she was selling to three residents in the building. Resident #1 told her family that LPN #6 was putting marijuana in a McDonald's or Braums' sacks and bringing it in. The interim administrator stated she had watched the facility cameras and saw LPN #6 bring a McDonald's sack in and take it to resident #1's room on 06/02/21. The interim ADM stated that two of the residents denied buying the marijuana but resident #1 admitted she had. She was asked when LPN #6 had been terminated. She stated she had been terminated on 06/02/21. At 10:10 a.m., the DON was asked what the policy was for reporting criminal acts. She stated, We do a state reportable, mark on the form criminal act, notify the policy department, notify legal responsible party, and the appropriate board. She was asked when she had been made aware of the above information. She stated the ADM had informed her on 06/04/21. The DON was asked which residents had been affected. She stated resident #1. The DON was asked when she did the state reportable and contacted the policy department. She stated she did that last night. She was asked when the nurse had been reported to the nursing board. She stated last night.

Based on record review and interviews, it was determined the facility failed to report alleged violations of physical abuse and/or neglect. This affected two (#26 and #42) of four sampled residents who were reviewed for abuse/neglect. This had the potential to affect 65 residents that resided in the facility. Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated, 04/25/21 at 1:17 p.m., documented, Resident came to this nurse and another nurse together to tell us that staff was getting mad every time he had to have a bowel movement. He also said that they are always sitting down and when he asks them to help they get mad because he has to use the full body lift and they have to lay him down for him to go on the bedpan. He also stated to his family member that he hadn't been changed all to a new brief since the day before. We are currently awaiting word from the upper management on what actions to take towards the aides, but this nurse talked to both aides and re-educated them on the importance of checking every resident that may be incontinent. The aides expressed understanding and told nurse that the resident gets mad at them because they have to use the full body lift to transfer him and he wants to use the sit to stand. The aides were told that as far as lifts go they have to use the full body until otherwise authorized and made the resident aware as well. Resident did not bring the issue of being changed to the charge nurses, they were informed by the family member. There was no documentation an investigation of neglect had been initiated. An incident report was not located and was not provided. On 08/12/21 at 10:25 a.m., the director of nurses (DON) was asked to review the nurse's note for resident #42, dated 04/25/21. The DON was asked if the event was investigated as abuse/neglect. She stated it should have been reported to some one. The DON was informed that a nurse knew and documented in the nurse notes. She was again asked if the incident should have been investigated. No information was provided. 2. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/24/20, documented the resident's cognition was intact. An incident report, dated 11/04/20 AM (no time), documented, .location of incident/accident .Shower Room .Resident told staff that she was afraid because on Wednesday 11-4-20 resident was getting a shower and got into an aguement [sic] [with] aide in which the resident called the aide a [expletive] so in return the aide sprayed the resident down [with] cold water .Witness was present during the time the resident stated these allocations [sic] . On 08/11/21 at 11:35 a.m., the director of nursing was asked what she considered abuse. She stated anything physical, hitting, pushing, shoving, verbal and anything neglectful. She was asked if spraying someone with cold water would be considered abuse. She stated, Yes. She was shown the incident report and asked if an abuse investigation had been conducted. She looked through the state reportable incidents and stated, I don't see anything. She was asked if an abuse investigation should have been conducted. She stated, I think so, yes. She was asked how residents were protected from further abuse if an abuse investigation was not conducted. She stated, I feel like it should have been conducted in order to protect them from further abuse.

Based on record review and interviews, it was determined the facility failed to thoroughly investigate, prevent and correct allegations of abuse/neglect. This affected two (#26 and #42) of four sampled residents who were reviewed for abuse/neglect. This had the potential to affect 65 residents that resided in the facility. Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 01/05/21 at 11:36 a.m., documented, At 9 am, Resident in shower with CNA (certified nurse aide), she was getting him up from shower chair using the Sit to Stand, he started leaning to his right and it [Sit to Stand lift] fell over. C/O of right hip pain .ordered an X-Ray of Right Hip. Called Mobile X-Ray . A nurse's note at 2:00 p.m., documented, Received call from DMX with notifications .right hip x-ray. Impression: fracture base of the right femoral neck .orders obtained to Send to ER . An initial incident report, dated 01/05/21, documented, .taken to shower room by the bath aide who was in the process of transferring him to the shower chair with the sit to stand and he fell to his right side. He let go of the shower bar with his right hand and the left side of the sit to stand then tilted up .the wheels slid in the water .resident who c/o some pain in his right leg .xray results .acute slightly displaced fracture . A final incident report, dated 01/05/21, documented, .Resident returned on 1/9/21, he did not have surgery, the decision was made because he was not ambulatory prior to the incident and the Dr. felt the risks outweigh the benefits. All Staff were in-serviced on safe transfers by the therapist and the bath plan for the resident was changed and 2 staff will assist at all times and he will transfer with a bar. Maintenance installed a higher bar to accommodate him . A nurse's note, dated 01/11/21 at 6:02 p.m., documented: Resident remains SNF [skilled nursing facility] for displaced intertrochanteric fracture of right femur, [CONDITION(S)] right dominant side, anxiety, depression, & dysphagia for PT/OT for balance, gait, mobility, safety awareness, & assistance with ADL's .Resident transfers with sit-to-stand lift & x2 staff assistance .episodes of bladder incontinence noted when unable to reach urinal .C/o pain to right hip . A nurse's note, dated 01/22/21 at 11:16 a.m., documented, .resident was c/o R [right] hip pain this AM and stated the aides on night shift hurt his leg and he can not move it because it hurts. he was crying and very frustrated . A nurse's note, dated 01/22/21 at 4:03 p.m., documented, x-ray shows more displaced than last x-ray, dr [name omitted] notified and he ordered for resident to go back to [previous hospital] . A nurse's note dated, 04/25/21 at 1:17 p.m., documented, Resident came to this nurse and another nurse together to tell us that staff was getting mad every time he had to have a bowel movement. He also said that they are always sitting down and when he asks them to help they get mad because he has to use the full body lift and they have to lay him down for him to go on the bedpan. He also stated to his family member that he hadn't been changed all to a new brief since the day before. We are currently awaiting word from the upper management on what actions to take towards the aides, but this nurse talked to both aides and re-educated them on the importance of checking every resident that may be incontinent. The aides expressed understanding and told nurse that the resident gets mad at them because they have to use the full body lift to transfer him and he wants to use the sit to stand. The aides were told that as far as lifts go they have to use the full body until otherwise authorized and made the resident aware as well. Resident did not bring the issue of being changed to the charge nurses, they were informed by the family member. There was no documentation an investigation of neglect had been conducted. On 08/09/21 at 2:32 p.m., the resident reported a girl that work at the facility is mean to me. He was asked if the girl continued to work here. He stated Yes. it happened when she broke my leg. She was what caused the broken leg. She is the meanest. On 08/12/21 at 1025 a.m., the director of nurses (DON) was asked to review incident report for resident #42, dated 01/05/21. She was asked to identity the nurse aide. Stated the nurse aide involved was CNA #1. The DON was asked if CNA #1 transferred the resident by herself on 01/05/21 and did she follow the facility protocol with mechanical lifts. She stated the CNA transferred the resident by herself and did not follow the facility protocol. The DON was asked to review the incident report, dated 1/25/21 for resident #42. The DON was asked if abuse had been considered. She stated she did and reported the CNAs. The DON was informed the final report was not located in the information provided. She was asked if a final report had been completed with the information of the outcomes. She stated she would need to look for it. No further documentation was provided. The DON was asked asked to review the nurse note for resident #42, dated 04/25/21. The DON was asked if the event was investigated as abuse/neglect. She stated it should have been reported to some one. The DON was informed that a nurse knew and documented in the nurse notes. Again was asked if the incident should have been investigated. No information was provided. 2. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident assessment, dated 08/24/20, the resident's cognition was intact. An incident report, dated 11/04/20 AM (no time), documented, .location of incident/accident .Shower Room .Resident told staff that she was afraid because on Wednesday 11-4-20 resident was getting a shower and got into an aguement [sic] [with] aide in which the resident called the aide a [expletive] so in return the aide sprayed the resident down [with] cold water .Witness was present during the time the resident stated these allocations [sic] . On 08/11/21 at 11:35 a.m., the director of nursing was asked what she considered abuse. She stated anything physical, hitting, pushing, shoving, verbal and anything neglectful. She was asked if spraying someone with cold water would be considered abuse. She stated, Yes. She was shown the incident report and asked if an abuse investigation had been conducted. She looked through the state reportable incidents and stated, I don't see anything. She was asked if an abuse investigation should have been conducted. She stated, I think so, yes. She was asked how residents were protected from further abuse if an abuse investigation was not conducted. She stated, I feel like it should have been conducted in order to protect them from further abuse. At 12:20 p.m., the resident was asked about the incident. She stated the bath aide, certified nurse aide (CNA) #1, the same one who is here today, had sprayed her with cold water. She was asked if it was intentional. She stated, Yes. She stated the CNA was mad because she needed help washing. She stated the CNA was always rude. CNA #1's personel file documented a hire date of 12/21/20. There was no documentation that a back ground check had been conducted or abuse training had been provided prior to or upon hire. On 08/12/21 at 9:49 a.m., the interim administrator was asked if a background check had been conducted prior to or upon hire. She stated no and they had just completed one today. At 10:40 a.m., the interim ADM was asked the policy for conducting employee back ground checks. She stated before they are hired. She was asked the policy for providing abuse training. She stated, On hire.

Based on record review and interviews, it was determined the facility failed to ensure a resident's care plan was fully developed and revised to ensure the residents needs were met. This affected one (#54) of 15 sampled residents whose care plans were reviewed. The facility census was 65. Findings: 1. Resident #54 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A five day skilled assessment, dated 10/31/2020, documented: the resident refused to participate with the interviews; staff reported resident has a long term and short term memory deficits; he required extensive assistance with bed mobility, transfers, dressing, eating, toileting, hygiene and bathing; and he did not walk. A nurse's note, dated 01/16/21 at 4:30 a.m., documented, Resident reported to CNA (certified nurse aide) at approx [sic] 2:50am that he had fallen in bathroom and hit his head on the door. He was laying in his bed when he reported this. He had 2 skin tears to his right elbow, 1 to his left wrist, an abrasion to right upper back and a bruised/discolored area to right lower back. Slightly red area to top/right side of head .transferred to [local emergency department] . The resident's care plan for falls was not updated until 2 weeks later to reflect new interventions. A nurse's note, dated 02/17/21 at 6:25 a.m., documented, resident lying in bed and told CNA that he just fell stated he tried to stand up to go to bathroom and got dizzy and slid to floor .[blood pressure] 152/76 .Ao [sic] x2 .scab from area on left lower leg off and dried blood noted .placed call light in reach and encouraged to use when needing help or getting up . The resident's care plan for falls was not updated with any new interventions. A nurse's note, dated 06/14/21 at 8:57 p.m., documented, .find resident half sitting leaning on right forearm on the floor in between recliner and bed .[doctor] notified and order received for skin tear [treatment] as noted. No other orders. Will continue to monitor. The resident's care plan for falls was not updated with any new interventions. On 08/17/21 at 1:00 p.m., in the presence of the regional nurse consultant, the administrator was asked if any new interventions were attempted when resident continued to fall. After review of the care plan, she stated, If so, they are not documented. The administrator was asked if the interventions documented in the care plan, such as encourage to call for assistance, were appropriate for a resident with advanced dementia. She stated, No.

Based on observation, record review and staff interviews, it was determined the facility failed to ensure nail care was provided as ordered and as needed for one (#30) of three sampled dependent residents reviewed for activities of daily living (ADL) care. The facility identified 19 residents who were dependent on staff for ADLs. Findings: Resident #30 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 03/04/21, documented, .Even though I spend much of my time in bed, I want to look nice. Remind me, prn [as needed] to attend to my grooming/hygiene tasks . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .NAIL CARE Q [every] WEEK ON SUNDAYS AND PRN . A resident assessment, dated 05/23/21, documented the resident's cognition was severely impaired and they required limited assistance of one person for personal hygiene. The ADL report for August 2021 documented the resident was not provided personal hygiene six out of 11 days and was not bathed two of four scheduled showers. On 08/09/21 at 10:03 a.m., the resident was observed laying in his bed. His finger nails were observed long with a dark substance under them. On 08/10/21 at 9:12 a.m., the resident was observed sitting up in his wheelchair attending an activity. His finger nails were observed long with a dark substance under them. On 08/11/21 at 11:30 a.m., health care nursing aide #1 was asked when residents were provided nail care. She stated usually in the shower and as needed. She was asked when the resident was scheduled to be showered. She stated every Tuesday, Thursday and Saturday. She was asked where nail care was documented. She stated in the electronic health record under the personal care and bathing task. She was asked the last time the resident had been shower. She stated she had given him one yesterday. She was asked the last time nail care had been provided. She stated she didn't know because she didn't do it with the shower. On 08/11/21 at 11:41 a.m., the director of nurses (DON) and assistant DON (ADON) were asked when the residents were provided nail care. The DON stated usually during baths. They were asked when the residents were showered. The ADON stated they have a shower schedule. She was asked where nail care was documented. She stated on the ADL report. She stated nail care was ordered to be completed every Sunday and PRN. The ADON was asked when nail care had been last provided to the resident. She stated he has it ordered but she didn't see an area for staff to document it was completed. She stated she looked at the last two Sundays and there was no documentation it had been provided. She was asked how many times nail care had been provided to the resident in August. She stated, Nail care isn't popping up in here, so I don't know. The DON and ADON were made aware and acknowledged the findings.

Based on observation, record review and staff interview, it was determined the facility failed to conduct COVID-19 testing in a manner consistent with current Centers for Disease Control (CDC) guidance for two tests observed. The director of nurses (DON) failed to don the appropriate personal protective equipment (PPE) prior to testing the staff members. The DON identified a census of 65 residents and 84 staff members. Findings: The CDC guidance titled COVID-19 Specimen Collection .Collecting and Handling Specimen Safely, updated February 26, 2021, documented, For healthcare providers collecting specimens . [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. On 08/13/21 at 2:30 P.M., the DON was observed performing rapid [MEDICATION(S)] testing on laundry staff #1. She was observed wearing a surgical mask and gloves. The DON was not observed to wear eye protection or a gown during specimen collection. The DON reported she wore full PPE when testing large amounts of staff. At 3:00 P.M., the DON was observed performing rapid testing on an unnamed staff member. She was observed wearing surgical mask, gloves, and a gown. The DON was not observed to wear eye protection during specimen collection. On 08/17/21 at 4:32 P.M., the DON was informed of improper use of PPE during COVID-19 specimen collection. She acknowledged the findings.

Based on record review and interview, it was determined the facility failed to assess, monitor and intervene in a timely manner for one (#31) of one sampled residents with a change in condition. The resident required the assistance of two staff members and a lift for transfers. The resident was assisted by one staff member without the use of a lift and sustained a fracture of her fibula and had a new onset of pain which was not assessed for 16 hours after staff being notified of the incident. The facility identified 86 residents who resided in the facility. Findings: Resident #31 had [DIAGNOSES REDACTED]. A care plan, dated 01/16/18, documented the required extensive to total assist with ADL's, two person assist with toileting/transferring to and from the wheelchair/toilet/bed using a sit to stand lift. An annual assessment, dated 11/07/19, documented the resident's cognition was intact and required total assistance of two staff members for bed mobility and transfers. A social services note, dated 01/18/20 at 4:21 p.m., documented, (Recorded as Late Entry on 01/20/20 at 12:10) (Resident #31) complained about (CNA #1) hurting her ankle. She stated that she stood her up and when turning her around, she felt like she twisted her ankle. I asked her if she wanted me to go and tell the nurse, she said yes please; I think my ankle is hurt real bad. I went and told (RN #1) the nurse at the nurses station. She stated that she would take care of it. There was no documentation to indicate the resident was assessed for her complaint of pain. The next nurse's note entry, dated 01/19/20 at 6:02 a.m., documented, LLE [MEDICAL CONDITION] 2+ noted, res also voices discomfort to LLE . A nurse's note, dated 01/19/20 at 8:08 a.m., documented by RN #1, resident refusing to get up OOB this am. she is c/o LLE pain at the ankle. LLE has 1-2+ [MEDICAL CONDITION] noted. resident states that yesterday am when staff was getting her up oob the ankle twisted. pain meds given as ordered. (Name deleted hospice and nurse) notified and n.o. received to xray ankle this am and they will be out to see her today. A nurse's note, dated 01/19/20 at 10:49 a.m., documented xray report received and noted an acute and traumatic comminuted fx of the distal fibular metphysis c slight impaction . A nurse's note, dated 01/21/20 at 9:42 p.m., documented the hospice nurse was there with the resident. The resident was experiencing uncontrolled pain. A nurse's note, dated 01/22/20 at 1:09 a.m. documented the resident was being admitted to the hospital for pain management. On 02/06/20 at 12:26 p.m., the DON and ADON were asked if there was documentation an assessment was conducted on resident #31 by RN #1 after she was made aware of the concern on 01/18/20. The ADON stated she did not realize an assessment was not done. They were asked how many staff members should transfer the resident. The ADON stated two. They were asked if a lift was to be used in the transfer. They stated yes. They were asked how may staff were involved in this transfer. They stated one. They were asked if the staff member used a lift during the transfer. They stated no. At 12:39 p.m., the social service staff was asked if she recalled the incident with resident #31. She stated yes, the resident was in the lobby for a birthday party and called me over to her and she told me when the nurse put her in her chair, she heard a pop when she twisted her. She stated she then started hurting really bad. She stated CNA #1 was the staff member who transferred her. The social service staff was asked if she had notified anyone of the concern. She stated she went immediately and told RN #1. She was eating a salad at the nurses desk and told her she would get to it in a little bit. She was asked if she could tell the resident was in pain. She stated oh yes, yes, that was why she went right away to tell the nurse. At 1:12 p.m., the DON stated she was not able to find documentation to indicate the resident had been assessed for the change in condition after RN #1 had been notified of the incident. She was asked if there were any pain assessments conducted after the incident. She stated no.

Based on record review and interview, it was determined the facility failed to provide adequate staff for transfers for one (#31) of three sampled residents and provide supervision for residents with aggressive behaviors for two (#55 and #302) of three sampled residents who were reviewed for accidents and supervision. The facility identified 86 residents who resided in the facility. Findings: 1. Resident #31 had [DIAGNOSES REDACTED]. A care plan, dated 01/16/18, documented the required extensive to total assist with ADL's, two person assist with toileting/transferring to and from the wheelchair/toilet/bed using a sit to stand lift. An annual assessment, dated 11/07/19, documented the resident's cognition was intact and required total assistance of two staff members for bed mobility and transfers. A social services note, dated 01/18/20 at 4:21 p.m., documented, (Recorded as Late Entry on 01/20/20 at 12:10) (Resident #31) complained about (CNA #1) hurting her ankle. She stated that she stood her up and when turning her around, she felt like she twisted her ankle. I asked her if she wanted me to go and tell the nurse, she said yes please; I think my ankle is hurt real bad. I went and told (RN #1) the nurse at the nurses station. She stated that she would take care of it. There was no documentation to indicate the resident was assessed for her complaint of pain. The next nurse's note entry, dated 01/19/20 at 6:02 a.m., documented, LLE [MEDICAL CONDITION] 2+ noted, res also voices discomfort to LLE . A nurse's note, dated 01/19/20 at 8:08 a.m., documented by RN #1, resident refusing to get up OOB this am. she is c/o LLE pain at the ankle. LLE has 1-2+ [MEDICAL CONDITION] noted. resident states that yesterday am when staff was getting her up oob the ankle twisted. pain meds given as ordered. (Name deleted hospice and nurse) notified and n.o. received to xray ankle this am and they will be out to see her today. A nurse's note, dated 01/19/20 at 10:49 a.m., documented xray report received and noted an acute and traumatic comminuted fx of the distal fibular metphysis c slight impaction . An inservice, dated 01/24/20, documented staff received training on patient safety, proper amount of staff that must be present to asist in ranfers with lifts and no lifts, communication skills on information regarding which residnts are one person and whcih residents were two person, the proper use of full body lifts, sit to stand lifts, two person, one person and standby. On 02/06/20 at 12:26 p.m., the DON and ADON were asked if there was documentation an assessment was conducted by RN #1 on the resident after she was made aware of the concern on 01/18/20. The ADON stated she did not realize an assessment was not done. They were asked how many staff should have transfered the resident. The ADON stated two. They were asked if a lift should have been used in the transfer. They stated yes. She was suppose to be a lift, everyone had been educated and the CNA was written up. They were asked how may staff were involved in this transfer. They stated one. They were asked how staff were informed of what assistance was needed for each resident. The ADON stated she created a sheet with each residents name and required assistance. At 12:39 p.m., the social service staff was asked if she recalled the incident with resident #31. She stated yes, the resident was in the lobby for a birthday party and called me over to her and she told me when the nurse put her in her chair, she heard a pop when she twisted her. She stated she then started hurting really bad. She stated CNA #1 was the staff member who transferred her. The social service staff was asked if she had notified anyone of the concern. She stated she went immediately and told RN #1. She was eating a salad at the nurses desk and told her she would get to it in a little bit. She was asked if she could tell the resident was in pain. She stated oh yes, yes, that was why she went right away to tell the nurse. 2. Resident #55 was admitted with [DIAGNOSES REDACTED]. A care plan, dated 11/02/19, documented the resident had the potential to be verbally and physically aggressive. Staff was to intervene before his agitation escalated, guide him away from the source of distress and engage calmly in conversation. If the resident's response was aggressive, the staff was to walk calmly away and approach him later. The nurse's notes, from 10/01/19 through 01/07/20, documented the resident had episodes of aggression and/or combativeness toward staff 20 times and aggression toward another resident three times. There was no documentation to indicate frequent monitoring of the resident was implemented following the episodes of combativeness. There was no documentation to indicate interventions were implemented to ensure the continuous safety of the other residents. On 02/07/20 at 11:45 a.m., the DON was asked about the behaviors of the resident. She stated the staff had not done any monitoring of the resident's behaviors, it should have been done. 3. Resident #302 had [DIAGNOSES REDACTED]. A care plan, dated 12/05/19 documented the resident had the potential to be verbally and physically abusive. She was at high risk for elopement due to her cognitive status and exit seeking behaviors. Staff was to make frequent visual checks, intervene before her agitation escalates, redirect the resident and document her behaviors. A nurse's note, dated 12/05/19 at 2:05 a.m., documented the resident was found standing over the roommate's bed. The roommate has voiced that she was scared of the resident. The nurse was informed by the CNA that staff caught the resident attempting to place a pillow over the roommate's face but they were able to intervene. An undated incident report, documented the resident was seen in the early morning hours on 12/05/19 attempting to place a pillow over her roommate's face. The aide intervened and the pillow had not made contact with the roommate's face. The resident was removed from the room and taken to another area for the rest of the night. The following day it was decided to move the resident to a room with no roommate close to the nurse station. There was no documentation to indicate steps were taken to ensure the safety of the other residents following the incident. The nurse's notes from 12/06/19 through 02/05/20, documented the resident had episodes of wandering throughout the facility 15 times and wandering into other resident's rooms seven times. On 02/07/20 at 4:23 p.m., the corporate nurse and DON were asked about the incident involving the resident. The corporate nurse stated she had known the resident wandered but was unaware of any measures that had been put in place. The DON was unaware of the extent of the resident's wandering episodes.

Based on observation, record review, and interviews, it was determined the facility failed to assess one (#4) of two sampled residents for the safety in utilization of an electric w/c. The facility identified seven residents that utilized the use of electric w/c. Findings: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 12/03/19, documented the resident was cognitively intact for daily decision making; required total assistance for bed mobility, transfers, dressing, eating, toilet use, hygiene and bathing; and utilized a w/c for mobility. The care plan, dated 12/14/19, did not address the use of an electric w/c. The physician's orders did not address the use of an electric w/c. A nurse's note, dated 12/16/19 at 7:32 p.m., documented, resident stated, 'his chair had gotten away from him and he ran into the wood piece under his desk' in his room. resident sustained [REDACTED].arrived back .received 14 stitches to right lower leg . An Incident/Accident Report, dated 12/16/19, documented, .The resident stated 'his chair got away from him' & he ran his chair up under the desk area & hit the wood bracket underneath there cutting his lower R leg open . The clinical record did not contain an assessment for the safety to utilize an electric w/c at the time of admission or after the incident that resulted in a laceration to the right lower leg. On 12/19/20 at 1:00 p.m., the resident was seated in an electric w/c in his room. He spoke in a soft/quiet voice. The resident stated he had 14 stitches in his leg due to a recent event that his chair had gotten away from him and he collided into the wooden cabinet. On 12/26/19 at 2:33 p.m., the corporate nurse was asked if the resident had been assessed for the safety to utilize an electric w/c. She stated, Probably not. He should have been.

Based on observation, interview, and record review, it was determined the facility failed to develop/implement interventions to ensure a resident did not develop an avoidable pressure ulcer for one (#32) of two sampled residents who were reviewed for pressure ulcers. The facility's resident census and conditions of residents identified three residents with a pressure ulcer. The facility census was 53. Findings: Resident #32 had [DIAGNOSES REDACTED]. The annual assessment dated [DATE] documented the resident was cognitively intact for daily decision making. The assessment documented the resident required supervision/limited assistance for bed mobility, transfers, and toileting. The assessment documented the resident used a wheelchair for mobility. The assessment documented the resident was at risk for the development of pressure ulcers and had a stage II pressure ulcer. The assessment documented skin and ulcer treatments included the application of non-surgical dressings. There was no documentation in the assessment to indicate the use of pressure reducing devices for her chair/bed or turning/repositioning. The care plan revised 07/20/18 documented the resident had a stage II pressure ulcer to the coccyx that measured 3 centimeters (cm) x 1 cm x 0.2 cm. The care plan documented the staff were to do the following: ~ administer protein shakes with meals for wound healing, ~ cleanse the area with NS, apply collagen , silver calcium alginate, and cover with a dressing, ~ monitor for signs/symptoms of infection with every dressing change, and ~ administer [MEDICATION NAME] for pain control. The care plan documented the resident was at risk for skin breakdown related to wheelchair mobility. The staff were to do the following: ~ avoid shearing during positioning, transferring, and turning, ~ skin inspection weekly, ~ keep the resident clean and dry, and ~ keep linen clean, dry, and wrinkle free. There was no documentation in the care plan to indicate education regarding turning/reposition had been provided to the resident. The care plan did not address the resident's non-compliance. Medication administration records and treatment administration records dated 06/24/18 through 07/31/18 revealed no documentation to indicate protein shakes had been offered. physician's orders [REDACTED]. ~ 06/24/18-reopen wound to coccyx - cleanse with normal saline (NS) - pat dry. Apply collagen, then Silver Calcium Alginate. Cover, secure with tape. ~ 07/12/18-change wound care to [MEDICATION NAME]. Cleanse with NS, pat dry. Apply [MEDICATION NAME] to wound bed and secure with tape. ~ 07/31/18-clarification of wound care. Cleanse with NS, apply hydrogel with collagen powder. Cover with semi-permeable dressing. Secure with tape. The weekly skin assessment forms documented the following: ~ 06/25/18 pressure ulcer (PU) of coccyx, stage II, reopen, partial thickness; 3 cm x 0.2 cm x 0.2 cm. 50% slough, 40% eschar. The form did not identify mattress/chair treatment aides in use to support healing. ~ 07/01/18 stage II PU of coccyx; 1 cm x .5 cm x 0.2 cm partial thickness. Treatment - cleanse with NS, apply collagen powder, apply Silver Calcium Alginate. Cover. The form did not identify mattress/chair treatment aides in use to support healing. ~ 07/08/18 stage II PU of coccyx, full thickness - slough, 3 cm x 1 cm x 0.2 cm. Treatment - cleanse with NS. collagen powder, and cover. The form did not identify mattress/chair treatment aides in use to support healing. ~ 07/16/18 recurrent coccyx PU - stage III, full thickness. 3 cm x 1.5 cm x 0.1 cm, minimal slough. The form did not identify mattress/chair treatment aides in use to support healing. Treatment - cleansed with NS apply silver hydrogel and collagen, and cover. ~ 07/23/18 pressure ulcer of coccyx, stage III, full thickness 3 cm x 0.5 cm x 0.1 cm, 70% granulation- 30% slough, scant sanguineous drainage, slight odor. Treatment - cleanse with NS, apply Silver gel and collagen to wound bed. Cover with dressing. The form did not identify mattress/chair treatment aides in use to support healing. ~ 07/29/18 wound location - coccyx - pressure ulcer - not present on admission - acquired in house - stage III, full thickness, 4 cm x 1 cm x 0.2 cm, 80% slough, scant sanguineous drainage. No improvement, slightly tender to touch. Treatment - cleanse with NS. Apply collagen and Silver hydrogel to wound bed, Cover with dressing and secure with tape. The form did not identify mattress/chair treatment aides in use to support healing. The consultant dietician's note dated 07/8/18 documented the resident had a stage III PU on the coccyx. Recommendations included [MEDICATION NAME] 1 scoop 2 times per day mixed with food at lunch and dinner. Further recommendations included vitamin C 500 milligrams (mg) 2 times per day and zinc sulfate 220 mg daily. The resident was observed in her room seated in her wheelchair. She was pleasant in conversation and able to make her needs known. A folded blanket was observed in her wheelchair, but no pressure reducing device. She stated she was encouraged to lie down, but preferred to stay up during the day due to activities. On 07/31/18 at 1:20 p.m., licensed practical nurse (LPN) #3 was asked what interventions were implemented to prevent the resident from developing pressure ulcers. She stated, Nutrition. She was asked if the resident was encouraged to reposition by spending less time in her wheelchair. She stated, Yes. She stated the resident was non-compliant and wanted to stay in her wheelchair most of the time. She was asked if the education/non-compliance was documented. She stated, No. She was asked if the facility ever used special mattresses or gel cushions for residents identified at risk for PU. She stated sometimes the doctor ordered gel cushions. She stated she wasn't sure about the mattresses. At 2:00 p.m., corporate LPN #1 was asked when the pressure ulcer was acquired. She stated 06/25/18. She stated it was acquired in-house. She was asked if the resident had been identified at risk prior to 06/25/18. She stated, Yes. She was asked what interventions the facility had implemented to prevent the development or worsening of PU. She stated they had attempted restorative, but the resident refused; incontinent care was provided every 2 hours and as needed, and a supplement was offered if the resident ate 50% or less of her meals. She was asked if they had provided a pressure reducing device for her chair. She stated, No. She was asked if the resident received protein shakes. She stated it wasn't documented. She was asked if the care plan had been followed. She stated, No. She was asked to review the wound documentation. After review, she was asked if the wound had progressed from a stage II to a stage III. She stated, Yes, per the documentation. She was asked if the dietary recommendations from 07/18/18 had been implemented. She stated, No. She was asked if the pressure ulcer was avoidable. She stated, Yes. On 08/01/18 at 3:15 p.m., the certified dietary manager was asked if she was aware of the consultant dietician's recommendations from 07/18/18. She stated she was aware and the [MEDICATION NAME] had been started. She was asked about the protein shakes. She stated she remembered the resident was suppose to get them, but she had refused. She was asked if dietary had documented the offer/refusal of the protein shakes. She stated, No. The resident was asked if she had been offered a protein shake. She stated, No. She was asked if there had been a cushion for her chair. She stated she had a blanket, but not a cushion.

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and ensure interventions were in place to aid in the prevention of falls for one (#1) of four sampled residents with falls. This resulted in actual harm for resident #1 who required a transfer to the emergency room for treatment of [REDACTED]. The facility identified all 58 residents who resided in the facility were at risk for falls. Findings: A policy, titled Falls-Evaluation and Prevention, documented, "...Policy It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. Definition: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions... Procedure Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed... Following A Fall, The Following Steps Should Be UnderTaken Review the plan of care and update the interventions as appropriate..." Resident #1 was admitted with [DIAGNOSES REDACTED]. A careplan documented: "...Problem Start Date: 12/25/2013 Category: Cognitive Loss/Dementia Resident has impaired decision making R/T cognitive loss dementia Goal... Resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed. Approach... Give objective feedback when inappropriate decisions are made. Discuss future options to improve decision making skills..." A careplan documented: "Problem Problem Start Date: 12/26/2013 Category: Falls Resident at risk for falling R/T macular degeneration, (resident name deleted) will attempt to stand and transfer herself without calling for assist, will not use call light. Goal Resident will remain free from injury. Approach... Approach Start Date: 12/26/13 Give resident verbal reminders not to ambulate/transfer without assistance... Keep bed in lowest position with brakes locked... Provide frequent toileting assistance... Provide resident an environment free of clutter." A significant change assessment, dated 06/06/14 documented the resident was moderately impaired with cognitive skills for daily decision making. She was independent with transfers and ambulation. A walker and wheelchair was used for mobility. An incident/accident report, dated 08/31/14 at 4:00 a.m., documented the resident was found on the floor in her room by the nurse. There was a small raised area to the lateral posterior area of her head. The report documented at 6:15 a.m., there was a bruise to the top of her right great toe, and at 7:30 a.m., there was discoloration to the resident's right eye. For additional comments and/or steps taken to prevent recurrence, the facility documented, "encourage Resi to use call light - body alarm on + intact." A fall investigation form, documented the resident had a previous history of falls. The external risk factors were antidepressant and cardiovascular medications. The times these medications were last given was not documented. For Appliances and devices, a body alarm was documented. Other contributing factors was a history of falls. A nurse's note, dated 08/31/14 at 4:29 a.m., documented, "...0400 (4:00 a.m.) this nurse enter rm... found resi on floor, resi stated, "I hit the back of my head..." An update to the care plan, dated 08/31/14, documented, "...Will continue with body alarm and frequent checks..." A final X-Ray report, dated 08/31/14 at 6:47 p.m., documented "...Patient (Name Deleted)... Exam Reason: Fall Exam Type: Portable Foot RT Findings:...There is an acute fracture is seen of the proximal phalanx of the first toe... Impression: Acute fracture deformity of the proximal phalanx of the first toe..." A nurse's note, dated 08/31/14 at 9:49 p.m., documented, "...C/o increasing pain in right foot and stated its radiating up. Increased swelling and discoloration noted. Ice and elevation applied. Xray ordered for right foot...Results show fx of great toe..." An update to the care plan, dated 09/01/14, documented, "...will use low bed with mat and bed alarm..." An incident/accident report, dated 09/03/14 at 12:20 a.m., documented the resident was found in her room on her mat beside the low bed. An abrasion was documented to her right knee. The resident stated, "I went to bathroom using bedside commode." For additional comments and/or steps taken to prevent recurrence, the facility documented, "frequent (checks) on Resident encourage resident to use call light." The fall investigation form, dated 09/03/14, documented the resident had a history of [REDACTED]. The external risk factors documented were antidepressant medication. The time this medication was last given was not documented. For risk factors, poor skin turgor was documented. A nurse's note, dated 09/03/04 at 0:43, documented, "...0020 (12:20 a.m.) this nurse call to rm... CNA enter rm found resi setting on mat beside bed low bed, resi stated, "I went to bathroom using bedside commode...noted 2 cm abrasion to right knee...assist back to low bed x's 2 assist..." An update to the care plan, dated 09/03/14, documented, "...Resident will be checked frequently by staff, also encouraged to use call light..." An incident/accident report, dated 09/03/14 at 8:30 p.m., documented the nurse entered the resident's room to administer her medications and observed the resident lying on the floor on her left side by the vanity. For additional comments and/or steps taken to prevent recurrence, the facility documented, "Bed alarm in place + in proper working order resident had removed alarm." A fall investigation form, dated 09/03/14, documented the internal risk factors were a decline in function, unsteady gait, impaired vision and joint pain. Appliances and devices were documented as a walker. Other contributing factors documented the fall occurred while the resident was unattended. An update to the care plan, dated 09/03/14, documented, "...Bed alarm in place and in proper working order..." A nurse's note, dated 09/04/14 at 3:47 p.m., documented, "...9/3/14 2030 (8:30 p.m.)- When this nurse entered room to administer HS medications, observed resident on laying on floor. Resident positioned on L side, in front of vanity closet on west side of room...Reddened area noted to R lateral side under breast. Stated it was sore but couldn't remember hitting it..." An update to the care plan, dated 09/04/14, documented, "...will continue with current plan of care..." A quarterly assessment, dated 09/06/14, documented the resident was moderately impaired with cognitive skills for daily decision making. She was independent with transfers, and she required supervision with ambulation, dressing, toilet use and bathing. She was occasionally incontinent of urine and always continent of bowel. An incident/accident report, dated 09/13/14 at 9:48 a.m., documented the resident attempted to transfer herself from the bedside commode when she lost her balance and landed on her buttocks. For additional comments and/or steps taken to prevent recurrence, the facility documented, "Continue use of safety mat + bed alarm. Encourage staff to continue frequent checks + toileting prn." The fall investigation form, dated 09/13/14 documented an at risk plan was in place, there was a previous history of falls, multiple occurrences and a fall from rising, transferring and walking. The internal risk factors were documented as a decline in function and impaired cognition. Appliances and devices were documented as a bed alarm and walker. Other contributing factors were documented as a history of falls and the fall occurred while the resident was unattended. Risk factors were documented as poor vision. A nurse's note, dated 09/13/14 at 4:09 p.m., documented "...CNA AM notified this nurse that resident attempted to transfer self from bedside commode to bed and lost her balance and fell on to buttocks onto safety mat next to bed..." An update to the care plan, dated 09/13/14, documented, "...will continue with safety mat bed alarm low bed frequent checks and toileting..." An incident/accident report, dated 10/07/14 at 4:45 p.m., documented, "Observed on floor by the AM DON. Resident stated she tried to go to the bed + her feet got tangled up + she fell . Hit head on chair..." For additional comments and/or steps taken to prevent recurrence, the facility documented, "Placed call buttons on chair + bed, ensured call lights are working + personal alarm working. Encourage resident to use call lights." A fall investigation form, dated 10/07/14 documented an at risk fall plan was in place, the resident had a previous history of falls and the fall occurred from rising, transferring and walking. The internal risk factors were a decline in function and an unsteady gait. The external risk factors were antianxiety medication, cardiovascular medication and hypnotic medication. The times these medications were last given was not documented. Appliances and devices were documented as a chair alarm and a walker. Other contributing factors were history of falls, multiple occurrences and the fall occurred while the resident was unattended. A nurse's note, dated 10/07/14 at 8:48 p.m., documented "...Resident observed on floor by AM, DON at 1645 (4:45 p.m.). Chair alarm was sounding. Resident stated that she was trying to go to bed and her feet got tangled up and she fell hitting her head on the chair in her room...Hospice nurse came to facility and assessed resident. Stated ear felt different where she hit it. Ear is warm to touch and red..." An update to the care plan, dated 10/07/14, documented, "...(resident name deleted) was reminded to ask for assistance..." An incident/accident report, dated 10/26/14 at 8:30 p.m., documented the resident attempted to stand up from her bed and lost her balance. She landed in her bed and was complaining of discomfort to her left upper rib area. For additional comments and/or steps taken to prevent recurrence, the facility documented, "...Call light in reach - bed alarm intact." A nurse's note, dated 10/26/14 at 9:49 p.m., documented "...(7a-11p) resident at 2030 (8:30 p.m.), attempted to stand up from her bed; lost balance/landing in her bed; c/o left upper rib pain;...notified dr. (name deleted) -ordered prn ice pack to area, and continue pain med regimen..." There was no documentation of a fall investigation form. An update to the care plan, dated 10/26/14, documented, "...bed alarm replaced and in working order..." An incident/accident report, dated 11/16/14 at 8:45 p.m., documented a CNA was doing rounds on hall 400 when she observed the resident on the floor in her room near the bathroom. The report documented the location of injury was the right shoulder, but did not document what the injury was. The report documented the resident was sent to the hospital at 9:00 p.m. For additional comments and/or steps taken to prevent recurrence, the faciltiy documented, "reinforced using call light pt. refuses to keep bed alarm in bed will unhook, take it off and turn off alarm." A nurse's note, dated 11/16/14 at 10:26 p.m., documented "...employee was doing rounds on 400 hall, when observed resident on the floor near bathroom. employee yelled for help... I observed resident on floor, resident conscious but was having pain on Right shoulder...had employee stay with resident while I called ambulance for transfer to (hospital name deleted)..." There was no documentation of a fall investigation form. Updates to the care plan, dated 11/16/14, documented, "...(Resident) had removed her body alarm and had gotten herself up off low bed and attempted to toilet herself. (Resident) is independent and refuses to use call light and is able to turn off body alarm. she was told that she should use her call light she acknowledge that she should have but to late now. Asked (resident's family member) if we could move her closer to the nurses station she denied request we also asked if to have Dr. maybe review pain medication for reduction (family member) states she needs her medication and no we are not doing that continue with current plan of care..." The resident sustained [REDACTED]. A nurses note, dated 11/17/14 at 1:54 a.m., documented "...0130 resi returned from (hospital name deleted) by ambulance with daughter at bedside. V.S. and assessment completed. New orders rec'd to ...2. wear sling/swath at all times. 3. place on Fall risk precaution..." On 12/16/14 at 8:15 a.m., the resident was observed sitting up in her recliner eating breakfast. She had a sling on her right arm. The resident was asked how she hurt her arm. She stated she fell . At 12:20 p.m., the resident was observed eating her lunch in the dining room. She had a sling on her right arm. At 12:45 p.m., an interview was conducted with the Administrator. She was shown the incident/accident reports for resident #1. She was asked if new interventions should have been implemented to help prevent fall recurrence and injuries. She stated, "Yes."

Based on observation, record review and interviews, it was determined the facility failed to have an effective Quality Assurance (QA) program which identified and implemented corrective actions to areas of deficient practices cited and prevented the reoccurrence of the deficient practice. This resulted in an actual harm. The facility census was 54. Findings: The facility failed to identify and implement corrective actions for falls prevention. This resulted in an actual harm to residents #11 and #15. Refer to F-323. On 12/04/13 at 1:35 p.m., the administrator was asked what types of quality problems had been identified by the QA program. She stated they had identified wounds, labs, dietary and bed linens. She was asked how the QA committee relayed information to the staff. She stated during in-services. On 12/04/13 from 1:55 p.m. through 2:00 p.m., two staff members were asked what they knew about the QA committee. They stated they did not know anything about the QA committee.

Based on observation, record review and interview, it was determined the facility failed to provide adequate supervision and interventions to prevent falls for two (#11 and #15) of seven sampled residents reviewed for falls with injuries. This resulted in an actual harm. Resident #11 experienced multiple head injuries with lacerations that required stitches and staples, hematomas, and bruising. This had the potential to affect all 54 residents who resided in the facility. Findings: A facility policy, titled 'Fall Prevention Policy', documented, "...identify residents at risk for falls and to implement a fall prevention approach to reduce the risk of falls and possible injury...Every resident will be evaluated for falls upon admission, quarterly, annually, sig change & post fall and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls..." 1. Resident #11 had [DIAGNOSES REDACTED]. A care plan, dated 11/07/12, documented, "...Problem: ...Category: Falls: (name deleted) has history of falling R/T to refusal to use call light for assistance. Goal: (name deleted) will remain free from injury when she uses call light for assistance... Approach: Analyze (name deleted) falls to determine pattern/trend...Keep call light in reach at all times... Teach (name deleted) safety measures such using call light for assistance especially at night when most of her falls occur..." The care plan was not updated after 11/07/12. There were no nurses notes in the clinical record or provided for the months of February 2013, through May 2013. An incident report, dated 02/16/13 at 12:15 a.m., documented, "... Resident pushed call light. Upon aide entering room found sitting on floor. Small laceration to head on R upper skull. Dried blood present cleansed wound, applied antibiotic ointment helped back to bed..." There was no documentation in the clinical record that neuro checks were initiated. There was no documentation the facility implemented additional interventions to aid in the prevention of recurrence of falls with injuries. The fall was not updated on the care plan. An incident report, dated 02/25/13 at 11:30 p.m., documented, "...This nurse enter (room number deleted) found Resident on floor (beside her bed on floor notified nurse resident was lying in floor). Resi had sm ST 0.5 cm above R eye - et 0.2 cm st to top of L hand...additional comments or steps to prevent recurrence: Instructed resi to use call light @ noc for assist, call light @ bedside c in reach ..." There was no documentation neuro checks were initiated. The fall was not updated on the care plan. There were no additional comments and/or steps taken to prevent recurrence of falls. A fall risk assessment, dated 05/22/13, documented a score of 11, which indicated the resident was at high risk for falls. An incident report, dated 06/18/13 at 12:30 a.m., documented, "... CNA bed (check mark) enter (room number deleted) et found Resi on floor beside bed-noted hematoma c sly abrasion to L FA, bruise to R wrist...additional comments or steps to prevent recurrence: encourage resi to use call light @ noc to get up to Bath Rm. et CNA to Bed (check mark) q 2 (hours) ..." There was no documentation in the nurse's notes related to the fall. The fall and interventions were not updated on the care plan. There was no documentation in the clinical record for this fall regarding bed checks every two hours. There was no documentation the facility implemented additional interventions to aid in the prevention of recurrence of falls with injuries. An incident report, dated 06/23/13, at 11:00 p.m., documented, "...OOB s assist to find glasses resulting unwitnessed fall. States "I slipped off the side of my bed." Eye glasses were on her person @ time of incident. Denies injury during incident...additional comments or steps to prevent recurrence: Personal body alarm, padding on floor beside bed. Call light use reenforced (sic). Personal items W/R (within reach). Offered toileting. Request dose reduction of ambien..." A nurse's note, dated 06/23/13, at 11:00 p.m., documented, "...call light answered to discover (name deleted) sitting up on the floor beside her bed. States "I slipped off the side of my bed." (name deleted) was looking for her eyeglasses which were on her person @ time of incident. 0 injury noted or reported. Denied need for toileting. Personal alarm activated c floor pad placed next to her bed. Call light W/R & (name deleted) instructed to use for OOB activity..." A nurse's note, dated 06/24/13, 7-3, documented, "...Continues c abrasion to L side forehead & bruising refuses to have mat beside bed..." A nurse's note, dated 06/24/13, 3-11, documented, "... C/O pain in her R Shoulder 0 bruising to L side of forehead comfort measures taken..." The fall and interventions were not updated on the care plan. An incident report, dated 08/05/13 at 11:00 p.m., documented, "...this Nurse enter (room number deleted) found Resi sitting on floor beside bed Resi stated, she was sitting in w/c & lean over et fell forward et hit the top of head on bed 0 abrasion very sm hematoma...additional comments or steps to prevent recurrence: Instructed Resi to used call light @ noc for assist - (arrow up and down) et use w/c for transfer..." A nurses note, dated 08/05/13 at 11:30 p.m., documented, "...This nurse enter (room number deleted) - was found sitting on floor beside her bed. Resi stated, "I was in my w/c et lean over et fell forward et hit the top of head on bed. 0 abrasion very sm hematoma..." There was no documentation the facility implemented additional interventions to aid in the prevention of recurrence of falls with injuries. An annual assessment, dated 08/10/13, documented the resident was cognitively intact. The resident was independent with bed mobility, transfers, ambulation in her room, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. The assessment documented activity with ambulation in the corridor and bathing did not occur during this look back period. The assessment documented the resident's balance during transitions and walking, moving from seated to standing position and turning around was not steady, but she was able to stabilize herself without staff assistance. The assessment documented the resident was steady at all times with moving on and off the toilet and with surface to surface transfers. She required a walker and a wheelchair for mobility. The assessment documented the resident had falls since admission. She had two or more falls with no injury and two or more falls with injury and was able to stabilize herself without staff assistance while walking and turning around. The resident had no documented falls on the care plan. An incident report, dated 08/25/13 at 11:00 p.m., documented, "...Res attemp (sic) to transfer self from w/c to bed- fell to floor-this nurse enter (room number deleted) Resi was sitting on floor beside Bed- 0 injury...additional comments or steps to prevent recurrence: 2 CNA transfer Resi to bed s diff- this nurse instructed Resi to use call light @ bedside for transfer..." A nurse's note, dated 08/25/13 at 11:00 p.m., documented, "...Resi attemp to transfer self from w/c to bed. This nurse enter (room number deleted) et found Resi sitting on floor beside her bed- sly confused..." There was no documentation the facility implemented additional interventions to aid in the prevention of recurrence of falls with injuries. The fall and interventions were not updated on the care plan. An incident report, dated 09/13/13, at 12:45 a.m., documented, "...Resi attemp (sic) to transfer self from wc to Bed et fell et hit head (R forehead) c 6" half moon shape Laceration c lg amt of Blood..." A nurse's note, dated 09/13/13, at 12:45 a.m., documented, "... This nurse was call to (room number deleted) et found Resi on floor in middle of Rm - noted lg laceration to R forehead...this nurse notify (hospital name deleted) ER...Ice pack to forehead- (name deleted) Ambulance here @ facility..." A hospital report, dated 09/13/13, at 4:05 a.m., documented, "...History: Neck pain following trauma. [AGE] year-old female status [REDACTED]. A hospital report, dated 09/13/13, at 4:59 a.m., documented, "...Indication: [AGE] year-old status [REDACTED]." A nurse's note, dated 09/13/13, at 5:15 a.m., documented, "...Resi return c N.O. for ABTX & wound care all orders carried out- Resi has 8 staples c multi stitches in between staples..." There was no documentation the facility assessed the resident's falls and implemented interventions to aid in the prevention of the recurrence of falls with injury. The fall and interventions were not updated on the care plan. An incident report, dated 09/29/13, at 9:30 p.m., documented, "...resident was found on floor by CNA c laceration to R forehead, pressure was applied, sent to (hospital name deleted) for further eval via ambulance. Resident attempted to bend over in w/c lost balance & hit head on bed frame..." A nurse's note, dated 09/29/13 at 10:00 p.m., documented, "...resident observed in room by CNA c open wound on forehead, sitting on floor next to bed. This nurse was notified & upon entering room resident was sitting on floor. R side of forehead was open c blood, skin was pushed down leaving open wound, when asked what happened resident said she was attempting to pick something up off floor while seated in w/c, lost balance and hit head on corner of bed frame, pt was sent via ambulance to (hospital name deleted) for further evaluation..." A discharge instruction summary, dated 09/29/13 at 11:10 p.m., documented, "...Head Injury, Adult: You have had a head injury... Laceration Care, Adult: A laceration is cut or lesion that goes through all layers of the skin and into the tissue just beneath the skin...Your caregiver will use stitches (sutures) staples, wound glue (adhesive), or skin adhesive strips to repair the laceration...However, all wounds will heal with a scar... Diag: Head injury...Laceration..." A nurse's note, dated 09/30/13 at 12:00 a.m., documented, "...res returned to facility via ambulance c assist of EMT x 2. Alert & oriented Bandage in place to right forehead. denies pain. Neuro checks initiated & are WNL. 0 acute distress..." A nurse's note, dated 09/30/13 at 9:30 p.m., documented, "...client (arrow up) propels self ad lib in w/c throughout facility interacts well c peers. denies pain or discomfort. Sutures intact to forehead sl. swelling noted. sl. Bruising noted...." There was no documentation the facility assessed the resident's falls and implemented interventions to aid in the prevention of the recurrence of falls with injury. The fall and interventions were not updated on the care plan. An incident report dated, 11/05/13 at 9:30 a.m., documented, "... Pt slid from w/c 0 injuries...additional comments or steps to prevent recurrence: monitor pt (check mark) Q2 (hours)..." There was no documentation in the nurse's notes related to the fall. There was no documentation the facility assessed the resident's falls and implemented interventions to aid in the prevention of the recurrence of falls with injury. An incident report dated, 11/06/13 at 11:10 a.m., documented, "...Resident on floor in hallway of room. Stated she was in the bathroom & slipped. Then slid herself to room door denies (arrow up) pain. Encouraged resident to ask for help when using BR..." There was no documentation in the nurse's notes related to the fall. There was no documentation the facility assessed the resident's falls and implemented interventions to aid in the prevention of the recurrence of falls with injury. A quarterly assessment, dated 11/07/13, documented the resident's cognitive skills for daily decision making were moderately impaired. The resident was independent with bed mobility, transfers, ambulation in her room, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Activity with ambulation in her room, in the corridor and bathing did not occur during this look back period. The assessment documented the resident's balance during transitions and walking, moving from seated to standing position, turning around, moving on and off the toilet and surface to surface transfers was not steady, but the resident was able to stabilize herself without staff assistance. She required a wheelchair for mobility. The assessment documented the resident had falls since admission. She had two or more falls with no injury and two or more falls with injury and was able to stabilize herself without staff assistance while walking and turning around. On 12/03/13 at 2:20 p.m., the resident was observed to have a half moon scar above her right eye. The resident was asked how she got the scar above her right eye. She stated she fell in her room and hit her head. On 12/04/13 at 10:45 a.m., the DON was asked if additional interventions were implemented to help prevent injuries related to the resident's falls. She stated, "No." She was asked if there was any documentation the resident was monitored every two hours to help prevent falls. The DON stated there was no documentation the resident was monitored every two hours. 2. Resident #15 was admitted on [DATE], for skilled services related to a left femur fracture and surgical repair. An incident report, dated 08/06/13 at 4:30 p.m., documented, "...resident was discovered on floor by CNA laying on L side. Rolled supine. c/o pain upon mvmt (movement) of L leg (X-ray) ordered...Additional comments and/or steps taken to prevent recurrence: ...re-educate pt on call light use and instructed pt on calling for help when needed..." There was a head injury indicated on the physical diagram of the incident report. An incident report dated 08/07/13 at 10:30 a.m., documented, "...pt was found on floor. fell out of w/c. 0 apparent injuries States he was transferring to bed...Additional comments and/or steps taken to prevent recurrence: if patient is in wc make sure alarm is on and have him @ nurses station. Low bed to be placed in room." An incident report, dated 08/07/13 at 7:45 p.m., documented, "...Res on floor in front of w/c..." No interventions were documented in the resident's clinical record. An incident report, dated 08/08/13 at 8:00 a.m., documented, "...upon observation resident on knees leaning against low bed on floor mat, resident states he didn't know what happened or how he got there, 0 apparent injuries, denies hitting head... Additional comments and/or steps taken to prevent recurrence: resident remains on low bed for fall precautions encouraged to ask for help.." No new interventions were documented in the resident's clinical record An incident report, dated 08/15/13 at 10:45 a.m., documented, "...Pt (up) unassisted became off balanced when transferring self from w/c to high back chair in tv (television) area fall 0 injuries... Additional comments and/or steps taken to prevent recurrence: Reminded resident to ask for assistance." No new interventions were documented in the resident's clinical record. An incident report, dated 08/16/13 at 7:00 p.m., documented, "...Resident fell out of w/c onto floor in dining room, hitting head on floor. Neuros initiated..." There was an injury to the head indicated on the physical diagram. No new interventions were documented in the resident's clinical record. The admission resident assessment, dated 08/19/13, documented the resident was severely impaired in cognitive skills for daily decision making. He was rarely/never understood by others and rarely/never understands others. He required extensive assistance of one person for transfers, bed mobility and toileting. Walking in the room or in the corridor did not occur during the assessment period. He required extensive assistance of one person with locomotion on and off the unit. He had functional limitation in range of motion of his lower extremity with impairment of both sides. He used a wheelchair for mobility and was occasionally incontinent of bowel and bladder. He had an active [DIAGNOSES REDACTED]. The fall history documented he had fallen in the last month and within the last two to six months with a fracture. The CAAS documented falls as a triggered care area and the need for care planning. The care plan, dated 08/19/13, documented, "Problem: (resident name deleted) has history of falls R/T cognition. Goal: (resident name deleted) will remain free of injury. Approaches:...Give (resident name deleted) verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times... Problem: Falls - I am at risk for falls R/T falls and D/T HX of falls at home and here (facility) several times. Goal: I will have no further injuries from falls. Approaches:...Nsg will encourage use of call light at all times. Nsg will ensure instructions on using call light are understood..." There had been no updates to the care plan since 08/19/13. An incident report, dated 08/31/13 at 8:30 p.m., documented, "...Resident discovered to be on floor of room. 0 injuries apparent. Stated nothing hurts MAE s complaint. Resident not to be in room s alarm intact." No new interventions were documented in the resident's clinical record. An incident report, dated 09/01/13 at 6:00 p.m., documented, "Pt rolled off low bed to mat was on knees wiping pee up c blankets when staff entered room... No injury documented. Additional comments and/or steps taken to prevent recurrence: continue to remind pt to get assist c transfers..." No new interventions were documented in the resident's clinical record. An incident report, dated 09/04/13 at 7:20 a.m., documented, "...was called to clients room upon entry observed client on his knees on the floor pad/mattress leaning (arrow up) (illegible) on bed. When asked what he was doing he stated, 'my bed was wet was trying to get out of here.' Head to toe completed 0 new red areas, bruising, swelling or injuries noted..." No new interventions were documented in the resident's clinical record. An incident report, dated 09/07/13 at 6:30 a.m., documented, "...pt was walking to BR s assistance & lost balance landing on R side & L elbow hitting wall." No injuries were documented on the incident report. No new interventions were documented in the resident's clinical record. An incident report, dated 09/07/13 at 9:00 p.m., documented, "...Pt was attempting self transfer from w/c to bed when he became unbalanced & landed on floor, denies hitting head. 0 injuries apparent... Additional comments and/or steps taken to prevent recurrence: Pt was reminded to ask for assistance when transferring..." No new interventions were documented in the resident's clinical record. An incident report, dated 09/08/13 at 3:30 p.m., documented, "...Pt observed on floor in room. pt attempted self transfer from w/c to bed, became unbalanced & fell to floor, denies hitting head, 0 apparent injuries... Additional comments and/or steps to prevent recurrence: pt was reminded to call for help when transferring..." No new interventions were documented in the resident's clinical record. An incident report, dated 09/22/13 at 7:00 p.m., documented, "...resident on floor in solarium stated he was fixing to tack the carpet Small abrasion to top of head..." No new interventions were documented in the resident's clinical record. An incident report, dated 09/23/13 at 4:30 p.m., documented, "...client was sitting in w/c in tv room went to transfer himself from w/c to regular chair lost balance and slid to floor. Stated 'I just slid down.' 0 injuries noted Head to toe completed..." No new interventions were documented in the resident's clinical record. An incident report, dated 10/05/13 at 8:45 p.m., documented, "...resident attempted to get out of w/c (illegible) slid to floor. Denies hitting head..." No new interventions were documented in the resident's clinical record. An incident report, dated 10/08/13 at 2:25 p.m., documented, "...(arrow up) from w/c unassisted landed in floor laying on back denies hitting head middle back pain resolved p making pt comfortable in recliner... Additional comments and/or steps to prevent recurrence: do not leave pt unsupervised d/t fall risk. Make sure pull alarm is (illegible)..." No new interventions were documented in the resident's clinical record. An incident report, dated 10/29/13 at 3:15 a.m., documented, "...Client observed lying supine on floor. Head to toe completed assisted x's 2 staff members to bed. denies pain denies hitting head. 0 redness, swelling or open areas noted... Additional comments and/or steps taken to prevent recurrence: call light in reach, pull alarm on. Explained needs assist to get out of bed q 15 min visual (check mark) by staff..." No new interventions were documented in the resident's clinical record. An incident report, dated 11/02/13 at 2:00 p.m., documented, "...Pt was (arrow up) from w/c unassisted c body alarm activated became entangled in w/c stumbled resulting in pt landing on R elbow... Abrasion to the R elbow..." No new interventions were documented in the resident's clinical record. An incident report, dated 11/03/13 at 1:30 p.m., documented, '' pt (arrow up) unassisted activated body alarm landing in floor 0 injuries..." No new interventions were documented in the resident's clinical record. An incident report, dated 11/07/13 at 2:40 a.m., documented, "...Resident attempt to go to BR by self (illegible) slid off bed onto floor. 0 injuries noted. remind (illegible) resident to get assistance when using BR..." No new interventions were documented in the resident's clinical record. On 12/04/13 at 8:00 a.m., the DON was asked if staff should change interventions based on falls, if the previous interventions were not effective. She stated, "Yes." The DON was asked if staff notified her when incidents/falls occurred. She stated, "Not always." She was shown the incident reports with no interventions. She stated, "I don't know what else to do."

An Immediate Jeopardy situation was determined to exist based on the facility failure to recognize, report, and intervene in order to prevent resident to resident mistreatment. Based on interview and record review, it was determined the facility neglected to: Supervise one resident (#4) to prevent inappropriate sexual conduct, and Prevent verbal and physicial mistreatment by one resident (#31) by failing to notify the resident's physician of increasing verbal and physical aggression against other residents. The facility identified 8 cognitively impaired residents with behaviors. Residents #5, #12, #43, and #50 expressed either fear or verbalized incidents of inappropriate sexual contact or aggressive physicial behaviors by residents #4 and #31. The failure to recognize and report the incidents prevented protection for the residents. This had the potential to affect all 51 residents who resided at the facility. Findings: An undated facility policy titled, "Misappropriation of Property, Abuse, Neglect Investigation and Prevention Policy and Procedure," documented: "...INTENT & GUIDELINES This facility will develop and operational (sic) policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences... PROCEDURE...It is the responsibility of all employees of this facility and affiliated agencies to notify the Administrator, Director of Nursing or their immediate supervisor immediately if they observed or become aware of an incident of resident abuse and/or neglect, whether alleged, suspected or observed. ...It is the Administrator and/or Director of Nursing (sic) to ensure that immediately upon learning of the alleged allegation an initial (investigation) will began (sic) to established (sic) if allegation has probable cause for a thorough investigation... The initial investigation will be completed in 6 hours at the time reported to the Administrator and or Director of Nursing... If there is probable cause to continue (...) the alleged allegation (sic) all agencies and state agencies will be notified within 24 hours of the initial investigation, and a complete follow up in the next 5 working days... If after the initial investigation and there is no evidence to warrant further investigation, the incident will be documented either in residents nurse notes and or written up and filed in the Director of Nursing office. No State and or other agencies will be notified... Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness... ALSO NOTE IF THE ALLEDGED (sic) IS DUE TO A FALSE ALLEGATION THE INCIDENT WOULD NOT BE REPORTED TO THE AGENCIES BUT HANDLED IN FACILITY WITH PROPER DOCUMENTATION AND THE INVESITAGTION (sic) WOULD CEASE..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A behavior monitoring flowsheet, dated 03-15-11 through 03-31-11, documented, "...making sexual remarks to female staff..." It was documented the resident exhibited the behavior once on the first shift on 03-15-11. A nurse's note for resident #4, dated 05-17-11 at 2:50 p.m., documented, "...Was reported resident in female resident's rm beside her bed in which she was lying in (and) he pulled the covers off her exposing her in her depends (disposable brief). Res taken out of rm (and) instructed not to go into others rms. Res stated he has known her for yrs (and) he was just talking to her. Instr. him it would be better for all concern (sic) to talk c female residents when they are not in their rms..." An undated care plan update documented, "...wanders into others room (sic) @ x's..." The goal was, "...I will refrain from wandering into others rooms. Nsg will monitor..." The intervention was, "...staff will redirect when found in others rooms, educate on reasons of inappr (secondary to) privacy..." A social service progress note, dated 07-05-11, documented, "...Was reported to SSD by nurse that over the weekend (resident) had become verbally (and) physically abusive to another male resident. (Resident) swore other male resident was one of five men who had attacked a woman. Nursing staff had trouble re-directing him..." A physician's progress note, dated 07-28-11, documented, "...Now is having behavior issues with some inappropriate touching..." A quarterly assessment, dated 08-28-11, documented the resident was moderately impaired in cognitive skills and exhibited no behaviors except wandering. It was documented the resident required supervision only for locomotion on the unit and used a wheelchair. Active [DIAGNOSES REDACTED]. A care plan update, dated 08-29-11, documented, "...I have actual deficits in short term mem (and) decision making difficulty at times...dx Alzheimers..." The goal was, "...I will be oriented to person, place, surroundings, circumstance in a safe environment...8/29/11 - cont c some deficit did pretty good c interview told birthdate..." Interventions included, "...staff will assess cognitive ability..." A nurse's note, dated 08-31-11 at 12:00 p.m., documented, "...Noted fondaling (sic) another female's breast - staff removes female from situation, res informed it was not acceptable behavior..." A behavior monitoring flowsheet, dated 08-2011, documented, "...makes sexual remarks to female staff/res...Asking female resident to go to bed c him..." It was documented the resident exhibited the behavior twice on 08-31-11, and the staff provided one on one monitoring, redirection, and distractions as interventions. A nurse's note, dated 09-09-11 at 9:00 p.m., documented, "...(One) behaviors (sic) noted c females..." A nurse's note, dated 09-09-11 as a late entry, documented, "...Resident had been about facility in w/c, as he does every day. He was down 200 hall and stopped to talk to female resident. He then wheeled down hall and she came back this way. No one saw anything. Touching, hitting, grabbing or anything..." An undated care plan update documented, "...I had an episode of inappropriate sexual behavior (grabbed another res buttock/crotch area)..." The goal was, "...I will refrain from any/all other inappropriate behavior by next review..." Interventions were, "...Staff will monitor whereabouts frequently, instruct/educate (resident #4) in actions of inappropriateness and need to refrain, staff to remove from episode if it occurs again, alert adm/(charge nurse)/DON of occurrence, notify MD of continuance (and) suggest gero (sic) psych if needed..." Review of the clinical record revealed no documentation to show the staff had implemented a plan to monitor the resident's whereabouts. A social service progress note, dated 09-09-11, documented, "...It was reported to SSD by charge nurse that (resident) has been having inappropriate behaviors in a sexual manner. Last evening he grabbed a female resident in the crotch, the female resident is extremely upset. Charge nurse is notifying doctor (and) his family..." A physician's progress note, dated 09-10-11, documented, "...pt with dementia...staff c/o of inappropriate behavior, but not all staff agree with this problem at this time, pt went to (geriatric psych) previously for similar problems..." A nurse's note, dated 09-13-11, on the evening shift, documented, "...(No) attempts to leave. Does follow female resident about. Thinks she is his girlfriend (and) she thinks he is her husband..." A nurse's note, dated 09-23-11 and untimed, documented, "...Resident argumentive (sic) this shift, arguing about his room, trying to go in someone else's room that belongs to two ladies. He states that is his room too..." A physician's progress note, dated 10-06-11, documented, "...pt with dementia...staff has no c/o of inappropriate behavior at this time...Dementia and hallucinations..." A nurse's note, dated 10-15-11 at 2:00 p.m., documented, "...Wanders in (and) out of others (sic) rm. Redirected TNTC times..." A nurse's note, dated 10-16-11 at 1:30 a.m., documented, "...Aide was doing rounds when she notified nurse that pt had...skin tear...(right) hand...Pt stated he got mad @ tv (and) punched it. TV was found on floor c blood on it. Pt was very sweet (and) cooperative c staff..." A nursing monthly summary, dated 10-17-11, documented the resident exhibited physical and verbal behavioral symptoms directed toward others, wandered, and suffered from [MEDICAL CONDITION]. The form documented, "...Is confused...gets sundowners...@ times gets verbally abusive (and) threatens other male residents..." On 10-31-11 at 5:00 p.m., resident #50, an alert and oriented resident stated she was afraid of another resident. Resident #4 had told her he liked her. She stated resident #4 had come into her room in the evening and it scared her. She stated she told him to get out of her room and he did. The resident was asked when this had happened and she stated one day last week, while her husband was in the hospital, and she was in her room by herself. She was asked if she had told anyone. She stated, "No I didn't." She stated that was why she kept her cane close. On 10-31-11 at 5:00 p.m., the room for resident #4 was observed to be 315 A. On 11-01-11 at 10:49 a.m., an interview was conducted with resident #5, who resided in room [ROOM NUMBER] B. Resident #5 was alert and oriented. Upon entry to the resident's room, a chain lock was noted on the resident's door and a sign that documented "Close" was observed on the outside of the door. Resident #5 was the roommate of resident #12. Resident #5 was asked if she ever felt afraid because of the way she or some other resident was treated. She stated, "Yes." Resident #5 was asked who she was afraid of and why. She stated, "It was one night I was tired of being cooped up in here. I was looking at pictures up front and someone reached between my legs from behind and grasped me and just crushed it (genital area). It was this man up here (resident #4). I turned around and said you (expletive) I'll hit you. (Employee #1) said you can't touch that man or talk that way." The resident was asked if she told anyone what had happened. She stated, "Yes, (LPN #1) the head nurse that night. She acted like it was nothing. (Roommate Resident #12)'s (family member) went to the desk and didn't leave. After that, a man from the other nursing home came and put a lock on the door. After that he (resident #4) came by three times. One day I was coming out of bathroom and there he was (in the resident's room). He asked if he could help me. He hasn't bothered me in about 3 weeks. Now he's on my hall. He was next door (his assigned room), they moved him. I don't know where and (but) now he is back on the hall. The nurses say they've talked to him but it hasn't done any good." On 11-01-11 at 10:55 a.m., resident #12, an alert and oriented resident, was asked if she was afraid of any resident. She stated, "Yes. I woke up and (resident #4) was at the foot of my bed and it scared me." Resident #12 was asked if resident #4 had touched her inappropriately or physically abused her. She stated, "No." Resident #12 stated he was the reason they had a lock put on the door. On 11-01-11 at 11:10 a.m., the administrator was asked for incident reports, including incidents reported to the State Health Department and for documentation of all incidents that had been investigated. Review of the incident reports revealed no documentation to show the incident on 08-31-11 had been reported to the administrator or the State Health Department. An investigative report and State reported incident for the incident on 09-09-11 was reviewed. No interventions to prevent future episodes of inappropriate sexual contact were documented. On 11-01-11 at 12:13 p.m., the administrator was asked if she was aware of the incident regarding resident #4 touching an unknown female resident's breast. She stated, "No, not aware of that one." The administrator was asked what the staff did to protect the residents after that incident. She stated, "I don't know. Surely they did something." The administrator was asked if the incident should have been reported to her. She stated, "Yes. It (an incident report) should have been left in my door." The administrator stated the incident could have been reported to her former DON. The administrator was asked who was responsible for investigating allegations of abuse/neglect. She stated, "Me and the DON. I have a box out there to put stuff in but I don't know where the previous DON has put stuff." The administrator was asked if there was a policy on how she should be informed of incidents. She stated, "If urgent they should call me at home." The administrator was asked if the incident should have been reported to the State Health Department. She stated, "It should have been." The administrator was asked if she was aware of the incident on 09-09-11. She stated, "By the time it got back to me it was blown out of proportion." The administrator stated the CNA on duty said she thought resident #4 had bumped resident #5. The administrator was asked what was done to protect the residents after the incident on 09-09-11. She stated, "We put a lock on her (resident #5) door and talked to the family (resident #4's family) and advised them he (resident #4) may have to be sent out to geri psych." The administrator stated the resident's care plan had also been updated. When asked for the documentation to show the staff had implemented the intervention of monitoring the resident's whereabouts that was listed on the care plan update as an intervention, the administrator stated, "I need to get better with that." The administrator was asked what had been done to protect the other female residents in the facility. She stated, "No one had a problem. Just (those) around his room." The administrator was asked if she was aware that resident #50, who lived on the 400 hall which was distant from the room of resident #4, was afraid of resident #4 and that he had gone into that female resident's room during the previous week while her roommate was out of the facility. The administrator stated, "No." The administrator was informed of the nursing note dated 05-17-11 when resident #4 was found in a female resident's room. The female resident was uncovered and her adult brief exposed. She stated, "No, I was not aware of that." The administrator was asked if she was aware resident #4 had entered the room of resident #5 and #12 approximately three weeks earlier and had asked resident #5 if she required assistance as she was exiting the bathroom. She stated, "No." The administrator was asked when resident #4 first began exhibiting unwanted sexual behaviors. She stated, "Well, he had been here about a month and that's kind of when they noticed he was going to women's doors. Thought he was getting lost. That's why he has the sign with his name by his door." The administrator stated, "It's never been reported that he inappropriately touched them." She stated resident #4 would hold the hand of resident #55 and they had even kissed. 2. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 08-22-11, did not address behaviors. A nurse's note, dated 08-24-11, documented, "3-11 (3:00 p.m. to 11:00 p.m. shift) Resident (up) in w/c about facility...to D/R per staff...Resident hollering a (sic) cussing a ( sic) hitting fist on table. Resident quietly ask to stop and be quiet to no avail...Resident down hall way self propelling in w/c., another residet (sic) passed or came up by him and they had altercation, residet (sic) grabbed other residet (sic) by left arm and squeezed & twisted it. Altercation broken up by staff. (Left) arm of other residet (sic) red but no injuries apparet (sic)..." A fax cover sheet, dated 08-24-11, documented, "Dr. (Name deleted) Concern: Resident...got into altercation & twisted another residents arm. no apparent injuries, (left) arm red on other resident..." A nurse's note, dated 08-30-11 at 12:00 a.m., documented, "...Resi (resident) has episodes of hitting cursing..." A nurse's note, dated 08-30-11 at 9:00 a.m., documented, "@ 0910 (9:10 a.m.) res. had words c another male resident both turned and went to their rooms when staff approached..." A psychiatric physician's progress note, dated 08-30-11, documented, "SUBJECTIVE...Staff reports pt much more resistant to care...OBJECTIVE...Mood per:...Staff angry...Affect...angry...Cognition: Judgment...impaired poor impulse control...(Diagnosis)...Alz type dementia c beh. (behavioral) dist. (disturbances)...MDD c [MEDICAL CONDITION]" A telephone order, dated 08-30-11, documented, "...Transfer to (Name deleted psychiatric hospital)..." A hospital discharge plan of care, dated 09-12-11, documented: ~ "...Counselor's Recommendations...Events precipitating admission yelling out, cussing, hitting tables, hitting at staff.", ~ "Discharge [MEDICAL CONDITION] with behavioral disturbance...", and ~ "Target symptom(s) combative, yelling..." A significant change assessment, dated 09-19-11, documented the resident was unable to complete the BIMS interview. The assessment documented the staff assessed the resident as having severely impaired cognitive skills for daily decision making with both long and short term memory problems. The assessment documented the resident showed signs and symptoms of [MEDICAL CONDITION] by exhibiting both inattention and disorganized thinking as continuous behaviors which did not fluctuate. The assessment documented the resident exhibited both physical and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others which had occurred 1 to 3 of the previous 7 days. The assessment documented the presence of the resident's behaviors put the resident and others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. The assessment documented the resident was independent in locomotion on and off the unit with setup assistance only, required limited one person assistance for bed mobility, transfers, dressing, eating, and toilet use, and required extensive one person assistance with ambulation in room and corridor, personal hygiene, and bathing. The assessment documented the resident required a walker or wheelchair for mobility. The assessment documented the resident had taken antipsychotic medication during the 7 days prior to the assessment. A nurse's note, dated 09-21-11, documented, "Resident (up) in w/c about facility. Make (sic) few remarks to different people. Raised hand toward other resident but did not hit..." A psychiatric physician's progress note, dated 09-29-11, documented, "SUBJECTIVE...Staff reports he is now taking meds. still occ (occasionally) curses, (not) physically combative. still occ. hits table...OBJECTIVE...Mood per: Pt: ok Staff better...Cognition: Judgment...impaired poor impulse control...(Diagnosis)[MEDICAL CONDITION] c behav. (behavioral) disturbances...MDD c [MEDICAL CONDITION]" The October 2011 monthly physician's orders [REDACTED]. A nurse's note, dated 10-02-11, documented, "3-11 Resident @ nurses desk threatening to kill another resident - (female) Instr (instructed) him this wasn't nice & then he started pounding on desk c both fists gritting teeth saying 'I'm going to kill her! I'm going to kill all of them, they're all crazy!' Again instr not to say stuff like that & she wasn't saying or doing anything to him. Resident in question voiced her fear of him as she was trying to back away from him in case he did try to harm her. Res taken to his rm (room) hitting @ staff & cussing. Female resident reassured (no) harm would come to her. This all occurred around 1940 (7:40 p.m.)..." A nurse's note, dated 10-04-11, documented, "3-11...cussed another resident & attempted to hit resident but staff intervened before able to connect..." A nurse's note, dated 10-05-11, documented, "3-11...family out to feed him. Another resident rolled over to pt & was counting very loudly & this pt threatened other pt, staff separated pts. Counting pt went over to this pt & proceeded to count loudly again. Separated once more & counseled counting pt..." There was no evidence the physician was notified of the resident's exacerbation and escalation of verbally and physcially aggressive behaviors over this period of three days. A nurse's note, dated 10-21-11 at 2:00 p.m., documented, "...calling other residents (females) '[***] es & whores' ..." A nurse's note dated 10-22-11 at 3:00 p.m., documented, cursing frequently directed toward others sitting @ table-reached out & hit back of females w/c (no) injuries caused counseled resident s further episodes..." A nurse's note, dated 10-23-11, documented, "7-3 cursing a couple x's (times) (no) striking out @ others removed from stimulating situation..." There was no evidence the physician was notified of the resident's exacerbation and escalation of verbally and physcially aggressive behaviors over this period of three days. A nurse's note, dated 10-29-11, documented, "7-3 Res. (up) in w/c cussing @ staff...(up) wandering around facility, comfort measures given..." On 11-01-11 at 11:23 a.m., resident #43, an alert and oriented resident who resided on the 400 hall, was asked if she was afraid of any resident in the facility. She stated resident #31. She was asked what was the problem with resident #31. She stated resident #31 got a little wild at times. She stated the facility had sent resident #31 out of the facility twice and he came back to the facility. She stated both times resident #31 went out of the facility "he was out of his head." She stated resident #31 was a "sex fiend." She stated he liked and wanted to crawl in "your bed." She stated resident #31 comes onto the hall she lives and when he knocks on her room door she tells him to go away. She stated she had a lock on her door. She stated as far as she knew the staff never put him to bed. She stated it was late at night when he tried to come in her room." Resident #43 was asked if she had told anybody about resident #31 trying to come into her room. She stated, "Yes we've told them and told them, and that's why we got the locks on the door." Resident #43 was asked who she had told about resident #31 trying to come into her room. She stated she had told the nurses, the administrator, and the AD. She stated staff were to watch resident #31 more closely. Resident #43 was asked if the staff did watch resident #31 more closely. She stated, yes, when he comes on this hall the staff come and get him. Immediate Jeopardy Identified On 11-01-11, an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to supervise cognitively impaired residents to aid in the prevention of resident to resident inappropriate sexual contact and/or physical aggression. At 12:44 p.m., OSDH was notified and verified the existence of the IJ. At 12:46 p.m., the administrator was notified of the IJ situation. On 11-01-11 at 3:28 p.m., the administrator was asked if the resident exhibited aggressive behaviors towards other residents. She stated resident #31 was mostly aggressive with staff. The administrator stated, "We have shipped him out so many times; we don't know anything else to do with him." The administrator was told that resident #43 had voiced fears of resident #31. She stated she was unaware of any aggressive behavior towards residents but the facility staff did monitor the resident and could tell when he was beginning to get agitated. The administrator stated, "I don't know that he has ever been physical with another resident, staff member yes. He's one of those you just have to approach a certain way in a certain manner. It is his behavior, his cognition on him. He got Alzheimer's in his early 40's." The administrator was asked if any interventions for the resident's behaviors were documented in the clinical record. She stated they would be listed on the care plan. The surveyor informed the administrator there was no care plan related to the resident's behaviors. The administrator was asked if there were any State reportable incident reports for the resident. She stated, "No, nothing that happened with staff. We do monitor him." At 3:52 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "Immediate Jeopardy Plan of Removal Corrections to be made 1. Resident placed on one-to-one obeservation (sic) with staff member until he can be removed from facility. Time 1:10 pm Date 11/1/11 2. Male resident's (family member) was notified regarding transfer to an inpatient geri-psych facility for evaluation of behaviors. (Family member) prefers to transfer resident to the (hospital name withheld) today. Time 1:15 pm date 11/1/11 3. Family picked up resident at 2:30 pm for discharge 4. The abuse and neglect policy and procedure has been updated and now includes resident-to-resident- abuse. New policy and procedure updates will be iniated (sic) immediately and all staff will be inserviced by 11/2/11 at 2 pm 5. Facility will inservice all staff members about abuse and neglect and of when and to whom abuse shall be reported. This will be completed by 12 noon on 11/2/11. This will be done by the administrator (name withheldl) and RN/DON (name withheld). 6. Further inservice training on abuse reporting and prevention is scheduled quarterly. This will be done by the administrator (name withheld) and RN/DON (name withheld). 7. An in-house resident survey will be completed to identify resident fears and develop/implement sense of security for the residents by 11/2/11 by 12 noon. 8. All residents will be evaluated for behavior issues, by 11/2/11 at 12 noon. All residents that are identified as a potential threat will be further assessed of the potential for causing harm to other residents and appropriate behavior plans will be put into place to address such concerns. Further, a pre-admission screening form will be utilized to identify behavioral issues of pending admissions to the facility. 9. The abuse and neglect policies and procedures will be reviewed will (sic) all new employees at the time of hire. This will be done by the department supervisor. 10. The quality assurance committee will be monitoring the abuse preveintion (sic) program every month. This will be done by the administrator (name withheld) and RN/DON (name withheld)." Supplement to Plan of Removal On 11/01/11 at 7:52 p.m., the administrator presented a supplement to the plan of removal concerning resident #31. The supplement documented, "Corrections to be made: 1. Male resident identified as having potential to harm other resident's. 2. Resident has been placed in bed, where he is unable to get up by himself. Resident has a nursing assistant: (name withheld), assigned to do q 15 minute checks through the night to ensure resident is safe and remains in bed. 3. Male resident's (family member) notified of need of transfer to inpatient Geri-Psych unit in AM of 11/2/11. 4. 3-11 Charge Nurse has been informed of necessary measures to prevent harm to other residents. 5. 3-11 Charge Nurse will give instruction to 11-7 Lead Nurse. Administrator, (name withheld) will call at 11 pm to ensure information has been given to 11-7 Lead Nurse and rest of staff. 6. In AM 11/2/11, 7-3 shift will get resident up and take him to the dining room where he will sit with an aide under constant supervision. 7. RN, Director of Nursing, will contact Geri-Psych unit and follow up with necessary paperwork to transfer patient for psych evaluation and treatment. 8. Doc (document) q 15 min cks (checks) on paper form. 9. Resident will be monitored q 15 min til 7-3 staff is in consentant (sic) supervision. (Name withheld) Restorative will 7-3 (sic) doc on form." On 11-04-11 at 9:10 a.m., the administrator was asked for the investigation and reporting related to the allegation of abuse related to resident #43 being afraid of resident #31. She stated she had not finished it yet, she was still working on it. At 10:45 a.m., the administrator brought the surveyor an initial incident report form related to an allegation of abuse/mistreatment which had been faxed to OSDH on 11-04-11. Immediacy Removed On 11-04-11 at approximately 11:00 a.m., the administrator provided documentation ensuring all staff had been in-serviced on the facility's abuse and neglect policy and procedure, that all residents had been assessed for behaviors and plans had been put into place for residents identified as having potentially threatening behaviors, and that all residents had been surveyed to determine if they had fears regarding any other resident in the facility. The IJ was removed, effective 11-03-11 at 7:15 a.m., when the last staff member was inserviced, after staff were interviewed in regard to their knowledge of the facility's abuse and neglect policy, reporting allegations of abuse and neglect, and what to do in case of inappropriate resident behaviors. The deficient practice remained at a pattern level of actual harm.

An Immediate Jeopardy situation was determined to exist based on the facility failure to recognize, report, and intervene in order to prevent resident to resident mistreatment. Based on interview and record review, it was determined the facility neglected to: Supervise one resident (#4) to prevent inappropriate sexual conduct, and Prevent verbal and physicial mistreatment by one resident (#31) by failing to notify the resident's physician of increasing verbal and physical aggression against other residents. The facility identified 8 cognitively impaired residents with behaviors. Residents #5, #12, #43, and #50 expressed either fear or verbalized incidents of inappropriate sexual contact or aggressive physicial behaviors by residents #4 and #31. The failure to recognize and report the incidents prevented protection for the residents. This had the potential to affect all 51 residents who resided at the facility. In addition the facility failed to: Ensure an allegation of staff neglect of one resident (#29) of 1, was reported immediately to the administrator of the facility, and -have evidence the allegation was thoroughly investigated, and -protect residents from further neglect, and -report the allegation of neglect to officials as required by state law for 1 (#29) of 1 sampled residents who expressed concerns related to staff treatment. One resident (#29) had a documented allegation of neglect against a CNA. Findings: An undated facility policy titled, "Misappropriation of Property, Abuse, Neglect Investigation and Prevention Policy and Procedure," documented: "...INTENT & GUIDELINES This facility will develop and operational (sic) policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences... PROCEDURE...It is the responsibility of all employees of this facility and affiliated agencies to notify the Administrator, Director of Nursing or their immediate supervisor immediately if they observed or become aware of an incident of resident abuse and/or neglect, whether alleged, suspected or observed. ...It is the Administrator and/or Director of Nursing (sic) to ensure that immediately upon learning of the alleged allegation an initial (investigation) will began (sic) to established (sic) if allegation has probable cause for a thorough investigation... The initial investigation will be completed in 6 hours at the time reported to the Administrator and or Director of Nursing... If there is probable cause to continue (...) the alleged allegation (sic) all agencies and state agencies will be notified within 24 hours of the initial investigation, and a complete follow up in the next 5 working days... If after the initial investigation and there is no evidence to warrant further investigation, the incident will be documented either in residents nurse notes and or written up and filed in the Director of Nursing office. No State and or other agencies will be notified... Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness... ALSO NOTE IF THE ALLEDGED (sic) IS DUE TO A FALSE ALLEGATION THE INCIDENT WOULD NOT BE REPORTED TO THE AGENCIES BUT HANDLED IN FACILITY WITH PROPER DOCUMENTATION AND THE INVESITAGTION (sic) WOULD CEASE..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A behavior monitoring flowsheet, dated 03-15-11 through 03-31-11, documented, "...making sexual remarks to female staff..." It was documented the resident exhibited the behavior once on the first shift on 03-15-11. A nurse's note for resident #4, dated 05-17-11 at 2:50 p.m., documented, "...Was reported resident in female resident's rm beside her bed in which she was lying in (and) he pulled the covers off her exposing her in her depends (disposable brief). Res taken out of rm (and) instructed not to go into others rms. Res stated he has known her for yrs (and) he was just talking to her. Instr. him it would be better for all concern (sic) to talk c female residents when they are not in their rms..." An undated care plan update documented, "...wanders into others room (sic) @ x's..." The goal was, "...I will refrain from wandering into others rooms. Nsg will monitor..." The intervention was, "...staff will redirect when found in others rooms, educate on reasons of inappr (secondary to) privacy..." A social service progress note, dated 07-05-11, documented, "...Was reported to SSD by nurse that over the weekend (resident) had become verbally (and) physically abusive to another male resident. (Resident) swore other male resident was one of five men who had attacked a woman. Nursing staff had trouble re-directing him..." A physician's progress note, dated 07-28-11, documented, "...Now is having behavior issues with some inappropriate touching..." A quarterly assessment, dated 08-28-11, documented the resident was moderately impaired in cognitive skills and exhibited no behaviors except wandering. It was documented the resident required supervision only for locomotion on the unit and used a wheelchair. Active [DIAGNOSES REDACTED]. A care plan update, dated 08-29-11, documented, "...I have actual deficits in short term mem (and) decision making difficulty at times...dx Alzheimers..." The goal was, "...I will be oriented to person, place, surroundings, circumstance in a safe environment...8/29/11 - cont c some deficit did pretty good c interview told birthdate..." Interventions included, "...staff will assess cognitive ability..." A nurse's note, dated 08-31-11 at 12:00 p.m., documented, "...Noted fondaling (sic) another female's breast - staff removes female from situation, res informed it was not acceptable behavior..." A behavior monitoring flowsheet, dated 08-2011, documented, "...makes sexual remarks to female staff/res...Asking female resident to go to bed c him..." It was documented the resident exhibited the behavior twice on 08-31-11, and the staff provided one on one monitoring, redirection, and distractions as interventions. A nurse's note, dated 09-09-11 at 9:00 p.m.,documented, "...(One) behaviors (sic) noted c females..." A nurse's note, dated 09-09-11 as a late entry, documented, "...Resident had been about facility in w/c, as he does every day. He was down 200 hall and stopped to talk to female resident. He then wheeled down hall and she came back this way. No one saw anything. Touching, hitting, grabbing or anything..." An undated care plan update documented, "...I had an episode of inappropriate sexual behavior (grabbed another res buttock/crotch area)..." The goal was, "...I will refrain from any/all other inappropriate behavior by next review..." Interventions were, "...Staff will monitor whereabouts frequently, instruct/educate (resident #4) in actions of inappropriateness and need to refrain, staff to remove from episode if it occurs again, alert adm/(charge nurse)/DON of occurrence, notify MD of continuance (and) suggest gero (sic) psych if needed..." Review of the clinical record revealed no documentation to show the staff had implemented a plan to monitor the resident's whereabouts. A social service progress note, dated 09-09-11, documented, "...It was reported to SSD by charge nurse that (resident) has been having inappropriate behaviors in a sexual manner. Last evening he grabbed a female resident in the crotch, the female resident is extremely upset. Charge nurse is notifying doctor (and) his family..." A physician's progress note, dated 09-10-11, documented, "...pt with dementia...staff c/o of inappropriate behavior, but not all staff agree with this problem at this time, pt went to (geriatric psych) previously for similar problems..." A nurse's note, dated 09-13-11, on the evening shift, documented, "...(No) attempts to leave. Does follow female resident about. Thinks she is his girlfriend (and) she thinks he is her husband..." A nurse's note, dated 09-23-11 and untimed, documented, "...Resident argumentive (sic) this shift, arguing about his room, trying to go in someone else's room that belongs to two ladies. He states that is his room too..." A physician's progress note, dated 10-06-11, documented, "...pt with dementia...staff has no c/o of inappropriate behavior at this time...Dementia and hallucinations..." A nurse's note, dated 10-15-11 at 2:00 p.m., documented, "...Wanders in (and) out of others (sic) rm. Redirected TNTC times..." A nurse's note, dated 10-16-11 at 1:30 a.m., documented, "...Aide was doing rounds when she notified nurse that pt had...skin tear...(right) hand...Pt stated he got mad @ tv (and) punched it. TV was found on floor c blood on it. Pt was very sweet (and) cooperative c staff..." A nursing monthly summary, dated 10-17-11, documented the resident exhibited physical and verbal behavioral symptoms directed toward others, wandered, and suffered from [MEDICAL CONDITION]. The form documented, "...Is confused...gets sundowners...@ times gets verbally abusive (and) threatens other male residents..." On 10-31-11 at 5:00 p.m., resident #50, an alert and oriented resident stated she was afraid of another resident. Resident #4 had told her he liked her. She stated resident #4 had come into her room in the evening and it scared her. She stated she told him to get out of her room and he did. The resident was asked when this had happened and she stated one day last week, while her husband was in the hospital, and she was in her room by herself. She was asked if she had told anyone. She stated, "No I didn't." She stated that was why she kept her cane close. On 10-31-11 at 5:00 p.m., the room for resident #4 was observed to be 315 A. On 11-01-11 at 10:49 a.m., an interview was conducted with resident #5, who resided in room [ROOM NUMBER] B. Resident #5 was alert and oriented. Upon entry to the resident's room, a chain lock was noted on the resident's door and a sign that documented "Close" was observed on the outside of the door. Resident #5 was the roommate of resident #12. Resident #5 was asked if she ever felt afraid because of the way she or some other resident was treated. She stated, "Yes." Resident #5 was asked who she was afraid of and why. She stated, "It was one night I was tired of being cooped up in here. I was looking at pictures up front and someone reached between my legs from behind and grasped me and just crushed it (genital area). It was this man up here (resident #4). I turned around and said you (expletive) I'll hit you. (Employee #1) said you can't touch that man or talk that way." The resident was asked if she told anyone what had happened. She stated, "Yes, (LPN #1) the head nurse that night. She acted like it was nothing. (Roommate Resident #12)'s (family member) went to the desk and didn't leave. After that, a man from the other nursing home came and put a lock on the door. After that he (resident #4) came by three times. One day I was coming out of bathroom and there he was (in the resident's room). He asked if he could help me. He hasn't bothered me in about 3 weeks. Now he's on my hall. He was next door (his assigned room), they moved him. I don't know where and (but) now he is back on the hall. The nurses say they've talked to him but it hasn't done any good." On 11-01-11 at 10:55 a.m., resident #12, an alert and oriented resident, was asked if she was afraid of any resident. She stated, "Yes. I woke up and (resident #4) was at the foot of my bed and it scared me." Resident #12 was asked if resident #4 had touched her inappropriately or physically abused her. She stated, "No." Resident #12 stated he was the reason they had a lock put on the door. On 11-01-11 at 11:10 a.m., the administrator was asked for incident reports, including incidents reported to the State Health Department and for documentation of all incidents that had been investigated. Review of the incident reports revealed no documentation to show the incident on 08-31-11 had been reported to the administrator or the State Health Department. An investigative report and State reported incident for the incident on 09-09-11 was reviewed. No interventions to prevent future episodes of inappropriate sexual contact were documented. On 11-01-11 at 12:13 p.m., the administrator was asked if she was aware of the incident regarding resident #4 touching an unknown female resident's breast. She stated, "No, not aware of that one." The administrator was asked what the staff did to protect the residents after that incident. She stated, "I don't know. Surely they did something." The administrator was asked if the incident should have been reported to her. She stated, "Yes. It (an incident report) should have been left in my door." The administrator stated the incident could have been reported to her former DON. The administrator was asked who was responsible for investigating allegations of abuse/neglect. She stated, "Me and the DON. I have a box out there to put stuff in but I don't know where the previous DON has put stuff." The administrator was asked if there was a policy on how she should be informed of incidents. She stated, "If urgent they should call me at home." The administrator was asked if the incident should have been reported to the State Health Department. She stated, "It should have been." The administrator was asked if she was aware of the incident on 09-09-11. She stated, "By the time it got back to me it was blown out of proportion." The administrator stated the CNA on duty said she thought resident #4 had bumped resident #5. The administrator was asked what was done to protect the residents after the incident on 09-09-11. She stated, "We put a lock on her (resident #5) door and talked to the family (resident #4's family) and advised them he (resident #4) may have to be sent out to geri psych." The administrator stated the resident's care plan had also been updated. When asked for the documentation to show the staff had implemented the intervention of monitoring the resident's whereabouts that was listed on the care plan update as an intervention, the administrator stated, "I need to get better with that." The administrator was asked what had been done to protect the other female residents in the facility. She stated, "No one had a problem. Just (those) around his room." The administrator was asked if she was aware that resident #50, who lived on the 400 hall which was distant from the room of resident #4, was afraid of resident #4 and that he had gone into that female resident's room during the previous week while her roommate was out of the facility. The administrator stated, "No." The administrator was informed of the nursing note dated 05-17-11 when resident #4 was found in a female resident's room. The female resident was uncovered and her adult brief exposed. She stated, "No, I was not aware of that." The administrator was asked if she was aware resident #4 had entered the room of resident #5 and #12 approximately three weeks earlier and had asked resident #5 if she required assistance as she was exiting the bathroom. She stated, "No." The administrator was asked when resident #4 first began exhibiting unwanted sexual behaviors. She stated, "Well, he had been here about a month and that's kind of when they noticed he was going to women's doors. Thought he was getting lost. That's why he has the sign with his name by his door." The administrator stated, "It's never been reported that he inappropriately touched them." She stated resident #4 would hold the hand of resident #55 and they had even kissed. 2. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 08-22-11, did not address behaviors. A nurse's note, dated 08-24-11, documented, "3-11 (3:00 p.m. to 11:00 p.m. shift) Resident (up) in w/c about facility...to D/R per staff...Resident hollering a (sic) cussing a ( sic) hitting fist on table. Resident quietly ask to stop and be quiet to no avail...Resident down hall way self propelling in w/c., another residet (sic) passed or came up by him and they had altercation, residet (sic) grabbed other residet (sic) by left arm and squeezed & twisted it. Altercation broken up by staff. (Left) arm of other residet (sic) red but no injuries apparet (sic)..." A fax cover sheet, dated 08-24-11, documented, "Dr. (Name deleted) Concern: Resident...got into altercation & twisted another residents arm. no apparent injuries, (left) arm red on other resident..." A nurse's note, dated 08-30-11 at 12:00 a.m., documented, "...Resi (resident) has episodes of hitting cursing..." A nurse's note, dated 08-30-11 at 9:00 a.m., documented, "@ 0910 (9:10 a.m.) res. had words c another male resident both turned and went to their rooms when staff approached..." A psychiatric physician's progress note, dated 08-30-11, documented, "SUBJECTIVE...Staff reports pt much more resistant to care...OBJECTIVE...Mood per:...Staff angry...Affect...angry...Cognition: Judgment...impaired poor impulse control...(Diagnosis)...Alz type dementia c beh. (behavioral) dist. (disturbances)...MDD c [MEDICAL CONDITION]" A telephone order, dated 08-30-11, documented, "...Transfer to (Name deleted psychiatric hospital)..." A hospital discharge plan of care, dated 09-12-11, documented: ~ "...Counselor's Recommendations...Events precipitating admission yelling out, cussing, hitting tables, hitting at staff.", ~ "Discharge [MEDICAL CONDITION] with behavioral disturbance...", and ~ "Target symptom(s) combative, yelling..." A significant change assessment, dated 09-19-11, documented the resident was unable to complete the BIMS interview. The assessment documented the staff assessed the resident as having severely impaired cognitive skills for daily decision making with both long and short term memory problems. The assessment documented the resident showed signs and symptoms of [MEDICAL CONDITION] by exhibiting both inattention and disorganized thinking as continuous behaviors which did not fluctuate. The assessment documented the resident exhibited both physical and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others which had occurred 1 to 3 of the previous 7 days. The assessment documented the presence of the resident's behaviors put the resident and others at significant risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. The assessment documented the resident was independent in locomotion on and off the unit with setup assistance only, required limited one person assistance for bed mobility, transfers, dressing, eating, and toilet use, and required extensive one person assistance with ambulation in room and corridor, personal hygiene, and bathing. The assessment documented the resident required a walker or wheelchair for mobility. The assessment documented the resident had taken antipsychotic medication during the 7 days prior to the assessment. A nurse's note, dated 09-21-11, documented, "Resident (up) in w/c about facility. Make (sic) few remarks to different people. Raised hand toward other resident but did not hit..." A psychiatric physician's progress note, dated 09-29-11, documented, "SUBJECTIVE...Staff reports he is now taking meds. still occ (occasionally) curses, (not) physically combative. still occ. hits table...OBJECTIVE...Mood per: Pt: ok Staff better...Cognition: Judgment...impaired poor impulse control...(Diagnosis)[MEDICAL CONDITION] c behav. (behavioral) disturbances...MDD c [MEDICAL CONDITION]" The October 2011 monthly physician's orders [REDACTED]. A nurse's note, dated 10-02-11, documented, "3-11 Resident @ nurses desk threatening to kill another resident - (female) Instr (instructed) him this wasn't nice & then he started pounding on desk c both fists gritting teeth saying 'I'm going to kill her! I'm going to kill all of them, they're all crazy!' Again instr not to say stuff like that & she wasn't saying or doing anything to him. Resident in question voiced her fear of him as she was trying to back away from him in case he did try to harm her. Res taken to his rm (room) hitting @ staff & cussing. Female resident reassured (no) harm would come to her. This all occurred around 1940 (7:40 p.m.)..." A nurse's note, dated 10-04-11, documented, "3-11...cussed another resident & attempted to hit resident but staff intervened before able to connect..." A nurse's note, dated 10-05-11, documented, "3-11...family out to feed him. Another resident rolled over to pt & was counting very loudly & this pt threatened other pt, staff separated pts. Counting pt went over to this pt & proceeded to count loudly again. Separated once more & counseled counting pt..." There was no evidence the physician was notified of the resident's exacerbation and escalation of verbally and physcially aggressive behaviors over this period of three days. A nurse's note, dated 10-21-11 at 2:00 p.m., documented, "...calling other residents (females) '[***] es & whores' ..." A nurse's note dated 10-22-11 at 3:00 p.m., documented, cursing frequently directed toward others sitting @ table-reached out & hit back of females w/c (no) injuries caused counseled resident s further episodes..." A nurse's note, dated 10-23-11, documented, "7-3 cursing a couple x's (times) (no) striking out @ others removed from stimulating situation..." There was no evidence the physician was notified of the resident's exacerbation and escalation of verbally and physcially aggressive behaviors over this period of three days. A nurse's note, dated 10-29-11, documented, "7-3 Res. (up) in w/c cussing @ staff...(up) wandering around facility, comfort measures given..." On 11-01-11 at 11:23 a.m., resident #43, an alert and oriented resident who resided on the 400 hall, was asked if she was afraid of any resident in the facility. She stated resident #31. She was asked what was the problem with resident #31. She stated resident #31 got a little wild at times. She stated the facility had sent resident #31 out of the facility twice and he came back to the facility. She stated both times resident #31 went out of the facility "he was out of his head." She stated resident #31 was a "sex fiend." She stated he liked and wanted to crawl in "your bed." She stated resident #31 comes onto the hall she lives and when he knocks on her room door she tells him to go away. She stated she had a lock on her door. She stated as far as she knew the staff never put him to bed. She stated it was late at night when he tried to come in her room." Resident #43 was asked if she had told anybody about resident #31 trying to come into her room. She stated, "Yes we've told them and told them, and that's why we got the locks on the door." Resident #43 was asked who she had told about resident #31 trying to come into her room. She stated she had told the nurses, the administrator, and the AD. She stated staff were to watch resident #31 more closely. Resident #43 was asked if the staff did watch resident #31 more closely. She stated, yes, when he comes on this hall the staff come and get him. 3. Resident #29 had [DIAGNOSES REDACTED]. The resident's quarterly assessment, dated 07-25-11, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, dressing, toilet use, and bathing; and the resident was independent with locomotion on and off the unit, eating, and personal hygiene. The assessment documented the resident was always continent of bowel and was occasionally incontinent of bladder. On 11-01-11 at 9:24 a.m., resident #29 was asked if she had ever been treated roughly by staff. The resident stated, "Yes." The resident was asked who it was and what had happened. She stated that she and "(name deleted, CNA #1) did not get along." She was asked what shift the CNA worked and she stated the 11p - 7a shift. On 11-03-11 at 9:27 a.m., the resident was asked if she had reported to anyone the rudeness of CNA #1. She stated, "Yes I have." She was asked what had happened. She stated she had asked CNA #1 to turn her during the night and she would not do it. She stated she had been left in the same position in bed all night. The resident was asked when the event had taken place. The resident stated, "Probably May. I told an aide first and she put me in a W/C and took me to see everyone from (name deleted, administrator) on." The resident stated, "I don't usually tell things like this, but she does not need to be here. She is a very uncaring person." The resident was asked if she had requested the CNA not be assigned to her. The resident stated she had asked that the CNA not be assigned to her but she had been a couple of times. The resident was asked when the last time the CNA had assisted her and she stated, "About three weeks ago, but I don't know if she was assigned to me or if she answered my call light." The resident's nurses notes, dated 06-17-11, documented, "Resident refusing assist (assistance) from CNA in transferring - was seen trying to get (up) (without) assist. Instr (Instructed) her not to do this (secondary to) hx (history) of falls (with) injuries. Stated, 'The reason I'm in this shape is because of (name deleted, CNA #1) not coming in & turning me at noc (night).' Instr her (name deleted, CNA #1) was not the only person who worked & to allow staff to assist her. She finally did. .." On 11-03-11 at 9:23 a.m., the DON was asked if CNA #1 worked on nights. The DON stated, "Yes." On 11-03-11 at at 10:06 a.m., The DON was asked about any allegations she was aware of regarding CNA #1 that would have happened in May of this year. The DON stated, "That was before I got here. You will need to talk with (name deleted, the administrator)." The DON was asked if there were any grievances against CNA #1. The DON stated she would have to check with the administrator and the office manager. On 11-03-11 at 11:18 a.m., in the administrator's office, the administrator and corporate consultants #1 and #2 were present for an interview. The administrator was given resident #29's clinical record. The administrator was asked if she were aware of the resident's accusations against CNA #1. The administrator stated, "No." The administrator was informed the resident stated the administrator knew about the event. The administrator was asked if she were aware. The administrator stated, "No. I have not heard about it." The administrator was asked if she was asked to not allow CNA #1 to care for resident #29. The administrator stated, "No, not that I remember." The administrator was asked if anyone had investigated the reported findings in the nurses notes that documented the resident "would not be in this condition if it weren't for" CNA #1. The administrator stated, "No. I did not know about it." The administrator was asked who it was that documented the event and words of the resident. The administrator stated, "(Name deleted, LPN #2)." The administrator stated LPN #2 was the ADON. On 11-03-11 at 2:30 p.m., the LPN/ADON was given the resident's clinical record and was asked about the event documented. The ADON was asked if she recalled the resident telling her that she would not have been in the condition she was if it had not been for CNA #1 and her not turning her in the night. The ADON stated, "Yes." She was asked if she regarded that as an allegation of neglect. The ADON stated, "Not really because there are three CNAs and they rotate the CNAs on different halls." She stated, "Am saying it could have been one of the other aides." The ADON stated the resident did not like CNA #1. The ADON was reminded of her documentation that the resident was specific that the CNA who neglected to turn her thru the night was CNA #1. Again the ADON was asked if she considered what the resident said as an allegation of neglect. The ADON stated, "Yes." The ADON was asked what the facility's policy documented for her to do once she received an allegation of abuse. The ADON stated, "Report it to the administrator." The ADON was asked if she had reported it to the administrator. She stated, "No I didn't. I did tell (name deleted, CNA #1) to stay out of her room. Immediate Jeopardy Identified On 11-01-11, an Immediate Jeopardy (IJ) situation was identified regarding the facility's failure to supervise cognitively impaired residents to aid in the prevention of resident to resident inappropriate sexual contact and/or physical aggression. At 12:44 p.m., OSDH was notified and verified the existence of the IJ. At 12:46 p.m., the administrator was notified of the IJ situation. On 11-01-11 at 3:28 p.m., the administrator was asked if the resident exhibited aggressive behaviors towards other residents. She stated resident #31 was mostly aggressive with staff. The administrator stated, "We have shipped him out so many times; we don't know anything else to do with him." The administrator was told that resident #43 had voiced fears of resident #31. She stated she was unaware of any aggressive behavior towards residents but the facility staff did monitor the resident and could tell when he was beginning to get agitated. The administrator stated, "I don't know that he has ever been physical with another resident, staff member yes. He's one of those you just have to approach a certain way in a certain manner. It is his behavior, his cognition on him. He got Alzheimer's in his early 40's." The administrator was asked if any interventions for the resident's behaviors were documented in the clinical record. She stated they would be listed on the care plan. The surveyor informed the administrator there was no care plan related to the resident's behaviors. The administrator was asked if there were any State reportable incident reports for the resident. She stated, "No, nothing that happened with staff. We do monitor him." At 3:52 p.m., the facility submitted an acceptable plan of removal. Facility Plan of Removal for Immediate Jeopardy The plan of removal documented, "Immediate Jeopardy Plan of Removal Corrections to be made 1. Resident placed on one-to-one obeservation (sic) with staff member until he can be removed from facility. Time 1:10 pm Date 11/1/11 2. Male resident's (family member) was notified regarding transfer to an inpatient geri-psych facility for evaluation of behaviors. (Family member) prefers to transfer resident to the (hospital name withheld) today. Time 1:15 pm date 11/1/11 3. Family picked up resident at 2:30 pm for discharge 4. The abuse and neglect policy and procedure has been updated and now includes resident-to-resident- abuse. New policy and procedure updates will be iniated (sic) immediately and all staff will be inserviced by 11/2/11 at 2 pm 5. Facility will inservice all staff members about abuse and neglect and of when and to whom abuse shall be reported. This will be completed by 12 noon on 11/2/11. This will be done by the administrator (name withheldl) and RN/DON (name withheld). 6. Further inservice training on abuse reporting and prevention is scheduled quarterly. This will be done by the administrator (name withheld) and RN/DON (name withheld). 7. An in-house resident survey will be

Based on observation, interview, and record review, it was determined the facility failed to: A. Ensure 1 (#5) of 2 sampled residents with observations of pain received [MEDICATION NAME] for pain as ordered by the physician, address the resident's complaints of almost continuous severe pain, and place [MEDICATION NAME]es for pain relief on the areas identified by the resident as areas of pain. The facility's failure to manage the resident's pain resulted in actual harm for resident #5. The facility's census and conditions report identified 27 residents as being on a pain management program; and B. Ensure consistent communication and coordination of care with the hospice organization for 1 (#5) of 5 sampled residents who received hospice services. The facility identified 11 residents as receiving hospice services. Findings: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Pain A comprehensive pain assessment, dated 06-23-11, documented, "...Med/Treatment [MEDICATION NAME] Patch 50 mcq (change) q 72 (hours)[MEDICATION NAME] (an [MEDICATION NAME] adjunct and used for [MEDICAL CONDITION]) 300 mg (one) po [MEDICATION NAME] 7.5 mg (one) po q 4 (hours) prn...Does resident have a [DIAGNOSES REDACTED].? [MEDICAL CONDITION] pain site...Rt shoulder..." A quarterly assessment, dated 06-29-11, documented the resident was cognitively intact, had functional limitation in range of motion of the upper extremities bilaterally, and had occasional severe pain over the previous five days that was rated a 10 on a 0 to 10 scale. A facsimile to the physician, dated 08-08-11, documented, "...Res c (increased) [MEDICAL CONDITION] pain. [MEDICATION NAME] 300 mg tid ordered, may we (increase) to qid please..." A response from the physician, dated 08-09-11, documented, "...Yes. Let me know if it works..." The order was noted by nursing staff on 08-10-11. A monthly nursing summary, dated 08-13-11, documented the resident was almost constantly in pain. MARs, dated 08-10-11 through 08-31-11, documented the resident's [MEDICATION NAME] dosage was increased from three times daily to four times daily. Physician orders, dated 09-2011, documented, "...03/22/[MEDICATION NAME] 50 mcg (sic) change q 72 hours...11/15/[MEDICATION NAME] 300 mg...(one) tab po tid...03/22/[MEDICATION NAME] 7.5 mg...q 4 hours prn pain...03/22/[MEDICATION NAME] 5%, apply patch to r shoulder qd remove q 12 hours..." A monthly nursing summary, dated 09-18-11, documented the resident was almost constantly in pain, verbalized complaints of pain, and facial expressions indicative of pain were observed. It was documented, "...Very independent - very outspoken - whines..." The resident's care plan, last updated 09-28-11, documented pain as a problem and listed an individualized pain management program as an intervention. MARs, dated 09-2011, documented the resident received [MEDICATION NAME] 300 mg three times daily. Physician orders, dated 10-2011, documented, "...03/22/[MEDICATION NAME] 50 mcg (sic) change q 72 hours...11/15/[MEDICATION NAME] 300 mg...(one) tab po tid...03/22/[MEDICATION NAME] 7.5 mg...q 4 hours prn pain...03/22/[MEDICATION NAME] 5%, apply patch to r shoulder qd remove q 12 hours..." Review of the clinical record revealed no documentation to show the facility identified the increase in the resident's [MEDICATION NAME]. This [MEDICATION NAME] order did not appear on the 10-2011 physician orders. MARs, dated 10-2011, documented the resident received [MEDICATION NAME] 300 mg three times daily. A monthly nursing summary, dated 10/17/11, documented the resident was almost constantly in pain, the intensity of the worst pain was an 8 on a 0 - 10 scale, and the resident described the pain as severe. It was documented, "...Chronic complainer - health (and) staff issues as well as her own family..." Review of the clinical record revealed no documentation to show the resident's complaints of almost constant pain were addressed. Review of the clinical record revealed no documentation to show the facility was aware of the increase in the resident's [MEDICATION NAME], which was ordered on 08-09-11, and did not appear on the 09-2011 or 10-2011 physician orders. There was no documentation to show the resident's pain management plan was coordinated with the resident's hospice organization, and there was no documentation to show the resident's pain medication regimen had been adjusted to aid in controlling the resident's pain. A physician's telephone order, dated 10-31-11, documented, "...May use [MEDICATION NAME] 1/2 patch daily. apply to areas of pain..." On 10-31-11 at approximately 4:30 p.m., the resident was observed seated in her recliner in her room. She stated she had been "down to the party" but thought she was not going to make it back because her shoulder hurt so bad. She stated whenever she applied any pressure, such as when using her wheeled walker, she experienced a great deal of pain. The resident stated she had received a [MEDICATION NAME] for pain and then took a nap. She stated she did not know what was wrong with her shoulder but did know she was unable to have surgery on the arm because she could not tolerate anesthesia. The resident was asked where her shoulder hurt. She pointed to the bony prominence at the top of her right shoulder, located at the end of the clavicle. No [MEDICATION NAME] was noted on the area where the resident indicated her pain was. On 10-31-11 at 5:10 p.m., the resident was observed seated in her wheelchair. The resident yelled out in pain. The resident's roommate stated, "Poor girl. She's always hurting." On 11-01-11 at 10:02 a.m., the resident was observed asleep in her recliner. The resident was observed to have facial grimacing, indicative of pain. On 11-03-11 at 9:58 a.m., the resident complained of pain to her right shoulder. She stated her pain was "the worst it can be, is that a 10?" No [MEDICATION NAME] was noted on her right shoulder. A [MEDICATION NAME] was observed on the lateral portion of the resident's right upper arm. The resident was asked if her arm hurt where the [MEDICATION NAME] was located. She stated, "No. It hurts on the top of my shoulder." The resident stated LPN #3 had just placed the [MEDICATION NAME] on her arm. The resident was asked what was the minimal amount of pain she felt when her pain was at it's lowest point. She stated, "I don't really know. I just know it hurts. They say that's old age." At 10:21 a.m., CNA #2 was asked if the resident complained of pain. He stated, "Yes she does." When asked what he did when the resident verbalized complaints of pain, CNA #2 stated, "I ask her where and come talk with the nurse and tell her (the nurse) she is in pain." CNA #2 was asked how he could tell the resident was in pain. He stated, "I can tell in her face, if she is sad for no reason, usually see it in her face." CNA #2 was asked if the resident was in pain often. He stated, "When I come in the mornings, I see it in her face, she doesn't want to go to the bathroom, or dining room for breakfast." At 10:29 a.m., LPN #3 was asked how often the resident's pain was assessed. She stated, "I ask her every morning and if she hasn't had anything, I give her something because she has chronic pain." LPN #3 was asked where she documented her assessment of the resident's pain. She stated, "Usually, more likely they're documenting." LPN #3 was asked who she was referring to. She stated, "The med aides but I need to document." LPN #3 was asked if the resident's pain medication was effective. She stated, "Pretty much. There are times when she gets up and walks because she has [MEDICAL CONDITION] and the arm. She thinks walking helps with the pain." LPN #3 was asked what "pretty much" meant. She stated, "Usually we don't have to take a dose (of as needed pain medication) more than in the morning and evening, but sometimes she prefers to take Tylenol. We have some patches that we place on areas of pain." LPN #3 was asked where she documented the effectiveness of the resident's pain medication. She stated, "On her MAR." When asked if she completed the documentation, LPN #3 stated, "No, the med aides do. I just assess whether it has been effective or not." LPN #3 was asked who was responsible for the resident's pain management program. She stated, "We are, as in the facility." LPN #3 was asked if she placed the [MEDICATION NAME] on the resident's arm. She stated, "Yes." When asked where the patch was placed, LPN #3 stated, "The right posterior arm." LPN #3 was asked if that was where the resident's pain was. She stated, "Yes." LPN #3 was asked if the resident had told her that was the location of her pain. She stated, "Yes." LPN #3 was asked what the dosage and frequency was of the resident's ordered [MEDICATION NAME]. She reviewed the MARs and stated, "300 three times a day." On 11-03-11 at 12:43 p.m., LPN #4 was asked to review the fax requesting an increase in the resident's [MEDICATION NAME] frequency and state if the doctor approved the increase. She stated, "Yes, he did. I noted that for her." LPN #4 was asked if the resident received the increase in the [MEDICATION NAME] frequency. She stated, "She should have. I would have written an order for [REDACTED]. LPN #4 was asked why the resident was not receiving the [MEDICATION NAME] four times daily. She stated, "I don't know because it doesn't look like anything has been changed since I changed it in August." LPN #4 was asked who checked the monthly orders against physician orders. She stated, "(MDS coordinator) gets the white copy of telephone order and she updates the MARs for the next month." At approximately 4:30 p.m., the DON presented the surveyors a copy of a pain management policy. On 11-03-11 at 6:28 p.m., the administrator was asked if the pain policy provided was just initiated by the facility on that day. She stated she had been unable to find the facility's pain policy. She stated there was a pain book and the policy was in it but they had not been able to find it so she called a sister home and had them fax one over because she knew it was the same policy. On 11-04-11 at approximately 9:21 a.m., the MDS coordinator was asked what happened with the [MEDICATION NAME] order. She stated, "They had faxed the doctor and he had responded back on the fax. They are supposed to write a telephone order from that." She was asked if a telephone order was written. She stated, "No. I went back in medical records and couldn't find the order." The MDS coordinator was asked if the resident's [MEDICATION NAME] frequency had been increased yet. She stated, "I told her (LPN #4) she needed to call the doctor and let him know that it hadn't been done and ask him if he still wanted it, then write a clarification order." Review of the orders revealed a telephone order was written on 11-02-11 to increase the [MEDICATION NAME] to four times daily. The surveyor and MDS coordinator reviewed the resident's care plan related to pain. The MDS coordinator was asked to provide the resident's individualized pain plan. She stated, "Our old DON had a book. At care plan meetings, she would work on that. Towards the end of her employment she started putting them in with the assessments." When asked what the plan entailed, the MDS coordinator stated, "Any chance for reduction. Would ask the resident if pain was being controlled, how many prns she took during that look back period. Really just to see if it was being controlled and any new problems." Hospice Review of hospice notes in the facility for resident #5 revealed a plan of treatment note, dated 11-15-10, an intradisciplinary group review and update to the hospice plan of care, dated 04-16-11, and a skilled nurse visit record, dated 06-20-11. The hospice chart contained no newer nursing or care plan documentation. A quarterly assessment, dated 06-29-11, documented the resident was cognitively intact, had functional limitation in range of motion of upper extremities bilaterally, and had occasional severe pain over the previous five days that was rated a 10 on a 0 to 10 scale. The assessment documented the resident did not have a condition or chronic disease that might result in a life expectancy of less than 6 months. The resident's facility care plan, last updated 09-28-11, did not address the resident was receiving hospice services. On 11-03-11 at 10:21 a.m., LPN #3 was asked how often the resident was seen by the hospice nurse. She stated, "Three times a week." LPN #3 stated the resident was seen by the hospice aide three times a week as well. LPN #3 was asked who was responsible for the resident's pain management program. She stated, "We are, as in the facility." LPN #3 was asked how care was coordinated with the hospice organization. She stated, "Each time I generally mention things to the CNAs who give her shower and to the nurse. If I have to, I call the office." LPN #3 was asked where the communication and coordination of services was documented. She stated, "I chart communication in the nurse's notes." LPN #3 was asked if the hospice organization attended the resident's care plan meetings. She stated, "I don't believe so. I haven't seen them in the meetings. They do have care plans. I've seen their care plans." LPN #3 was asked where the hospice's care plans were located. She stated, "I'm not certain if their care plan is in there, but they have a hospice chart." On 11-03-11 at 10:42 a.m., the DON was asked how the facility communicated and coordinated care with hospice organizations. She stated, "I know they all have their books out there. They communicate daily with the nurses and the nurses sign paper work for hospice staff." The DON was asked if hospice organizations attended resident care plan meetings. She stated, "No." The DON was asked if she was aware of the hospice's care plan for resident #5. She stated, "I have not looked through their binders. I don't know whether there is a care plan in there myself." On 11-03-11 at 11:19 a.m., the MDS/care plan coordinator was asked if hospice organizations were invited to care plan meetings. She stated, "The annual one." When asked why they were invited only to the annual care plan meetings, she stated, "That's just usually when we invite families and others on the annuals." The MDS/care plan coordinator was asked when residents were invited to attend care plan meetings. She stated, "The annual ones." When asked if the facility had ever been asked to attend a care plan meeting held by hospice organizations, she stated, "No, I can't say that we've ever been asked."