Every finding on record at Colonial Terrace Care Center

Based on record review and interview, the facility failed to ensure a physician responded to a pharmacy consult report regarding the prescription of an antipsychotic medication for the diagnosis of dementia for 1 (#7) of 6 sampled residents reviewed for unnecessary medications.The DON reported 30 residents at the facility had been prescribed psychotropic medications.Findings:A quarterly assessment, dated 02/02/26, showed Res #7 had a BIMS score of three (a BIMS score of three shows Res #7's cognition was severely impaired) and had been administered antipsychotic medication. A pharmacy consultation report titled Expanded DRR Report, dated 02/18/26, read in part, Seroquel [antipsychotic medication] is FDA [Federal Drug Administration]-approved for schizophrenia, bipolar disorder (mania, depression, maintenance), and as adjunct therapy in major depressive disorder (MDD). It is not approved for dementia-related psychosis. Please verify/update diagnosis and document rationale for antipsychotic usage. The consultation report showed the physician signed the document but had not given a rationale or new order for Res #7's Seroquel order.On 04/16/26 at 10:28 a.m., LPN #1 stated Res #7 was currently prescribed Seroquel for vascular dementia and had been so since admission to the facility on [DATE]. LPN #1 stated they knew Seroquel was not approved for the treatment of dementia but that was what the physician wanted as the diagnosis.On 04/16/26 at 10:33 a.m. the DON stated they did not find a policy on the topic of the physician responding to a pharmacy consult. The DON stated the physician should have responded to the pharmacy consultation and usually did.

Based on observation, record review, and interview, the facility failed to ensure medications that required refrigeration were stored at the appropriate temperature and controlled substances were stored in securely locked containers for 2 (medication room refrigerator and the DON's office) of 2 sampled medication storage areas reviewed for safe storage.The DON reported that seven residents were administered medications that required refrigeration at specific temperatures and 29 residents were administered controlled medications at the facility.Findings:On 04/16/26 at 8:33 a.m., the facility medication room was observed to have a small refrigerator that contained a cardboard box of medication and did not have a temperature log for the date of 04/16/26. The medication observed in the box was tuberculin purified derivative (sterile, diluted protein solution injected intradermally to test for Mycobacterium tuberculosis infection) and the thermometer inside the medication refrigerator read 50 degrees (F).On 04/16/26 at 9:35 a.m., the DON's office was observed while the DON was present. Upon entry to the unlocked office, the DON's desk was observed to have an unlocked drawer that contained the following medications:a. 42 tablets of Hydrocodone/Acetaminophen 5mg-325mg (pain medication),b. 14 tablets of Tramadol 50mg (pain medication),c. 8 syringes of Ativan 1mg (anti-anxiety medication),d. 19 syringes of Morphine 0.25 milliliters (pain medication), ande. 30 syringes of ABH (Ativan, Benadryl, Haldol). (a combination of anti-anxiety, antihistamine, antipsychotic medications).An undated policy titled Colonial Terrace Center Refrigerator Temp Policy, read in part, Nursing home medication room refrigerator temperature policies are designed to ensure the safety and efficacy of temperature-sensitive medication, such as insulin and vaccines. The standard requirement is that medication refrigerators maintain a consistent temperature between 36 degrees (F) and 46 degrees (F) 2 degrees to 8 degrees Celsius.An undated facility policy titled Narcotic Storage and Destruction, read in part, Storage Policies Secure Storage: Medications must be in a locked cabinet or cart with controlled substances in a separate, locked box within that area. Controlled Access: Only licensed nurses or authorized personal holding keys may access narcotics. Environment: Storage area must be well - organized and maintained at appropriate temperatures. Narcotics marked for destruction will be kept under lock and key x2 with the understanding that an office door is not considered to be the first or second lock.On 04/16/25 at 8:40 a.m., LPN #1 stated the medication refrigerator temperature was 50 degrees Fahrenheit. LPN #1 stated the refrigerator needed to be 46 degrees Fahrenheit or colder.On 04/16/26 at 9:01 a.m., Certified Medication Aide #2 stated there was no documented temperature reading on the medication refrigerator logbook for 04/16/26.On 04/16/26 at 9:41 a.m., the DON stated they destroyed discontinued medications every other month with the pharmacist.On 04/16/26 at 9:47 a.m., the DON stated anyone could have entered their office and removed the unsecured narcotic medications from their desk drawer.

Based on record review and interview, the facility failed to ensure resident representatives were notified of change for one (#32) of one sampled resident reviewed for notification of change. The administrator identified 39 residents who resided in the facility. Findings: The undated Notification of Change policy, read in parts, .The nurse will immediately notify the resident .resident representative for the following [list is not all inclusive]: A need to alter treatment significantly [a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment] .Document the notification and record any new orders in the resident's medical record . Resident #32 had diagnoses which included dementia, recurrent depressive disorders, and constipation. The Medication Administration Record, dated 01/01/24 through 01/31/24, documented the resident's Zoloft was increased from 25 mg daily to 50 mg daily for depression on 01/18/24 and had been ordered Namenda 5mg twice daily for dementia on 01/19/24. A Progress Note, dated 01/19/24, documented Resident #32 had new orders for Namenda and the Zoloft had been increased. The note did not reveal the resident's representative had been notified of the medication changes. The Medication Administration Record, dated 05/01/24 through 05/31/24, documented the resident was ordered a Fleets enema once daily, as needed, on 05/09/24. A Progress Note, dated 05/09/24, documented Resident #32 had been administered an enema for complaints of constipation with positive results. Review of the progress notes did not reveal the resident's representative had been notified of the order for the Fleets enema. The quarterly assessment, dated 05/21/24, documented the resident was severely impaired in cognition for daily decision making. On 06/19/24 at 2:53 p.m., the resident's representative stated they would like to be notified of medication changes and new orders. On 06/21/24 at 9:52 a.m., RN #1 stated they were to notify residents and/or resident representatives of medication order changes and document the notification in the progress notes. On 06/21/24 at 10:15 a.m., Corporate nurse #1 stated they did not have documentation the representative for Resident #32 had been notified of the medication changes.

Based on observation, record review, and interview, the facility failed to ensure residents were administered the correct doses of medications ordered by their physician for two (#19 and #93) of six sampled residents reviewed for medication administration. A facility resident roster, dated 06/17/24, documented 39 residents resided at the facility. Findings: An Adverse Consequences and Medication Errors policy, dated 2001, read in part, A medication error is defined as the preparation or administrator of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. Resident #19 had diagnoses which included acute kidney failure and diabetes mellitus with diabetic neuropathy. A Medications Administration Record for Resident #19, dated 06/01/24 - 06/18/24, documented the resident was to be administered five units of lispro insulin from a 200 unit per milliliter strength insulin pen before each meal. The order had a start date of 01/09/24 and an open end date. The record documented the resident had 52 doses of the medication between 06/01/24 and 06/18/24. On 06/18/24 at 11:21 a.m., RN #1 was observed administering insulin to Resident #19. RN #1 set the dose on an insulin pen and showed it to the surveyor. The pen was observed to be lispro 100 units per milliliter and was set to administer 5 units. RN #1 was then observed administering the medication. On 06/18/24 at 12:15 p.m., RN #1 and the surveyor reviewed Resident #19's medication orders in the resident's electronic medical record and then the insulin pen that had been used. RN #1 stated the pen that was used at 11:21 a.m. had a strength of 100 units per milliliter but the order was to use a pen with the strength of 200 units per milliliter. RN #1 stated the resident had been under-dosed. They stated the insulin pens in the medication cart had not been replaced since the order was change in January. 2. Resident #93 had diagnoses which included paroxysmal atrial fibrillation. A prescription order form, dated 06/07/24, documented Resident #93 was to be administered one Sotalol [an oral medication use to treat atrial fibrillation]120 mg tablet every morning. A Medication Administration Record form for Resident #93, dated 06/01/24 - 06/20/24, documented the resident had received 12 doses of Sotalol 120 mg tablets between 06/07/24 and 06/19/24. On 06/19/24 at 8:00 a.m., RN #1 was observed administering medications to Resident #93. RN #1 removed a tablet from a container and presented the container to the surveyor. The container label documented the medication was Sotalol 80 mg tablets and one was to be administered to the resident. RN #1 was observed administering the medication. On 06/19/24 at 9:04 a.m., RN #1 and the surveyor reviewed Resident #93's medication orders in the resident's electronic medical record and then the container of Sotalol that had been administered that morning. RN #1 stated the order for Sotalol was for one 120 mg tablet but the container read 80 mg tablets. RN #1 stated the resident had been under-dosed. They stated they had since looked in the medication cart and the correct dose was there. They stated they had not looked close enough and had given the 80 mg tablet instead of the 120 mg tablet. They stated there was a problem with communication amongst the nursing staff and discontinued meds have been left in the carts instead of moved to the DON's office. On 06/20/24 at 10:24 a.m., Regional Nurse stated that when RN #1 had administer the insulin to Resident #19 and Sotalol to Resident #93, they had not followed facility policy or the standards of care when they did not check the actual medications on hand against the physician's order.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent. A facility resident roster, dated 06/17/24, documented 39 residents resided at the facility. Findings: An Adverse Consequences and Medication Errors policy, dated 2001, read in part, A medication error is defined as the preparation or administrator of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. A Treatments Administration History form for Resident #19, dated 06/01/24 - 06/19/24, read in part, Humalog KwikPen Insulin (insulin lispro) Insulin pen; 200 unit/mL (3 mL); Amount to administer: 5 units; subcutaneous .The form further documented the resident received the afternoon dose of the medication on 06/18/24. A Medication Administration Record form for Resident #93, dated 06/01/24 - 06/20/24, read in part, sotalol tablet; 120 mg; Amount to Administer: 1 tab; gastric tube . The form further documented the resident received the morning dose of the medication on 06/19/24. On 06/18/24 at 11:21 a.m., RN #1 was observed administering insulin to Resident #19. RN #1 set the dose on an insulin pen and showed it to the surveyor. The pen was observed to be lispro 100 units per milliliter and was set to administer 5 units. RN #1 was observed administering the medication. On 06/18/24 at 12:15 p.m., RN #1 and the surveyor reviewed Resident #19's medication orders in the resident's electronic medical record and then the insulin pen that had been used. RN #1 stated the pen uses was 100 units per milliliter but the order was to use a pen with the strength of 200 units per milliliter. RN #1 stated the resident had been under-dosed. On 06/19/24 at 8:00 a.m., RN #1 was observed administering medications to Resident #93. RN #1 removed a tablet from a container and presented the container to the surveyor. The container label documented the medication was Sotalol [an medication to treat atrial fibrillation] 80 mg tablets and one was to be administered to the resident. RN #1 was observed administering the medication. On 06/19/24 st 9:04 a.m., RN #1 and the surveyor reviewed Resident #93's medication orders in the resident's electronic medical record and then the container of Sotalol that had been administered that morning. RN #1 stated the order for Sotalol was for one 120 mg tablet but the container read 80 mg tablets. RN #1 stated the resident had been under-dosed. On 06/20/24 at 10:24 a.m., Regional Nurse stated that when RN #1 had administer the insulin to Resident #19 and Sotalol to Resident #93, they had not followed facility policy or the standards of care when they did not check the actual medications on hand against the physician's order.

Based on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner for one of one ice machines observed. Corporate nurse #1 identified 38 residents who received nourishment from the kitchen. Findings: The untitled, undated policy, read in parts, .It is the policy .that ice machines will be cleaned weekly and as needed. Maintenance will clean ice machine at a minimum of weekly . The Ice Machine Log, dated June 2024, documented the ice machine had been cleaned on 06/03/24, 06/10/24, and 06/17/24. On 06/17/24 at 9:02 a.m., the ice machine was observed with the dietary manager. The deflector panel on the inside of the ice machine was observed to contain a black/brown substance that was easily wiped off with a paper towel. The dietary manager stated the maintenance supervisor was responsible to clean the ice machine. The coil cover in the top portion of the ice machine was observed to contain a orange/yellow substance that was easily wiped with a paper towel. On 06/17/24 at 9:05 a.m., the maintenance supervisor stated the ice machine was cleaned weekly. The maintenance supervisor observed the ice machine and stated it looked like it needed to be cleaned more often due to the buildup.

Based on observation, record review, and interview, the facility failed to ensure indwelling urinary catheter tubing was placed to maintain infection control for one (#16) of one sampled resident who had an indwelling urinary catheter. Corporate nurse #1 identified one resident who had an indwelling urinary catheter. Findings: Resident #16 had diagnoses which included neuromuscular dysfunction of the bladder, retention of urine, and history of urinary tract infection. The quarterly assessment, dated 05/03/24, documented the resident had an indwelling urinary catheter and required maximal assistance for transfers to the chair. On 06/18/24 at 9:15 a.m., Resident #16 was observed in the hall in their wheel chair. The catheter tubing was observed to touch the floor. On 06/19/24 at 8:42 a.m., Resident #16 was observed in their room sitting in their wheel chair. They stated they were totally dependent on staff for transfers. The catheter tubing was observed to touch the floor. On 06/19/24 at 11:29 a.m., Resident #16 was observed by the nurses station in their wheel chair. The catheter tubing was observed to drag on the floor under the wheel chair. On 06/20/24 at 8:26 a.m., CNA #1 stated indwelling urinary catheter tubing was not to touch the floor. On 06/20/24 at 10:02 a.m., RN #1 stated indwelling urinary catheter tubing was not to touch the floor. They stated they would need to set up monitoring to ensure infection control was maintained regarding the placement of catheter tubing.

Based on record review and interview, the facility failed to ensure pain medication was administered per the physician's order for one (#1) of six sampled residents whose medications were reviewed. Corporate nurse #1 identified 29 residents on routine pain medication. Findings: Resident #1 had diagnoses which included neuropathy. The Care Plan, dated 02/21/24, documented to administer pain medication as ordered by the physician. The Prescription Order, dated 03/16/24, documented the resident had been ordered diclofenac sodium 1% (a pain reliever) topically to bilateral feet twice daily. The Treatment Administration History, dated 04/01/24 through 04/30/24, did not contain documentation the diclofenac had been administered on 04/08/24 for the a.m. shift or 04/11/24 for the a.m. or p.m. shift. The Treatment Administration History, dated 05/30/24, did not contain documentation the diclofenac had been administered on the a.m. or p.m. shift. The Treatment Administration History, dated 06/10/24, did not contain documentation the diclofenac had been administered on the p.m. shift. Review of the progress notes for April, May, and June 2024 did not reveal documentation regarding the missing documentation of the diclofenac. On 06/19/24 at 10:17 a.m., Resident #1 stated some days they did not receive the medication for their feet and they wanted the medication to be provided twice daily as ordered for pain management. On 06/20/24 1:27 p.m., Corporate nurse #1 stated they had no documentation as to why the diclofenac was not documented as administered per the physician's order. On 06/21/24 at 7:52 a.m., RN #1 stated the Resident # 1 would usually remind the nurses about the diclofenac gel for their feet. RN #1 stated the lack of documentation related to administration was an oversight and did not know why the pain medication was not documented as administered per the physician's order.

Based on observation, record review, and interview, the facility failed to promote resident dignity by staff standing over residents while assisting them to eat for two (#9 and #11) of three sampled residents reviewed for dignity. The administrator identified 38 residents resided in the facility. Findings: 1. Res #9 had diagnoses which included achondroplasia. A significant change assessment, dated 03/15/24, documented the resident's cognition was severly impaired and they required partial/moderate assistance with eating. On 04/10/24 at 8:18 a.m., CNA #3 was observed standing over the resident in the dining room while assisting them to eat their breakfast. On 04/10/24 at 8:31 a.m., CNA #3 was asked asked what was the protocol for assisting residents with eating. They stated they should sit next to the residents while assisting them with their meals. They were asked if they sat while assisting Res #9 with their breakfast. They stated they did not sit. 2. Res #11 had diagnoses which included CHF, SOB, diabetes, and seizures. A quarterly assessment, dated 01/17/24, documented the resident's cognition was moderately impaired and they required substantial/maximal assistance with eating. On 04/10/24 at 8:12 a.m., the DON was observed standing over the resident in the dining room while assisting them to eat their breakfast. On 04/10/24 at 8:47 a.m., the DON was asked what was the protocol for assisting residents with eating. They stated they should have sat down next to Res #11 while assisting them with their breakfast.

Based on record review and interview, the facility failed to ensure an RN worked seven days a week, eight hours a day, for nine of nine days reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The PBJ report for quarter one, documented no RN hours were reported for 11/09/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, 12/03/22, 12/10/22, 12/24/22, and 12/25/22. On 05/17/23 at 2:35 p.m., documentation of RN coverage was requested for the above dates from the BOM. On 05/17/23 at 2:50 p.m., the BOM stated they did not have any RNs who worked on the provided dates. They stated neither of the core facility RNs clocked in and they did not have agency RNs that were working in the facility. On 05/17/23 at 2:53 p.m., the administrator was asked what the facility protocol was regarding RN coverage. They stated there would be an RN seven days a week, eight hours per day. The administrator was asked who was responsible to ensure RN coverage. They stated the administrator and the DON. The administrator was asked why there was no RN coverage on the above listed dates. They stated because the DON was not here. The administrator was asked what other resources the facility had for RN coverage. They stated they could utilize RNs from sister homes and agency staffing.

Based on observation, interview, and record review, the facility failed to ensure residents with bed rails were assessed for the use for three (#2, 26, and #31) of three sampled residents who were reviewed for bed rails. Corporate Nurse #1 identified nine residents who utilized bed rails. Findings: The Proper Use of Side Rails policy, dated December 2016, read in part, .An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails .The use of side rails as an assistive device will be addressed in the resident care plan .Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . 1. Resident #2 had diagnoses which included congestive heart failure. The quarterly assessment, dated 04/03/23, documented the resident was moderately impaired in cognition for daily decision making and required extensive assistance from staff for bed mobility. The assessment was not coded to indicate the use of half side rails. The Care Plan, revised 04/05/23, did not reveal a care plan had been developed for the use of the half side rail. Review of the clinical record did not reveal an assessment for the use and safety of the bed rail or a physician's order. On 05/09/23 at 4:34 p.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. On 05/10/23 at 10:49 a.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. On 05/15/23 at 11:12 a.m., the resident was asked how the bed rail was raised and lowered. They stated they did not know how to do it and that staff raised and lowered the rail for them. The resident was asked how long they had the half bed rail. They stated they did not know. They stated when they pulled on it during repositioning the rail leans and wobbles. 2. Resident #26 had diagnoses which included congestive heart failure. The Care Plan, revised 12/27/22, did not reveal a care plan had been developed for the use of the half side rail. The quarterly assessment, dated 03/16/23, documented the resident was cognitively intact for daily decision making and required limited assistance from staff for bed mobility. The assessment was not coded to indicate the use of half side rails. Review of the clinical record did not reveal an assessment for the use and safety of the bed rail or a physician's order. On 05/10/23 at 10:13 a.m., the resident was observed in bed with a half side rail in the raised position on the right side of the bed. On 05/12/23 at 9:05 a.m., the resident was observed in bed with a half side rail in the raised position on the right side of the bed. On 05/15/23 at 12:39 p.m., the resident was asked how the half bed rail was raised and lowered. They stated they raised/lowered it themselves or the staff would do it if they asked. 3. Resident #31 had diagnoses which included vascular dementia. A Physician's Order, dated 01/05/23, documented half bed rails for repositioning and bed mobility. The Care Plan, dated 02/02/23, did not reveal documentation for the use of the half side rail. The quarterly assessment, dated 04/02/23, documented the resident was moderately impaired in cognition for daily decision making and required supervision from staff for bed mobility. The assessment was not coded to indicate the use of half side rails. Review of the clinical record did not reveal an assessment for the use and safety of the bed rail. On 05/09/23 at 4:23 p.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. The resident was asked why they had a half side rail. They stated, To keep me from falling out of bed, I've fallen out before. The resident was asked when they had fallen out of bed. They stated approximately six months ago. They stated the maintenance supervisor installed the bed rail after the fall. On 05/10/23 at 10:46 a.m., Resident #31 was observed in bed with a half side rail in the raised position on the left side of the bed. On 05/10/23 at 11:23 a.m., the resident was observed in bed with the half bed rail in the raised position on the left side of the bed. The resident was observed to utilize the bed rail to sit on the side of their bed. The bed rail moved back and forth and side to side when the resident pulled on it. On 05/15/23 at 11:13 a.m., CNA #1 was asked why Resident #2 had a half bed rail. They stated to assist with turning. They were asked how long they had the half bed rail. They stated as far as they knew the resident had the half bed rail since October 2022. CNA #1 was asked how the half bed rail was raised and lowered. They stated the staff raised and lowered the bed rail but the resident leaned to the left so they kept a pillow against the bed rail to assist with positioning. CNA #1 was asked why Resident #31 had the half bed rail. They stated the bed rail was used to assist the resident to get out of bed. They stated the resident raised and lowered the half bed rail themselves. On 05/15/23 at 11:20 a.m., CNA #5 was asked why Resident #26 had a half bed rail. They stated they were not sure but thought it was to keep the resident from falling. On 05/15/23 at 11:29 a.m., RN #1 was asked who was responsible to assess residents for the use of bed rails. They stated they did not know. They were asked how they determined a resident was safe to utilize bed rails. They stated they assessed the residents' ability to keep themselves upright in bed. They were asked why Resident #2 had a half bed rail. They stated it was to keep the resident from leaning too much and they were scared the resident would fall out of bed. They stated the resident was not aware of their body position. They were asked how long the resident had the half bed rail. They stated for approximately seven months. RN #1 was asked why Resident #26 had a half bed rail. They stated to help the resident with repositioning. RN #1 was asked how long Resident #31 had the half bed rail. They stated four to five months. They were asked why the resident had a half bed rail. They stated the resident requested it because he fell out of bed approximately four to five months ago and they did not feel safe. RN #1 was asked what other interventions had been implemented before the placement of the half rail. They stated a lot of times if a resident falls out of bed they implement a fall mat or bed rails. RN #1 was asked what risks were associated with utilizing bed rails for a resident with a history of falling out of bed. They stated the residents' clothing could get caught in the bed rail or their hand could get caught when the staff lowered the bed rail. On 05/15/23 at 11:46 a.m., the DON was asked how many residents utilized bed rails. They stated approximately half. The DON was asked who was responsible to assess residents for the use of bed rails. They stated the charge nurses. They were asked where the assessments for the use of bed rails were documented. They stated in the progress notes. The DON was asked how often residents were assessed for the use of bed rails. They stated they thought it was an ongoing assessment.

Based on record review and interview, the facility failed to complete comprehensive care plans for five (#2, 10, 26, 31, and #34) of 12 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, dated December 2016, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. Resident #2 had diagnoses which included congestive heart failure. The quarterly assessment, dated 04/03/23, documented the resident was moderately impaired in cognition for daily decision making and required extensive assistance from staff for bed mobility. The assessment was not coded to indicate the resident utilized side rails. On 05/09/23 at 4:34 p.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. Review of the clinical record did not reveal a care plan had been developed for the use of the half side rail. 2. Resident #26 had diagnoses which included congestive heart failure. The quarterly assessment, dated 03/16/23, documented the resident was cognitively intact for daily decision making and required limited assistance from staff for bed mobility. The assessment was not coded to indicate the resident utilized side rails. On 05/10/23 at 10:13 a.m., the resident was observed in bed with a half side rail in the raised position on the right side of the bed. Review of the clinical record did not reveal a care plan had been developed for the use of the half side rail. 3. Resident #31 had diagnoses which included vascular dementia. The quarterly assessment, dated 04/02/23, documented the resident was moderately impaired in cognition for daily decision making and required supervision from staff for bed mobility. The assessment was not coded to indicate the resident utilized side rails. On 05/09/23 at 4:23 p.m., the resident was observed in bed with a half side rail in the raised position on the left side of the bed. Review of the clinical record did not reveal a care plan had been developed for the use of the half side rail. On 05/15/23 at 1:08 p.m., the MDS coordinator and Corporate Nurse #1 was asked how often care plans were reviewed to ensure the resident had a comprehensive care plan in place. The MDS coordinator stated with quarterly, annual, or with significant change assessments. The MDS coordinator was asked why a comprehensive care plan for Resident #2, Resident #26, and Resident #31, had not been developed to include the residents' use of half side rails. They stated they had reviewed the care plan for Resident #2 after the quarterly assessment but had not included the use of half side rails. The MDS coordinator stated they did not know why a care plan for the use of half side rails had not been developed for Resident #26 and Resident #31. Corporate Nurse #1 stated there should be comprehensive care plans for the residents. 4. Resident #34 had diagnoses which included neuromuscular dysfunction of the bladder and excoriation (skin-picking) disorder. The significant change assessment, dated 01/23/23, documented the resident had an indwelling urinary catheter and was at risk for pressure ulcer development. The MAR, dated 03/01/23 through 03/31/23, documented the resident had treatment orders in place for a pressure ulcer to the left heel. The Care Plan, updated 03/16/23, did not include documentation regarding the resident's risk for pressure ulcer development, actual pressure ulcers, or the use of an indwelling urinary catheter. The quarterly assessment, dated 04/02/23, documented the resident had an indwelling urinary catheter, was at risk for pressure ulcers, and had an unhealed Stage II pressure ulcer. On 05/09/23 at 1:28 p.m., Resident #34 was observed to have an indwelling urinary catheter and bandages to bilateral feet. On 05/16/23 at 4:06 p.m., the MDS coordinator was asked why a comprehensive care plan had not been developed to include the resident's risk for pressure ulcers/actual pressure ulcers. They stated they did not know. On 05/17/23 at 9:44 a.m., the MDS coordinator was asked how long the resident had the indwelling urinary catheter. They reviewed the electronic clinical record and stated since October 2020. They were asked where the care plan for the indwelling urinary catheter was documented. They stated they could not find the care plan for use of a catheter. The MDS coordinator was asked why a comprehensive care plan had not been developed to include the use of an indwelling urinary catheter. They stated they were rebuilding the care plan. 41809 5. Resident #10 had diagnoses which included chronic obstructive pulmonary disease and chronic bronchitis. An admission assessment, dated 11/29/22, documented under the care area assessment summary the resident had cognitive loss, visual function, communication, activity of daily living functional status, urinary incontinence/indwelling catheter, falls, pressure ulcer/injury, and psychotropic medication use. Review of the clinical record for Resident #10 did not reveal a care plan had been developed after the admission assessment. On 05/12/23 at 5:40 p.m., the MDS coordinator was asked what the protocol was for completing a comprehensive care plan. They stated a comprehensive care plan should be completed on admission, after a significant change, quarterly, and annually. The MDS coordinator was asked who was responsible to complete the comprehensive care plan. They stated the MDS nurse. The MDS coordinator was asked how care plans were monitored to ensure they were completed and accurate. They stated the DON/RN should review the care plans. The MDS coordinator was asked to provide the care plan for Resident #10. They stated Resident #10 did not have a comprehensive care plan. The MDS coordinator was asked why the care plan was not completed. They stated they did not know because they had not started working at the facility until March 2023.

Based on record review and interview, the facility failed to implement the facility's antibiotic stewardship program. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: An Infection Prevention and Control Program policy, revised October 2018, read in parts, .Culture reports, sensitivity data, and antibiotic usage review are included in surveillance activities .Medical criteria and standardized definitions of infections are used to help recognize and manage infections . A review of the facility's antibiotic stewardship and surveillance book did not reveal antibiotic use protocols or an active system to monitor antibiotic use had been documented. On 05/15/23 at 1:46 p.m., Corporate Nurse #1, was asked to provide the antibiotic stewardship. They stated they were not doing it and it had been a year since it was last done. They stated the antibiotic surveillance and stewardship was to be documented in the electronic clinical record, but they had not been completing it.

Based on observation, interview, and record review, the facility failed to ensure residents' beds were maintained when bed rails were utilized for three (#2, 26, and #31) of three sampled residents who were reviewed for bed rails. Corporate nurse #1 identified nine residents who utilized bed rails. Findings: The Bed Safety policy, dated December 2007, read in parts, .Ensure that bed side rails are properly installed .The maintenance department shall provide a copy of inspections to the administrator .If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative . 1. Resident #2 had diagnoses which included congestive heart failure. On 05/09/23 at 4:34 p.m., the resident was observed in bed with a half bed rail in the raised position on the left side of the bed. On 05/10/23 at 10:49 a.m., the resident was observed in bed with a half bed rail in the raised position on the left side of the bed. On 05/15/23 at 11:12 a.m., the resident stated when they pulled on the half bed rail during repositioning the rail leans and wobbles. 2. Resident #26 had diagnoses which included congestive heart failure. On 05/10/23 at 10:13 a.m., the resident was observed in bed with a half bed rail in the raised position on the right side of the bed. On 05/12/23 at 9:05 a.m., the resident was observed in bed with a half bed rail in the raised position on the right side of the bed. 3. Resident #31 had diagnoses which included vascular dementia. A Physician's Order, dated 01/05/23, documented half bed rails for repositioning and bed mobility. On 05/09/23 at 4:23 p.m., the resident was observed in bed with a half bed rail in the raised position on the left side of the bed. The resident was asked why they had a half bed rail. They stated, To keep me from falling out of bed, I've fallen out before. They stated the maintenance supervisor installed the bed rail. On 05/10/23 at 11:23 a.m., the resident was observed in bed with the half bed rail in the raised position. The resident was observed to utilize the bed rail to sit on the side of their bed. The bed rail was observed to move back and forth and side to side when the resident pulled on it. On 05/15/23 at 12:26 p.m., the administrator was asked who was responsible to ensure residents' beds were safe and bed rails were properly installed and maintained. They stated the maintenance supervisor but they had recently ended employment at the facility. The administrator was asked where the safety inspections, including that of bed rails, was documented. They stated in the maintenance logs. On 05/15/23 at 12:32 p.m., the administrator observed the bed rail for Resident #31. The administrator stated the bed rail seemed secure. Resident #31 stated to the administrator they utilized the bed rail because they had fallen out of bed. On 05/15/23 at 12:36 p.m., the administrator observed the bed rail for Resident #2. The administrator stated the bed rail could be more secure when they moved the bed rail from side to side and back and forth. On 05/15/23 at 12:39 p.m., the administrator observed the bed rail for Resident #26 and stated the rail could use tightening. On 05/15/23 at 1:44 p.m., the administrator stated they had reviewed the maintenance log but bed and bed rail safety were not documented. The administrator was asked when they had last reviewed the maintenance log to ensure beds and bed rails had been inspected for proper installation and safety. They stated it was probably in March 2023. They stated they had no documentation from maintenance to provide.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician and implemented for four (#7, 17, 18, and #42) of five sampled residents reviewed for unnecessary medications. Corporate Nurse #1 identified 48 residents who received medications. Findings: An undated Drug Regimen Review Policy, read in parts, .The attending physician will document in the resident record, that the identified irregularity has been reviewed and what, if any action has been taken to address it. If the physician chooses not to act upon the pharmacy consultant recommendations, the physician must document rationale as to why the change is not indicated in the resident record . 1. Resident #7 had diagnoses which included depression. A Medication Regimen Review, dated 03/29/23, documented a recommendation to add Famotidine 20 mg twice a day or Omeprazole 20 mg every day. The physician addressed and agreed with the recommendation. Review of the clinical record revealed the facility had not implemented the recommendation for Resident #7. 2. Resident #18 had diagnoses which included chronic obstructive pulmonary disease. A Medical Director Report, dated 05/12/22, documented recommendation for a gradual dose reduction attempt for Paroxetine 20 mg every day. A Medical Director Report, dated 06/18/22, documented a recommendation for a gradual dose reduction attempt for Clonazepam 0.5 mg every four hours as needed. A Medical Director Report, dated 09/22/22, read in parts, .Gradual Dose Reduction Attempt .Trazodone 100mg HS .Do you feel a reduction could be attempted on the above medication(s) at this time . A Medical Director Report, dated 02/24/23, documented a recommendation to change Combivent Respimat to one puff four times a day due to manufacturer recommended dosing or change to Trelegy which was one puff daily. A Medical Director Report, dated 03/29/23, documented a recommendation to reduce the muscle relaxer, tizanidine 4 mg twice a day, to as needed due to the medication being poorly tolerated by older adults because of anticholinergic adverse effects, sedation, and increased risk for fractures. The Medical Director Reports, dated 05/12/22, 06/18/22, 09/22/22, 02/24/23, and 03/29/23 for Resident #18 were not signed by the physician. Review of the clinical record did not reveal the pharmacist recommendations had been addressed by the physician for Resident #18. 3. Resident #42 had diagnoses which included delusional disorder, schizophrenia, and depressive disorder. A Medication Regimen Review, dated 05/11/22, documented a gradual dose reduction attempt for Mirtazapine 15 mg HS. A Gradual Dose Reduction, dated 09/21/22, documented an attempt to reduce Trazodone 100 mg HS, venlafaxine ER 150 mg every day, and Buspirone 5 mg four times a day. The Gradual Dose Reduction for Resident #42 was not signed by the physician. A Medication Regimen Review, dated 11/21/22, documented a recommendation to discontinue Vitamin D 5000 U every day, Vitamin C 500 mg twice daily, and Zinc 50 mg every day related to a COVID-19 diagnosis. A Medical Director Report, dated 01/23/23, read in parts, .an antipsychotic order for Olanzapine 20mg HS for Delusional disorders of note, dementia dx on file. Black box warning the antipsychotic use gradual dose reduction was sent 1/2023 to the facility . The Medical Director Report for Resident #42 was not signed by the physician. A Gradual Dose Reduction was not located in the clinical record for Resident #42. The Medication Regimen Reviews, dated 05/11/22 and 11/21/22 were not signed by the physician. Review of the clinical record did not reveal the pharmacist recommendations had been addressed by the physician for Resident #42 35474 4. Resident #17 had diagnoses which included diabetes mellitus and hypokalemia. A Medical Director Report, from the consultant pharmacist, dated 10/26/22, read in part, .10/19/22 - Novolog AC PRN SS Sliding scale insulin use is on the Beers Criteria List, not recommended in LTC setting due to a higher risk of hypoglycemia without improvement in hyperglycemia management .Recommend DC of SS insulin, increase Trulicity to 1.5mg QW after 4 to 8 weeks if needed to achieve glycemic goals. If not DC'd, can we change first administration of sliding scale insulin to start at 250-300 at 3 units . A Medication Regimen Review, dated 02/23/23, read in parts, .Sliding scale insulin use is on the Beers Criteria List, not recommended in LTC setting due to higher risk of hypoglycemia without improvement in hyperglycemia management .Recommend DC of SS insulin . A Medical Director Report, from the consultant pharmacist, dated 02/24/23, .Recommend recheck of CMP level r/t increase in Potassium dose . The Medical Director Reports, dated 10/26/22 and 02/24/23 had not been signed by the physician. The Medication Regimen Review, dated 02/23/23, had not been signed by the physician. Review of the electronic clinical record did not reveal the physician had addressed the recommendations listed above from the consultant pharmacist for Resident #17. On 05/15/23 at 4:29 p.m., the DON was asked who was responsible to ensure gradual dose reductions and pharmacist recommendations were addressed by the physician. They stated the administrator and themselves were responsible. The DON was asked why the pharmacist recommendations, based on the Medical Director Reports, were not addressed by the physician for Resident #18, Resident #42, and Resident #17. They stated they did not know. They stated they were probably in the stacks of papers they found when they began employment at the facility. The DON was asked how they ensured recommendations from the consultant pharmacist were implemented. They stated once the physician faxed the signed recommendations to the facility the orders were put in the electronic clinical record. The DON was asked why the 03/29/23 pharmacist recommendation, which was signed by the physician, had not been implemented for Resident #7. They stated they did not know why it was not implemented. On 05/16/23 at 9:05 a.m., the consultant pharmacist was asked how the facility was notified of their recommendations to the physician. They stated after they had completed their consultation they emailed the reports to the facility. They stated the facility had access to the program they utilized and could access current and previous reports and recommendation as needed.

Based on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner for one of one ice machines observed and failed to ensure foods were prepared in a sanitary manner for one (the evening meal) of one meal preparation observed. Corporate Nurse #1 identified 48 residents who received nourishment from the kitchen. Findings: The undated Policy & Procedure for Ice Machine Maintenance & Cleaning policy, read in part, .Cleaning to be performed Quarterly or as deemed necessary .Use clean rags or disposable wipes to scrub all surfaces/including the ice storage compartments with ice machine cleaner or fresh distilled vinegar solutions .Clean reservoir and hoses .Clean condenser . 1. The Weekly Ice Machine Maintenance log entry, dated 04/12/23, read in part, .Wiped down and checked machine-it is clean . The Weekly Ice Machine Maintenance log entry, dated 04/19/23, read in part, .Wiped down splash curtain . The Weekly Ice Machine Maintenance log did not reveal any further monitoring/cleaning after 04/19/23. On 05/09/23 at 9:50 a.m., the ice machine was observed with the dietary manager. The dietary manager removed the front panel of the ice machine. The dietary manager stated, That's not clean. The panel of coils was observed to have a black, brown, and orange substance under, on top of, and on the sides of the panel. A slab of ice was observed to be against the black, brown, and orange substance and then fell into the bin of the ice machine. The deflector panel, in the bin of the ice machine, was observed to contain a light brown substance when wiped with white napkin. On 05/09/23 at 9:51 a.m., the dietary manager was asked what the black, brown, and orange substance was around the coils in the top portion of the ice machine. They stated dust accumulated on the coils and made a mud-type substance. The dietary manager stated, We can't use this ice, this is not clean at all. The dietary manager was asked who was responsible to ensure the ice machine was maintained in a sanitary manner. They stated they had cleaned it in December 2022 and it was worse than this. They stated the maintenance supervisor was responsible to clean the ice machine. They were asked how the ice machine was monitored to ensure it was maintained in a sanitary manner. They stated they needed to start monitoring the ice machine. On 05/09/23 at 10:27 a.m., the maintenance supervisor was asked who was responsible to ensure the ice machine was maintained in a sanitary manner. They stated they were responsible. They were asked why the ice machine had a black, brown, and orange substance around the coils and a light brown substance on the deflector panel in the bin. They stated they had recently returned from a two week vacation and no one had cleaned the ice machine during that time. They were asked how often the ice machine was cleaned. They stated they checked it once a week and wiped it down if needed. They stated they cleaned the deflector panel weekly and emptied the ice machine on 03/25/23. They stated they would empty the ice machine and run a cleaner through it every three to four months. They were asked when the ice machine last had the cleaner run through it. They stated approximately two weeks ago. They were asked where they documented the cleaning of the ice machine. They stated in the maintenance log. 2. On 05/09/23 at 5:07 p.m., Cook #1 was observed to prepare ham and cheddar croissant sandwiches for the evening meal. Cook #1 was observed to don gloves and touch ladle handles, the food trays, the counter top in the food service area, and would then place the top of the croissant onto the sandwich, hold it onto the plate with their gloved hand, and cut it in half. Cook #1 was observed, at times to obtain slices of ham and cheese to place on the croissants with the same gloved hands. On 05/09/23 at 5:21 p.m., Cook #2 was observed to prepare a bacon, lettuce, and tomato sandwich and french fries for a resident. Cook #2 was observed to don gloves, touch the counter top in the food preparation area, the spatula handle used to cook the bacon, and plates. The cook was observed to open a bag of sliced bread, obtain two slices, place them on the plate with the same gloved hands. Once the sandwich was assembled, Cook #2 was observed to pick up the prepared sandwich and smash it between their same gloved hands. Cook #2 was observed to empty the cooked french fries onto the plate and used their same gloved hands to ensure the french fries did not fall off the plate. On 05/10/23 at 10:29 a.m., Cook #1 was asked how food was to be handled to maintain infection control during meal service. They stated they were to use utensils, including tongs, and change their gloves as needed. Cook #1 was asked why utensils had not been used and their gloves changed to maintain infection control during the evening meal service on 05/09/23. They stated they did not know. On 05/10/23 at 10:32 a.m., Cook #2 was asked how food was to be handled to maintain infection control during meal preparation and food service. They stated they were to wear gloves at all times. They were asked when gloves were to be changed. They stated when their hands got sweaty or if they had to obtain a different food item. Cook #2 was asked how bagged, sliced bread was to be obtained. They stated they could obtain it straight from the bag as long as they had gloves on. They were asked why utensils had not been used and their gloves changed when they prepared the bacon, lettuce, and tomato sandwich for the evening meal on 05/09/23. They stated they should have changed their gloves. On 05/10/23 at 10:36 a.m., the dietary manager was asked how food was to be handled to maintain infection control during meal service. They stated staff were to wash their hands, wear gloves at all times, and utilize utensils or deli papers to obtain food. They were asked how they monitored to ensure infection control was maintained during meal preparation and food service. They stated they observed the staff. They were asked why the staff had not maintained infection control during food service and meal preparation during the evening meal on 05/09/23. They stated it was a crazy day.

Based on record review and interview, the facility failed to ensure code status was accurate for one (#37) of one sampled residents who were reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided in the facility. Findings: The Do Not Resuscitate Order policy, dated April 2017, read in part, .Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record . Resident #37 had diagnoses which included chronic obstructive pulmonary disease. The Care Plan, dated 10/03/22, documented the resident had a DNR. Review of the electronic face sheet for Resident #37 revealed the code status was DNR. A signed DNR, dated 10/04/22, was observed in the electronic clinical record. A Physician's Order, dated 02/23/23, documented the resident was a full code. On 05/15/23 at 2:13 p.m., RN #1 was asked where the code status' were documented. They stated they referred to the electronic clinical record or the code status binder at the nurses station. RN #1 was asked what the code status was for Resident #37. They reviewed the electronic clinical record and stated the face sheet documented the resident was a DNR. They were asked why the physician orders documented Resident #37 was as full code. They stated they were not sure. They stated the resident may have had a change in status and the clinical record had not been updated by the MDS coordinator. On 05/15/23 at 2:33 p.m., the DON was asked what the code status was for Resident #37. They reviewed the electronic clinical record and stated the face sheet documented the resident was a DNR. They were asked what the physician's order was regarding code status. They stated the physician's order documented the resident was a full code. They stated they would need to check into the discrepancy. On 05/15/23 at 4:40 p.m., the DON stated they were not sure why the physician's order indicated the resident was a full code when there was a signed DNR in the clinical record. The DON was asked how they monitored to ensure there were not discrepancies regarding residents' code status. They stated the MDS coordinator and the administrator reviewed the code status binder at the nurses station. They were asked how often physician orders were reviewed to ensure the code status was accurate. They stated they thought they were reviewed quarterly. The DON was asked when the physician's orders for Resident #37 were last reviewed. They stated they had reviewed them in late March 2023. They were asked why the discrepancy had not been identified during the review. They stated they had not seen the order for the full code status.

Based on record review and interview, the facility failed to request a level II PASARR for one (#23) of one sampled resident reviewed for level II PASARRs. Corporate Nurse #1 identified eight residents with level two PASARR assessments who resided in the facility. Findings: Resident #23 had diagnoses which included anxiety, major depressive disorder, and schizophrenia. An admission assessment, dated 06/10/21, documented Resident #23 had a diagnosis of schizophrenia. A level I PASARR, dated 06/11/21, documented Resident #23 had no diagnosis of serious mental illness. An annual assessment, dated 05/02/23, documented Resident #23 had diagnoses which included depression, schizophrenia, and anxiety. Section A question A1500 asked if Resident #23 was currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. The selected answer was no. Resident #23 did not have a completed level II PASARR in the clinical record. On 05/16/23 at 9:40 a.m., Corporate Nurse #1 was asked what diagnosis of mental disorder was coded on the admission or annual assessment. They stated there was no mental disorder coded. The corporate nurse was asked what diagnoses Resident #23 had when they admitted to the facility. They stated schizophrenia. The corporate nurse was asked what mental disorder was coded on the level I PASARR. They stated there was no mental disorder listed on the level I PASARR. On 05/16/23 at 11:30 a.m., the administrator was asked what the process/protocol was for PASARRs. They stated they usually reviewed them, if there was any psychological diagnosis they referred to OHCA (Oklahoma Health Care Authority) for a level II PASARR. The administrator was asked who was responsible to monitor to ensure level I PASARRs were completed and referred when necessary. They stated the MDS coordinator would bring the PASARR to either the DON or the administrator.

Based on record review and interview, the facility failed to ensure baseline care plans were completed for two (#10 and #37) of four sampled residents reviewed for baseline care plans within 48 hours of admission. Corporate Nurse #1 identified 17 residents who were admitted to the facility in the past six months. Findings: The policy Care Plans - Baseline, dated December 2016, read in parts, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight .hours of admission . 1. Resident #10 was admitted on [DATE] and had diagnoses which included chronic obstructive pulmonary disease. Review of the clinical record did not reveal a baseline care plan had been developed for the resident. On 05/12/23 at 4:50 p.m., the MDS coordinator was asked who was responsible to develop baseline care plans. They stated they were responsible. They were asked where the baseline care plan was documented for Resident #10. They stated a baseline care plan had not been developed for the resident. 2. Resident #37 was admitted on [DATE] and had diagnoses which included chronic obstructive pulmonary disease. Review of the clinical record did not reveal a baseline care plan had been developed for the resident. On 05/15/23 at 1:08 p.m., the MDS coordinator was asked where baseline care plans were documented. They stated they were documented on a paper form. The baseline care plan was requested for Resident #37. On 05/15/23 at 1:45 p.m., Corporate Nurse #1 stated they had not completed a baseline care plan for Resident #37. 41809

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after a quarterly assessment for one (#42) of twelve sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 48 residents resided at the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, dated December 2016, read in part, .The interdisciplinary team must review and update the care plan .at least quarterly, in conjunction with the required quarterly MDS assessment . Resident #42 had diagnoses which included Alzheimer's disease, schizophrenia, and anxiety disorder. Review of the clinical record revealed the care plan for Resident #42 was last revised on 01/23/23. A review of the clinical record for Resident #42 revealed a quarterly assessment was completed on 03/16/23. On 05/17/23 at 2:38 p.m., the MDS coordinator was asked when the care plan for Resident #42 was revised. They reviewed the electronic record and stated 01/23/23, but Resident #42 had a comprehensive assessment on 03/16/23 and it should have been updated on that date. The MDS coordinator was asked why the care plan was not updated and revised after the comprehensive assessment. They stated they did not know, they were not employed at the facility at that time.

Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect for one (#3) of four sampled residents who were reviewed for abuse/neglect. Resident #3 was transfered/repositoned in an unsafe [NAME] by staff which resulted in a nondisplaced fracture of the left humerus. There was a delay in treatment and administartation was not notifed in a timely manner when the resident identified to staff the alleged perpetrator The facility identified 41 residents who resided in the facility. Findings: A facility policy titled, Abuse Prohibition Procedure, updated 01/31/20, documented, .The resident has a right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion .Neglect .The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Identification: Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident .immediately to their supervisor or Senior Staff Member .The Senior Staff Member is defined as the 'highest ranking person in the building at the time of the incident' .The supervisor or Senior Staff Member shall immediately report to the Administrator or person on call . When an employee becomes aware of an allegation or suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately .The charge nurse will: Notify the Administrator or person on-call, if after hours . Investigation .The charge nurse will: Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents . 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/16/21, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance of at least two staff members for bed mobility and transfers, was not steady and was only able to stabilize with staff assistance when transferring from bed/chair/wheelchair, and had impairment on one side of his upper extremity. Review of the MAR, dated March 2021, did not reveal prn [MEDICATION(S)] had been administered. Review of the MAR, dated April 2021, did not reveal prn [MEDICATION(S)] had been administered. Review of the MAR, dated May 2021, documented the resident had received [MEDICATION(S)] 5mg prn on 05/08/21. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .pain discomfort . The CMA had placed their initials under the section labeled Site. Review of the progress notes did not reveal any information in regards to the location of the resident's pain. An entry on the narcotic record, dated 05/10/21 at 2:15 a.m., documented the resident had received a prn dose of [MEDICATION(S)] 5mg. A nurse progress note, dated 05/10/21 at 4:06 a.m., documented, Resident c/o left arm pain 10/10, PRN pain med given at this time. Left arm is slightly swollen and bruised from elbow to wrist. Waiting instructions from PCP . The nurse note was signed by LPN #3. A nurse progress note, dated 05/10/21 at 6:23 a.m., documented, 10-6 called and reported that PCP responded regarding left arm with a new order for a [sic] x-ray to be completed on day shift, [Radiology company name withheld] will be contacted via this nurse and completed on 6-2 shift . An entry on the narcotic record, dated 05/10/21 at 11:00 a.m., documented the resident had received a prn dose of [MEDICATION(S)] 5mg. A nurse progress note, dated 05/10/21 at 11:00 a.m., documented, [Radiology company name withheld] tech arrived and attempted to complete x-ray to left arm and unable to obtain complete full set of x-ray d/t resident refused. Awaiting on results that was obtained . A nurse progress note, dated 05/10/21 at 11:40 a.m., documented, PCP contacted d/t resident was observed having more slurred speech than normal and difficulty with swallowing. With new order to send resident to [name of hospital withheld] ER for eval and treat and have his left arm assessed while there. Attempted to collect full set of vitals with resident refusing being combative, BP 118/62 R-16 T-97.2, resident mother [name withheld] contacted .METSA contacted and awaiting for transportation, ER notified . A radiology report, faxed to the facility on [DATE] at 11:58 a.m., documented, .LEFT HUMERUS X-Ray - 2 view: Findings: AP and lateral views were obtained. A nondisplaced fracture of the distal humerus is seen. There are no bony [CONDITION(S)]. [CONDITION(S)] changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. IMPRESSION: Acute distal humerus fracture . A nurse progress note, dated 05/10/21 at 12:09 p.m., documented, Metsa arrived and was sent to [hospital name withheld] for eval and treat with paperwork . An emergency department triage note, dated 05/10/21 at 12:31 p.m., documented the resident was brought to the hospital for increased slurred speech and painful/swollen left arm. A nurse progress note, dated 05/10/21 at 12:43 p.m., documented the facility had received the x-ray results and they had been sent to the hospital and to the resident's physician. An x-ray report from the hospital, dated 05/10/21 at 1:43 p.m., documented, .Final Result 1. Non-displaced fracture of the left supracondylar humerus. Consider dedicated elbow radiograph for thorough assessment. 2. Suspect osteopenia. 3. Glenohumeral [CONDITION(S)] . A nurse progress note, dated 05/10/21 at 4:46 p.m., documented the hospital notified the facility the resident was being transferred to another hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A hospitalist history and physical, dated 05/10/21 at 9:29 p.m., documented, .According to the nurse the patient is known as noncompliant at the nursing home. It sounded like he did not want to be turned and they turned him anyway and it is possible that this broke his left arm. Unclear how the fracture occurred. The patient complains of 7 out of 10 pain that is sharp in the left arm .ASSESSMENT AND PLAN: Nondisplaced left humeral fracture-arm is in a sling . An initial incident report on ODH form 283, dated 05/10/21, documented, .Incident Date 05/10/21 .Incident Type Certain Injuries .Description of Incident .[Resident #3] states that his elbow was hurting. Upon inspection it was noted that elbow was swollen and tender to touch. Bruising was noted around elbow and left arm. Xray was taken and showed acute distal humerus fracture. Resident was taken to [hospital name withheld] for fracture and resident was [sic] symptoms of possible stroke . An observer statement by temporary nurse aide #1, dated 05/10/21, documented that on 05/08/21 the resident wanted to sit on the side of the bed but the temporary nurse aide had been told the resident was to lay back down in bed after a few minutes. The statement documented, While I was laying him back down I heard a pop from [resident #3], I checked it out and got him into bed them went to [name withheld] and [LPN #4] and told them what happened what I heard and what I was seeing with the bruising on his arm, I continued to check on him and reported every time that he said I broke his arm and that his arm was broken. The statement was signed by temporary nurse aide #1. An observer statement by temporary nurse aide #2, dated 05/10/21, documented temporary nurse aide #2 was assisting temporary nurse aide #1 with moving resident #3 up in his bed. The statement documented temporary nurse aide #1 had the resident's arm when the resident was moved. The statement documented, .[temporary nurse aide #1] told me she heard something pop I told [LPN #4] she went and looked at it. She told me it was just fine I had went back in [resident #3] room he was telling me his arm was broke [LPN #4] said it wasn't and its always bruised like that so I left it alone. The statement was signed by temporary nurse aide #2. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form ODH 718, dated 05/10/21, documented temporary nurse aide #1 was suspended on 05/10/21. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form ODH 718, dated 05/10/21, documented temporary nurse aide #2 was suspended on 05/10/21. A hospital social worker progress note, dated 05/11/21 at 3:31 p.m., documented, .SW attempted to meet with Pt in regards to concerns of his care at the NH. SW unable to understand pt due to hx of stroke, Pt has worsening [CONDITION(S)] and slurred speech. Pt was presented with a broken left arm on arrival to [hospital name withheld], per consult Pt reports 'staff grabbed him' . A final incident report on ODH form 283, dated 05/13/21, documented, .summary of the investigation .Resident was sent to hospital for non-displaced fracture of left supracondylor [sic] humerus. Resident was noted to have increased slurred speech and drooling, was sent to rule out new CVA. [Temporary nurse aide #2] and [temporary nurse aide #1] was suspended during investigation. Interviewed the nurses on 5/8, 5/9, 5/10 all have stated that they were not informed of injury. [Temporary nurse aide #2] and [temporary nurse aide #1] have been suspended during the investigation and have been educated on how to properly lift a resident and how to properly report to the nurse. They have been informed that if the nurse does not respond to call the DON and DON will come investigate the situation. Resident is returning to facility 5/13/2021 for hospice care for unrelated diagnosis. It was found that [temporary nurse aide #2] and [temporary nurse aide #1] lifted resident improperly during a transfer. They have been educated about how to lift a resident properly in bed and from sitting position to laying down in bed. [Temporary nurse aide #2] and [temporary nurse aide #1] have been properly educated on how to report to nurse. They have been informed if the nurse does not respond to their needs that they are to call DON immediately and the DON will investigate . An investigation of injuries of unknown origins form, dated 05/13/21, documented the following: ~ Time injury was discovered - 6:00 a.m.; ~ Time of last observation prior to injury - 4:06 a.m.; ~ Time of administrator notification - 8:00 a.m.; ~ Type of injury - left supracondylar humerus non-displaced fracture; ~ Did the resident have a recent fall - No; ~ Ask the resident if they fell - Resident stated that his arm was pulled; ~ Describe the injury - Left elbow swollen, bruising, blue in color note on lower and upper left arm; ~ Document the resident's ability to tell what happened - Resident stated that aide pulled arm; ~ Nurses description of how the injury may have occurred - Nurses state that they were not given report of the injury; ~ What diagnosis/medications put the resident at risk for this type of injury - Resident is noncompliant with meds and osteopenia; ~ What interventions were in place prior to the injury - Resident required two person assistance at all times; and ~ What interventions were implemented after the injury - Resident was sent to the hospital for further evaluation. The investigation of injuries of unknown origin form was signed by the DON. A hospitalist discharge summary, dated 05/13/21 at 3:12 p.m., documented, .Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Back to nursing home on hospice .[CONDITION(S)] and slurred speech/stroke symptoms .Nondisplaced left humeral fracture-stable, seen by orthopedics who states sling and nonweightbearing [sic] .[CONDITION(S)] with RVR . A care plan, updated 05/15/21, documented, .Problem .I Require Assist With ADLS .Approach Start Date: 01/31/20 .Assist me with bed mobility, transfers and ambulation as needed . Review of the care plan did not reveal the amount or type of assistance required for the resident. A notice of disciplinary action for temporary nurse aide #1, dated 05/15/21, documented the employee had a safety violation which occurred on 05/08/21. The form documented, .Details of Events: Moved resident, injury noted Corrective action to be taken: Inform nurse, if nurse doesn't listen call DON. Educated on how to properly move resident . The notice of disciplinary action was signed by temporary nurse aide #1 on 05/15/21. Review of temporary nurse aide #1's time detail revealed she had worked after the incident on 05/11/21 and 05/12/21. On 06/03/21 at 12:03 p.m., CNA #4 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated two staff members assisted with the transfer while one staff member stabilized the wheelchair. She stated he required two person assist for repositioning. At 12:06 p.m., CNA #3 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated he was a two to three person assist for transfers and required two person assist for repositioning. At 12:15 p.m., CNA #5 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated the resident utilized a mechanical lift when he was compliant. She stated the resident required two person assistance for repositioning. At 12:46 p.m., LPN #4 was asked about the incident on 05/08/21 in which resident #3 had sustained a fracture of the left humerus. She stated the staff had not notified her of any injuries. She was asked why the resident had received a prn [MEDICATION(S)] on 05/08/21 during her shift. She stated she did not know. She was asked what the process was if a resident requested a prn pain medication. She stated the CMAs administered medication and usually there was not a nurse assessment. At 1:19 p.m., CMA #2 was asked about the incident on 05/08/21 for resident #3. She stated she had arrived to work on 05/10/21 for the day shift and noticed the resident was not acting like himself. She stated she notified the nurse and the resident had been sent to the hospital. She was asked what type of assistance the resident required for transfers and repositioning. She stated he required a mechanical lift for transfers and a draw sheet was used for repositioning. She was asked how often the resident requested a prn pain medication. She stated, Not very often. She stated the resident complained of pain one or two times a month but did not always want medication for it. At 1:29 p.m., LPN #5 was asked about the incident on 05/08/21 in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked if she had assessed the resident's arm. She stated yes. She stated the arm was observed to be swollen and bruised. She stated at approximately 6:30 a.m. the night shift nurse reported to her the physician ordered x-rays of the resident's left arm. She stated she entered the order into the computer and called the radiology company. She stated the radiology company arrived before lunch and the CMA had notified her the resident's speech was different and he had difficulty swallowing. She stated she assessed the resident and he refused to go to the hospital at first then decided he would go. She was asked what the night shift nurse had reported had happened to the resident's arm. She stated the nurse reported to her she did not know what had happened. She stated the night shift CNAs had gone into the resident's room and he told them his arm was broken and not to touch it. She was asked how the resident transferred from bed to chair. She stated the resident required two to three aides and a gait belt. She was asked what type of assistance the resident required to reposition in bed. She stated the resident required two person assistance and they used a draw sheet. She was asked how often the resident complained of pain. She stated, Not often. She was asked how CNAs were trained for transfers and repositioning. She stated the 'training aide' and another CNA trained the new employees. On 06/03/21 at 4:35 p.m., the administrator was asked why temporary nurse aide #1 was identified in the initial state report dated 05/10/21, as injuring resident #3's arm, worked shifts on 05/11/21 and 05/12/21 before the investigation was completed on 05/13/21, and the temporary nurse aide had been educated on 05/15/21. She stated the DON may have educated her verbally before 05/15/21. She stated the only documentation they had found was the disciplinary action form dated 05/15/21. She was asked where skills competency evaluations were located for temporary nurse aide #1 and temporary nurse aide #2. She stated she could not find them but would check with the DON. On 06/03/21 at 3:19 p.m., LPN #2 was asked about the incident on 05/08/21 regarding resident #3's fractured left humerus. He stated he worked on 05/08/21 from 10:00 p.m. until 6:00 a.m. He stated staff had not reported any injuries to him. He stated the resident was repositioned in bed on his shift and to his knowledge the resident had not voiced any complaints. He stated the resident had not requested a prn pain medication on his shift. At 3:43 p.m., CNA #6 was asked about the resident's fractured left humerus on 05/08/21. She stated the resident had turned on his call light on 05/08/21 and she had entered his room to provide incontinent care with another CNA. She stated the resident said his arm was broken and he wanted to go to the hospital. She stated she notified the charge nurse and the nurse replied by stating the resident's arm was not broken. She stated, She doesn't listen to us. She was asked how the resident was on 05/09/21. She stated the resident still complained of his left arm being broken and wanted to go to the hospital. On 06/07/21 at 9:51 a.m., LPN #3 was asked what her assessment of resident #3 was on her shift on 05/09/21 from 10:00 p.m. to 05/10/21 at 6:00 a.m. She stated the CNAs informed her the resident was asking for a pain pill at approximately 2:15 a.m. She stated she went to the resident's room and assessed the resident. She stated the resident usually did not take pain medication. She stated the resident told her his arm was broken. She stated the resident's arm was swollen and she asked the resident how the injury had occurred. She stated the resident told her he did not know. She stated the resident refused to go to the hospital but agreed to x-rays if the physician ordered them. She was asked how she had communicated the resident's change in condition to the physician. She stated she had called the physician and when he did not answer she had texted him. She stated she asked the resident when the injury had occurred. She stated the resident did not know but he described the staff member who had injured it. She stated the resident had identified temporary nurse aide #1 as the staff member who hurt his arm. She was asked if the temporary nurse aide was on duty when the resident identified her as the alleged perpetrator. She stated no. She was asked who she reported the allegation against temporary nurse aide #1 to. She stated she notified the day shift nurse and the day shift nurse notified the DON. She was asked what the facility's policy was if an allegation of abuse was made. She stated they were to notify the DON and if the alleged perpetrator was working they were sent home. She was asked why she did not notify the DON and/or administrator when she was made aware of the allegation against temporary nurse aide #1. She stated she had notified the day shift nurse and asked her to notify the DON. She stated, I don't like calling to wake people up early when she's coming in anyway. On 06/07/21 at 10:45 a.m., CNA #7 was asked about the incident on 05/08/21 with resident #3. She stated on 05/08/21 the resident told her his arm was broken. She stated he complained about his arm on 05/08/21 and on 05/09/21. She stated the resident was difficult to understand. She stated she and CNA #6 had reported the resident's injury to the nurse on duty on 05/08/21. On 06/07/21 at 3:21 p.m., the DON was asked where temporary nurse aide #1 and temporary nurse aide #2's skills competency evaluations were documented. She stated she had not had a chance to complete the skills competency evaluations. She stated they had been evaluated for some tasks but she had no documentation to support the tasks the temporary nurse aides had been successfully trained on. On 06/07/21 at 3:29 p.m., the DON was asked about the incident involving resident #3 on 05/08/21. She stated she had been made aware of the resident's injury in the morning of 05/10/21. She was asked if she had interaction with the resident on 05/08/21 or 05/09/21 while she was on duty. She stated she had seen the resident watching TV in his room a couple of times. She was asked what the investigation had entailed. She stated she got the resident's statement and tried to call the nurses and CNAs. She stated everyone was denying everything until she held inservice at 2:00 p.m. She stated after the inservice temporary nurse aide #1 and temporary nurse aide #2 reported to her they had heard a 'pop' when they had moved the resident on 05/08/21 and notified LPN #2, LPN #3, and LPN #4. She stated she interviewed LPN #2, LPN #3, and LPN #4 and they all stated the injury was not reported to them. She was asked why there was a delay in treatment when the nurse had administered a prn [MEDICATION(S)] at 2:15 a.m., documented she was awaiting instruction from the physician at 4:06 a.m., until the physician ordered x-rays for resident #3 at 6:23 a.m. She stated the physician should have been notified immediately. She stated there were two other facility physicians available if the staff could not get in touch with the first physician called. On 06/08/21 at 9:08 a.m., the DON was asked what had been implemented to prevent future injuries related to neglect. She stated, I educated all staff on transfers. She was asked when she had educated staff. She stated at an inservice on 05/12/21. She was asked how many staff she had inserviced. She stated ten. She was asked how many employees worked in the nursing department. She stated 30. She was asked why all staff were not educated. She stated all staff were educated but some may not have signed the inservice signature page. She was asked if anything else had been implemented to prevent future incidents. She stated, No, I just monitor a little bit closer. On 06/08/21 at 10:44 a.m., the administrator was asked what the facility had implemented to prevent future injuries related to neglect. She stated an inservice was conducted on mechanical lifts and they had verbal discussions with the staff about reporting any injury. She was asked where the verbal discussions were documented. She stated she did not know. She was asked who was responsible to ensure the residents were free from abuse/neglect and the facility's abuse/neglect protocol was followed. She stated it was ultimately her responsibility. On 06/08/21 at 3:52 p.m., the DON was asked why two temporary nurse aides transferred resident #3 when there is no documentation of training regarding transfers/repositioning. She stated she did not know how they had ended up on the same hall. She stated they were scheduled different halls. She was asked who made nurse aide assignments to ensure they are performing tasks/skills in which they had been trained. She stated she or the LPN #4 made the nurse aide assignments. She was asked how nurses were made aware of tasks/skills the temporary nurse aides had successfully completed. She stated she did not know. She stated 05/08/21 through 05/10/21 she must not have made the staff assignments.

Based on interview and record review, it was determined the facility failed to ensure residents were free from accident hazards with transfers/repositioning for one (#3) of three sampled residents who were reviewed for accident hazards. The facility identified 35 residents who required assistance with transfers and/or repositioning. Findings: 1. Resident #3 had diagnoses which included [CONDITION(S)] and [CONDITION(S)] of the non-dominant left side, heart failure, and [CONDITION(S)]. A quarterly assessment, dated 03/16/21, documented the resident was severely impaired in cognition for daily decision making, required extensive assistance of at least two staff members for bed mobility and transfers, was not steady and only able to stabilize with staff assistance when transferring from bed/chair/wheelchair, and had impairment on one side of his upper extremity. A nurse progress note, dated 05/10/21 at 4:06 a.m., documented, Resident c/o left arm pain 10/10, PRN pain med given at this time. Left arm is slightly swollen and bruised from elbow to wrist. Waiting instructions from PCP . The nurse note was signed by LPN #3. A nurse progress note, dated 05/10/21 at 6:23 a.m., documented, 10-6 called and reported that PCP responded regarding left arm with a new order for a [sic] x-ray to be completed on day shift, [Radiology company name withheld] will be contacted via this nurse and completed on 6-2 shift . A nurse progress note, dated 05/10/21 at 11:00 a.m., documented, [Radiology company name withheld] tech arrived and attempted to complete x-ray to left arm and unable to obtain complete full set of x-ray d/t resident refused. Awaiting on results that was obtained . A nurse progress note, dated 05/10/21 at 11:40 a.m., documented, PCP contacted d/r resident was observed having more slurred speech than normal and difficulty with swallowing. With new order to send resident to [name of hospital withheld] ER for eval and treat and have his left arm assessed while there. Attempted to collect full set of vitals with resident refusing being combative, BP 118/62 R-16 T-97.2, resident mother [name withheld] contacted ., METSA contacted and awaiting for transportation, ER notified . A radiology report, faxed to the facility on [DATE] at 11:58 a.m., documented, .LEFT HUMERUS X-Ray - 2 view: Findings: AP and lateral views were obtained. A nondisplaced fracture of the distal humerus is seen. There are no bony [CONDITION(S)]. [CONDITION(S)] changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. IMPRESSION: Acute distal humerus fracture . A nurse progress note, dated 05/10/21 at 12:09 p.m., documented, Metsa arrived and was sent to [hospital name withheld] for eval and treat with paperwork . An emergency department triage note, dated 05/10/21 at 12:31 p.m., documented the resident was brought to the hospital for increased slurred speech and painful/swollen left arm. A nurse progress note, dated 05/10/21 at 12:43 p.m., documented the facility had received the x-ray results. It documented the results had been sent to the hospital and to the resident's physician. An x-ray report from the hospital, dated 05/10/21 at 1:43 p.m., documented, .Final Result 1. Non-displaced fracture of the left supracondylar humerus. Consider dedicated elbow radiograph for thorough assessment. 2. Suspect osteopenia. 3. Glenohumeral [CONDITION(S)] . A hospitalist history and physical, dated 05/10/21 at 9:29 p.m., documented, .According to the nurse the patient is known as noncompliant at the nursing home. It sounded like he did not want to be turned and they turned him anyway and it is possible that this broke his left arm. Unclear how the fracture occurred. The patient complains of 7 out of 10 pain that is sharp in the left arm .ASSESSMENT AND PLAN: Nondisplaced left humeral fracture-arm is in a sling . An initial incident report on ODH form 283, dated 05/10/21, documented, .Incident Date 05/10/21 .Incident Type Certain Injuries .Description of Incident .[Resident #3] states that his elbow was hurting. Upon inspection it was noted that elbow was swollen and tender to touch. Bruising was noted around elbow and left arm. Xray was taken and showed acute distal humerus fracture. Resident was taken to [hospital name withheld] for fracture and resident was symptoms [sic] of possible stroke . An observer statement by temporary nurse aide #1, dated 05/10/21, documented that on 05/08/21 the resident wanted to sit on the side of the bed but temporary nurse aide #1 had been told the resident was to lay back down in bed after a few minutes. The statement documented, While I was laying him back down I heard a pop from [resident #3], I checked it out and got him into bed them went to [name withheld] and [LPN #4] and told them what happened what I heard and what I was seeing with the bruising on his arm, I continued to check on him and reported every time that he said I broke his arm and that his arm was broken. The statement was signed by temporary nurse aide #1. An observer statement by temporary nurse aide #2, dated 05/10/21, documented temporary nurse aide #2 was assisting temporary nurse aide #1 with moving resident #3 up on his bed. The statement documented temporary nurse aide #1 had the resident's arm when the resident was moved. The statement documented, .[temporary nurse aide #1] told me she heard something pop I told [LPN #4] she went and looked at it. She told me it was just fine I had went back in [resident #3] room he was telling me his arm was broke [LPN #4] said it wasn't and its always bruised like that so I left it alone. The statement was signed by temporary nurse aide #2. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form ODH 718, dated 05/10/21, documented temporary nurse aide #1 was suspended on 05/10/21. A Notification of Nurse Aide/Nontechnical Service Worker Abuse, Neglect, Mistreatment or Misappropriation of Property form ODH 718, dated 05/10/21, documented temporary nurse aide #2 was suspended on 05/10/21. A hospital social worker progress note, dated 05/11/21 at 3:31 p.m., documented, .SW attempted to meet with Pt in regards to concerns of his care at the NH. SW unable to understand pt due to hx of stroke, Pt has worsening [CONDITION(S)] and slurred speech. Pt was presented with a broken left arm on arrival to [hospital name withheld], per consult Pt reports 'staff grabbed him' . A final incident report on ODH form 283, dated 05/13/21, documented, .summary of the investigation .Resident was sent to hospital for non-displaced fracture of left supracondylor [sic] humerus. Resident was noted to have increased slurred speech and drooling, was sent to rule out new CVA. [Temporary nurse aide #2] and [temporary nurse aide #1] was suspended during investigation. Interviewed the nurses on 5/8, 5/9, 5/10 all have stated that they were not informed of injury. [Temporary nurse aide #2] and [temporary nurse aide #1] have been suspended during the investigation and have been educated on how to properly lift a resident and how to properly report to the nurse. They have been informed that if the nurse does not respond to call the DON and DON will come investigate the situation. Resident is returning to facility 5/13/2021 for hospice care for unrelated diagnosis. It was found that [temporary nurse aide #2] and [temporary nurse aide #1] lifted resident improperly during a transfer. They have been educated about how to lift a resident properly in bed and from sitting position to laying down in bed. [Temporary nurse aide #2] and [temporary nurse aide #1] have been properly educated on how to report to nurse. They have been informed if the nurse does not respond to their needs that they are to call DON immediately and the DON will investigate . An investigation of injuries of unknown origins form, dated 05/13/21, documented the following: ~ Time injury was discovered - 6:00 a.m.; ~ Time of last observation prior to injury - 4:06 a.m.; ~ Time of administrator notification - 8:00 a.m.; ~ Type of injury - left supracondylar humerus non-displaced fracture; ~ Did the resident have a recent fall - No; ~ Ask the resident if they fell - Resident stated that his arm was pulled; ~ Describe the injury - Left elbow swollen, bruising, blue in color note on lower and upper left arm; ~ Document the resident's ability to tell what happened - Resident stated that aide pulled arm; ~ Nurses description of how the injury may have occurred - Nurses state that they were not given report of the injury; ~ What diagnosis/medications put the resident at risk for this type of injury - Resident is noncompliant with meds and osteopenia; ~ What interventions were in place prior to the injury - Resident required two person assistance at all times; and ~ What interventions were implemented after the injury - Resident was sent to the hospital for further evaluation. The investigation of injuries of unknown origin form was signed by the DON. A care plan, updated 05/15/21, documented, .Problem .I Require Assist With ADLS .Approach Start Date: 01/31/20 .Assist me with bed mobility, transfers and ambulation as needed . A notice of disciplinary action for temporary nurse aide #1, dated 05/15/21, documented the employee had a safety violation which occurred on 05/08/21. The form documented, .Details of Events: Moved resident, injury noted Corrective action to be taken: Inform nurse, if nurse doesn't listen call DON. Educated on how to properly move resident . The notice of disciplinary action was signed by temporary nurse aide #1 on 05/15/21. Review of temporary nurse aide #1's time detail revealed she had worked after the incident on 05/11/21 and 05/12/21. On 06/03/21 at 12:03 p.m., CNA #4 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated two staff members assisted with the transfer while one staff member stabilized the wheelchair. She stated he required two person assist for repositioning. At 12:06 p.m., CNA #3 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated he was a two to three person assist for transfers and required two person assist for repositioning. At 12:15 p.m., CNA #5 was asked what type of assistance the resident required for transfers and repositioning in bed. She stated the resident utilized a mechanical lift when he was compliant. She stated the resident required two person assistance for repositioning. At 1:19 p.m., CMA #2 was asked what type of assistance the resident required for transfers and repositioning. She stated he required a mechanical lift for transfers and a draw sheet was used for repositioning. At 1:29 p.m., LPN #5 was asked about the incident on 05/08/21 in which the resident sustained a fracture of the left humerus. She stated she had arrived to work on 05/10/21 for the day shift and had received report from the night shift nurse the residents arm was hurting and she was awaiting orders from the physician. She was asked if she had assessed the resident's arm. She stated yes. She stated the arm was observed to be swollen and bruised. She stated at approximately 6:30 a.m. the night shift nurse reported to her the physician ordered x-rays of the resident's left arm. She stated she entered the order into the computer and called the radiology company. She stated the radiology company arrived before lunch and the CMA had notified her the resident's speech was different and he was not swallowing well. She stated she assessed the resident and he refused to go to the hospital at first then decided he would go. She was asked what the night shift nurse had reported had happened to the resident's arm. She stated the nurse reported to her she did not know what had happened. She stated the night shift CNAs had gone into the resident's room and he told them his arm was broken and not to touch it. She was asked how the resident transferred from bed to chair. She stated the resident required two to three aides and a gait belt. She was asked what type of assistance the resident required to reposition in bed. She stated two person assist and they used a draw sheet. She was asked how CNAs were trained for transfers and repositioning. She stated the 'training aide' and another CNA during their training. On 06/03/21 at 4:35 p.m., the administrator was asked why temporary nurse aide #1 was asked why temporary nurse aide #1 was identified in the initial state report dated 05/10/21, as injuring resident #3's arm, worked shifts on 05/11/21 and 05/12/21 before the investigation was completed on 05/13/21, and she had been educated on 05/15/21. She stated the DON may have educated her verbally before 05/15/21 but they could not find any documentation of education except the disciplinary action form dated 05/15/21. She was asked where skills competency evaluations were located for temporary nurse aide #1 and temporary nurse aide #2. She stated she could not find them but would check with the DON. At 3:43 p.m., CNA #6 was asked about the resident's fracture of his left humerus on 05/08/21. She stated the resident had turned on his call light on 05/08/21 and she had entered his room to provide incontinent care with another CNA. She stated the resident said his arm was broken and he wanted to go to the hospital. She stated she notified the charge nurse and the nurse replied by stating the resident's arm was not broken. She stated, She doesn't listen to us. She was asked how the resident was on 05/09/21. She stated the resident still complained of his left arm being broken and wanted to go to the hospital. On 06/07/21 at 9:51 a.m., LPN #3 was asked what her assessment of resident #3 was on her shift on 05/09/21 at 10:00 p.m. through 05/10/21 at 6:00 a.m. She stated the CNAs informed her the resident was asking for a pain pill at approximately 2:15 a.m. She stated she went to the resident's room and assessed the resident. She stated the resident usually did not take pain medication. She stated the resident told her his arm was broken. She stated his arm was swollen and she asked the resident how the injury had occurred. She stated the resident told her he did not know. She stated the resident refused to go to the hospital but agreed to x-rays if the physician ordered them. She was asked how she had communicated the resident's change in condition to the physician. She stated she had called the physician and when he did not answer she had texted him. She stated she asked the resident when the injury had occurred. She stated the resident did not know but he described the staff member who had injured it. She stated the resident had identified temporary nurse aide #1 as the staff member who hurt his arm. On 06/07/21 at 10:45 a.m., CNA #7 was asked about the incident on 05/08/21 with resident #3. She stated on 05/08/21 the resident told her his arm was broken. She stated he complained about his arm on 05/08/21 and on 05/09/21. She stated the resident was difficult to understand. She stated she and CNA #6 had reported the resident's injury to the nurse on duty on 05/08/21. On 06/07/21 at 3:21 p.m., the DON was asked where temporary nurse aide #1 and temporary nurse aide #2's skills competency evaluations were documented. She stated she had not had a chance to complete the skills competency evaluations. She stated they had been evaluated for some tasks but she had no documentation to support the tasks the temporary nurse aides had been successfully trained on. On 06/07/21 at 3:29 p.m., the DON was asked what the investigation had entailed. She stated she got the resident's statement and tried to call the nurses and CNAs. She stated everyone was denying everything until she held inservice at 2:00 p.m. She stated after the inservice temporary nurse aide #1 and temporary nurse aide #2 reported to her they had heard a 'pop' when they had moved the resident on 05/08/21 and notified LPN #2, LPN #3, and LPN #4. She stated she interviewed LPN #2, LPN #3, and LPN #4 and they all stated the injury was not reported to them. On 06/08/21 at 9:08 a.m., the DON was asked what had been implemented to prevent future incidents related to neglect and/or accident hazards. She stated, I educated all staff on transfers. She was asked when she had educated staff. She stated at an inservice on 05/12/21. She was asked how many staff she had inserviced. She stated ten. She was asked how many employees worked in the nursing department. She stated 30. She was asked why all staff were not educated. She stated all staff were educated but some may not have signed the inservice signature page. She was asked if anything else had been implemented to prevent future incidents. She stated, No, I just monitor a little bit closer. On 06/08/21 at 10:44 a.m., the administrator was asked what the facility had implemented to prevent future injuries related accident hazards and/or neglect. She stated an inservice was conducted on mechanical lifts and they had verbal discussions with the staff about reporting any injury. She was asked where the verbal discussions were documented. She stated she did not know. On 06/08/21 at 3:52 p.m., the DON was asked why two temporary nurse aides transferred resident #3 when there is no documentation of training regarding transfers/repositioning. She stated she did not know how they had ended up on the same hall. She stated they were scheduled different halls. She was asked who made nurse aide assignments to ensure they are performing tasks/skills in which they had been trained. She stated she or the LPN #4 made the nurse aide assignments. She was asked how nurses were made aware of tasks/skills the temporary nurse aides had successfully completed. She stated she did not know. She stated 05/08/21 through 05/10/21 she must not have made the staff assignments.

Based on record review and interviews, it was determined the facility failed to locate and implement pharmacy procedures to ensure accurate administration of medications for one (#3) of three sampled residents who had physician ordered fentanyl patches and actual harm occurred when resident #3 was hospitalized after she received a 100mcg fentanyl patch when she already had a 50mcg fentanyl patch in place and became oversedated. The facility identified four residents who received fentanyl patches. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A pain care plan, dated 07/12/13, "Problem: Pain...have chronic pain...I don't express my pain level staff anticipates my pain...Goal: ...will show relief from pain within 1 hour after my pain medication administered over the next 90 days... Approach: ...After administering my pain medication monitor me for 1 hour to note relief report to my physician of no relief noted for further orders...my pain is anticipated by staff: if noted grimacing, crying, rubbing an area, yelling out, or frowning report to charge nurse...If reported I am showing pain, assess me and if noted offer me my PRN pain medication...Report to my physician if my pain medication is sedating me for further orders..." A monthly physician's orders [REDACTED]. A pain care plan, updated 01/08/14, documented, "N/O Duragesic 50 mcg/hr Patch See Reentry (sic) orders." The care plan was not updated to include the special instructions to alternate sites and no new interventions were added to the care plan. A quarterly assessment, dated 01/11/14, documented the resident had a BIMS score of 5. This score indicated the resident was severely impaired with cognition. The assessment also documented the resident received scheduled pain medication and had not experienced pain in the last five days. An individual narcotics record, dated January 2014, documented a fentanyl 50mcg patch was signed out on 01/31/14 for the resident. The record also documented the old/used patch had been destroyed and CMA #1 and LPN #1 had both initialed the record which indicated they had destroyed and disposed of the old/used fentanyl medication patch. A MAR, dated January 2014, documented the resident received a Duragesic (fentanyl) 50mcg patch to her left arm on Friday, 01/31/14, at 12:00 p.m. A monthly physician's orders [REDACTED]. An individual narcotics record, dated February 2014, did not document that a Duragesic (fentanyl) patch had been signed out for the resident on 02/01/14. A MAR, dated February 2014, documented the resident received a Duragesic (fentanyl) 50mcg patch to her right back on Saturday, 02/01/14, at 1700 (5:00 p.m.) A nurse's note, dated 02/02/14 at 12:30 p.m., documented, "Med aide found a 100 mcg patch on pt. Pt has no order for 100 mcg. Notified (physician name deleted) who is on call...to report overdose. Doctor stated to watch Pt for S+S of OD. It will take 24 (hours) for it to run out of her system. Patch was removed as soon as it was noticed." A nurse's note, at 14:50 (2:50 p.m.) documented, "Pt shipped to ER for eval and treat due to BP 162/119 - 91 called Dr. (name deleted) + daughter (name deleted)..." An ambulance note, dated 02/02/14, documented, "Dispatched emergency status to (facility, name deleted) for high blood pressure...staff stated that yesterday (02/01/14) evening, the night staff was distributing patient medications and that the patient was given another residents (sic) pain medication patch. The staff advised that the patient had fentanyl patches prescribed to her at 50mcg, and that the nursing staff placed an additional 100mcg fentanyl patch on the patient which put the patient receiving 150mcg of the fentanyl. This morning the day shift was reviewing the medication charts and noticed the medication error, went to the patients (sic) room and found the additional patches on the patient. Staff advised that they immediately removed the additional patches but left the patients (sic) 50mcg patch on her arm. The patient is lethargic and unable to answer questions at this time..." A hospital record, dated 02/02/14, documented the resident was lethargic and unresponsive in the emergency room . The record also documented, "...Rec'd orders from Dr. (name deleted) to remove fentanyl patch from nursing home..." A hospital short stay summary, dated 02/02/14, documented, "...receives fentanyl patch 50 mcg every 3 days. The patient was brought in by the staff, because they accidentally gave her too much of fentanyl. She had her old...patch on and they placed another patient's 100 mcg patch on top of that...and the patient became less responsive and more drowsy..." The hospital record also documented the resident had been admitted to the hospital for observation on 02/02/14 and was discharged back to the facility on [DATE]. A hospital discharge summary, dated 02/03/14, documented, "...Chief complaint: Overdose...Diagnosis: [REDACTED]. A final state reported incident, dated 02/07/14, documented, "...02/01/14 It was identified that while passing medication nurse, (ADON, name deleted) was on 2-10 shift (sic) a medication variance occurred. The order was for fentanyl 50mcg, 100mcg was administered. The CMA on duty for 2/2/14 (name deleted) reported to charge nurse...reported to physician...it was determined by the physician to monitor for S/SX of sedation...ER, for eval and treat...transfer on 02/02/14, returned to facility on 02/03/14..." On 02/10/14 at 9:30 a.m., CMA #1 asked what the process was to apply and remove fentanyl patches. She stated they had to be signed out of the narcotic book. She stated that each resident had an individual narcotic sheet and the new fentanyl patch had to be signed out and deducted from that sheet. She stated the old or used patch had to be taken off the resident and was destroyed with the charge nurse. She stated both the CMA and charge nurse had to initial that the patch had been destroyed on the sheet. She was asked how the patch was destroyed. She stated that it was cut up and put in the sharps container or flushed down the toilet. On 02/11/14 at 4:25 p.m., the ADON was asked about the incident regarding the fentanyl patch on resident #3. He stated, "It was an oversite on my part." He stated he was unable to find the old patch that was on her and had asked the charge nurse to help him look for it. He stated they both looked and could not find it. He stated he then applied the 100mcg fentanyl patch and that he had not realized he had signed out the wrong strength patch on the wrong resident. He was asked if he knew why the error had occurred and stated, "No. He was asked if he had had any training regarding the error. He stated he attended an inservice to make sure the old patch was removed before a new patch was applied. He was shown the MARs for the fentanyl patch for January and February 2014. He was shown where the MARs documented the patch was due on 01/31 and 02/01 and asked if that was accurate. He stated, "Apparently it was carried through and wasn't accurate, and they should have been due every 72 hours not on next day." He was asked if there was a facility policy regarding fentanyl patches. He stated, "I believe there is." He was asked for the policy. He was asked who was responsible to check the MARs and ensure they were accurate. He stated, "The DON." A policy regarding fentanyl patches was not provided to the surveyors as requested. At 6:08 p.m., LPN #2 was asked if there was a pharmacy policy regarding fentanyl patches. She stated she believed there was but did not know. She was asked for the policy. She was asked if she had notified the pharmacy consultant after she had completed the investigation regarding the resident being oversedated and hospitalized after she received an additional 100mcg fentanyl patch. She stated, "No." She was asked why she had not notified the pharmacy consultant for education and guidance regarding a medication error that had resulted in a resident being oversedated and sent to the hospital. She stated, "I did not know I needed to, but I can see why I should have." At 6:30 p.m., the administrator was asked for the policy and procedure manuals regarding pharmacy services. She stated they were trying to find them and would bring them in when they were located. At 6:42 p.m., the DON was asked who was responsible to check the MARs for accuracy. She stated, "I check them before so we can have them ready on the first of the month. They should have been complete and accurate." She was asked why the MARs on resident #3 were not correct. She stated, "I just didn't catch it." She was asked for the pharmacy policies and procedures. She stated they were unable to locate the policy, but were looking for it. She was asked what the facility's policy was regarding fentanyl patches, rotation of sites, application of, removal of, and destruction of the patches. She stated the patches should be rotated and sites changed. She stated the CMAs are to discard the patch with the nurse on duty and both should sign the narcotic sheet. She stated they cut up the patch and flush it down the toilet or put it in the sharps biohazard container. She was asked who monitored the narcotic sheet for discrepancies when the patches were not signed off as destroyed. She stated, "The ADON." She was asked what happened if a discrepancy occurred. She stated the ADON reported them to her. She was asked if any had been reported to her in the last three months. She stated, "No." The DON was asked if she had reviewed the investigation regarding the resident being oversedated and hospitalized as a result of a significant medication error. She stated, "No." She was asked why. She stated, "I should have." By the end of the survey, the pharmacy policies and procedures regarding fentanyl patches had not been provided to the surveyors. At 7:22 p.m., during the exit conference, the administrator stated maybe the policy on fentanyl patches was in the pharmacy consultant book. She left the room and returned with a pharmacy policy book that contained a policy on fentanyl patches which had been unable to be located by the nursing staff.

Based on record review and interviews, it was determined the facility failed to ensure significant medication errors did not occur for two (#1 and #3) of three sampled residents who received [MEDICATION NAME]es and actual harm occurred when resident #3 was hospitalized after she received a 100mcg [MEDICATION NAME] when she already had a 50mcg [MEDICATION NAME] in place and became oversedated. The facility identified four residents who received [MEDICATION NAME]es. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A pain care plan, dated 07/12/13, "Problem: Pain...have chronic pain...I don't express my pain level staff anticipates my pain...Goal: ...will show relief from pain within 1 hour after my pain medication administered over the next 90 days... Approach: ...After administering my pain medication monitor me for 1 hour to note relief report to my physician of no relief noted for further orders...my pain is anticipated by staff: if noted grimacing, crying, rubbing an area, yelling out, or frowning report to charge nurse...If reported I am showing pain, assess me and if noted offer me my PRN pain medication...Report to my physician if my pain medication is sedating me for further orders..." A monthly physician's orders [REDACTED]. An pain care plan, updated 01/08/14, documented, "N/O [MEDICATION NAME] 50 mcg/hr Patch See Reentry (sic) orders." The care plan was not updated to include the special instructions to alternate sites and no new interventions were added to the care plan. A quarterly assessment, dated 01/11/14, documented the resident had a BIMS score of 5. This score indicated the resident was severely impaired with cognition. The assessment also documented the resident received scheduled pain medication and had not experienced pain in the last five days. An individual narcotics record, dated January 2014, documented a [MEDICATION NAME] 50mcg patch was signed out on 01/31/14 for the resident. The record also documented the old/used patch had been destroyed and CMA #1 and LPN #1 had both initialed the record which indicated they had destroyed and disposed of the old/used [MEDICATION NAME] medication patch. A MAR, dated January 2014, documented the resident received a [MEDICATION NAME] ([MEDICATION NAME]) 50mcg patch to her left arm on Friday, 01/31/14, at 12:00 p.m. A monthly physician's orders [REDACTED]. An individual narcotics record, dated February 2014, did not document that a [MEDICATION NAME] ([MEDICATION NAME]) patch had been signed out for the resident on 02/01/14. A MAR, dated February 2014, documented the resident received a [MEDICATION NAME] ([MEDICATION NAME]) 50mcg patch to her right back on Saturday, 02/01/14, at 1700 (5:00 p.m.) A nurse's note, dated 02/02/14 at 12:30 p.m., documented, "Med aide found a 100 mcg patch on pt. Pt has no order for 100 mcg. Notified (physician name deleted) who is on call...to report overdose. Doctor stated to watch Pt for S+S of OD. It will take 24 (hours) for it to run out of her system. Patch was removed as soon as it was noticed." A nurse's note, at 14:50 (2:50 p.m.) documented, "Pt shipped to ER for eval and treat due to BP 162/119 - 91 called Dr. (name deleted) + daughter (name deleted)..." An ambulance note, dated 02/02/14, documented, "Dispatched emergency status to (facility, name deleted) for high blood pressure...staff stated that yesterday (02/01/14) evening, the night staff was distributing patient medications and that the patient was given another residents (sic) pain medication patch. The staff advised that the patient had [MEDICATION NAME]es prescribed to her at 50mcg, and that the nursing staff placed an additional 100mcg [MEDICATION NAME] on the patient which put the patient receiving 150mcg of the [MEDICATION NAME]. This morning the day shift was reviewing the medication charts and noticed the medication error, went to the patients (sic) room and found the additional patches on the patient. Staff advised that they immediately removed the additional patches but left the patients (sic) 50mcg patch on her arm. The patient is lethargic and unable to answer questions at this time..." A hospital record, dated 02/02/14, documented the resident was lethargic and unresponsive in the emergency room . The record also documented, "...Rec'd orders from Dr. (name deleted) to remove [MEDICATION NAME] from nursing home..." A hospital short stay summary, dated 02/02/14, documented, "...receives [MEDICATION NAME] 50 mcg every 3 days. The patient was brought in by the staff, because they accidentally gave her too much of [MEDICATION NAME]. She had her old...patch on and they placed another patient's 100 mcg patch on top of that...and the patient became less responsive and more drowsy..." The hospital record also documented the resident had been admitted to the hospital for observation on 02/02/14 and was discharged back to the facility on [DATE]. A hospital discharge summary, dated 02/03/14, documented, "...Chief complaint: Overdose...Diagnosis: [REDACTED]. A final state reported incident, dated 02/07/14, documented, "...02/01/14 It was identified that while passing medication nurse, (ADON, name deleted) was on 2-10 shift a medication variance occurred. The order was for [MEDICATION NAME] 50mcg, 100mcg was administered. The CMA on duty for 2/2/14 (name deleted) reported to charge nurse...reported to physician...it was determined by the physician to monitor for S/SX of sedation...ER, for eval and treat...transfer on 02/02/14, returned to facility on 02/03/14..." On 02/10/14 at 9:30 a.m., CMA #1 asked what the process was to apply and remove [MEDICATION NAME]es. She stated they had to be signed out of the narcotic book. She stated that each resident had an individual narcotic sheet and the new [MEDICATION NAME] had to be signed out and deducted from that sheet. She stated the old or used patch had to be taken off the resident and was destroyed with the charge nurse. She stated both the CMA and charge nurse had to initial that the patch had been destroyed on the sheet. She was asked how the patch was destroyed. She stated that it was cut up and put in the sharps container or flushed down the toilet. On 02/11/14 at 4:25 p.m., the ADON was asked about the incident regarding the [MEDICATION NAME] on resident #3. He stated, "It was an oversite on my part." He stated he was unable to find the old patch that was on her and had asked the charge nurse to help him look for it. He stated they both looked and could not find it. He stated he then applied the 100mcg [MEDICATION NAME] not realizing he had signed out the wrong strength patch on the wrong resident. He was asked if he knew why the error had occurred and stated, "No. He was asked if he had had any training regarding the error. He stated he attended an inservice to make sure the old patch was removed before a new patch was applied. He was shown the MARs for the [MEDICATION NAME] for January and February 2014. He was shown where the MARs documented the patch was due on 01/31 and 02/01 and asked if that was accurate. He stated, "Apparently it was carried through and wasn't accurate, and they should have been due every 72 hours not on next day." He was asked who was responsible to check the MARs and ensure they were accurate. He stated, "The DON." At 6:42 p.m., the DON was asked who was responsible to check the MARs for accuracy. She stated, "I check them before so we can have them ready on the first of the month. They should have been complete and accurate." She was asked why the MARs on resident #3 were not correct. She stated, "I just didn't catch it." 2. Resident #1 had [DIAGNOSES REDACTED]. A pain care plan, dated 06/03/13, documented, "[MEDICATION NAME] 100mcg/75mcg patch q 72 hrs..." A quarterly assessment, dated 09/10/13, documented the resident had a BIMS score of 15. This score indicated the resident was independent with cognitive skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. This pain rate was based on a pain scale of 0 (no pain) to 10 (worse pain). A pain care plan, updated 09/10/13, documented, "[MEDICATION NAME] 100mcg/75mcg patch q 72 hrs...continues to show pain...continues c pain medication, she has express (sic) c/o pain 20x in last 30 days..." A quarterly assessment, dated 12/11/13, documented the resident had a BIMS score of 14. This score indicated the resident was independent with cognitive skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED]. apply with 75mcg to equal 175 mcg. Please remember to alternate sites...(DX: Pain, chronic...)" A monthly physician's orders [REDACTED]. topically, apply with 100 mcq to equal 175 mcg. Please remember to alternate sites...(DX: Pain, chronic...)" A Medication Administration Record, [REDACTED]. The record indicated the resident was to receive a new [MEDICATION NAME] 100mcg patch and a new 75mcg [MEDICATION NAME] on 02/01/14. A social service note, dated 01/27/14, documented, "...stays in her room through out the day. Due to her pain in her legs..." An undated activity note documented, "...does not attend any activities. Her pain inables (sic) her to participate..." A monthly physician's orders [REDACTED]. apply with 75mcg to equal 175 mcg. Please remember to alternate sites...(DX: Pain, chronic...)" A monthly physician's orders [REDACTED]. topically, apply with 100 mcg to equal 175 mcg. Please remember to alternate sites...(DX: Pain, chronic...)" A Medication Administration Record, [REDACTED]. An individual narcotic record revealed there was no [MEDICATION NAME] 75mcg patch signed out or applied to the resident on 02/01/14. An individual narcotic record documented a [MEDICATION NAME] 100mcg patch had been signed out on 02/01/14 at 1700 (5:00 p.m.). The documentation, under the medication that had been signed out, was not legible. A nurse's note, dated 02/02/14, documented, "...pt was asking about her pain patch that was suppose to be put on yesterday. It was noted in the MAR indicated [REDACTED]. Med aide noted patch was not there & started looking for it. found (sic) patch on another pt...Reported to DON..." An individual narcotic record revealed the [MEDICATION NAME] 75mcg patch was signed out and applied to the resident on 02/02/14. An individual narcotic record revealed the [MEDICATION NAME] 100mcg patch was signed out and applied to the resident on 02/02/14. On 02/11/14 at 10:20 a.m., the resident was asked if she had missed receiving her [MEDICATION NAME]es. She stated, "Yes." The resident was asked if she knew why the patches had not been applied. She stated, "No. The next day the med tech was looking for my patches and couldn't find one." The resident was asked if she had experienced pain when her patches had not been applied. She stated, "I really can't say. I don't remember." She was asked if anyone had assessed her for pain. She stated, "I don't think so. They checked me for the patch so they could put the new one on." At 4:39 p.m., the ADON was asked if he had placed the [MEDICATION NAME] 75mcg patch and the [MEDICATION NAME] 100mcg patch on the resident on 02/01/14. He stated if the 100mcg patch went on another resident then hers (resident #1) would have been missed. The ADON was shown the unlegible individual narcotic record, dated 02/01/14 for the [MEDICATION NAME] 100mcg patch. He was asked what documentation had been marked through. He stated, "I drew one line. Mistaken entry disregard and my initials." The ADON was asked if the resident had received her [MEDICATION NAME] 100mcg patch on 02/01/14. He stated, "No." The ADON was asked if the resident had received her [MEDICATION NAME] 75mcg patch on 02/01/14. He stated, "No." He was asked if he had completed a medication error incident report. He stated, "I don't recall doing a medication error report on her." At 5:29 p.m., LPN #2 was asked if she had been the charge nurse on 02/01/14. She stated, "Yes." The LPN was asked if the resident had received her patches on 02/01/14. She stated, "I want to say yes, but truthfully I could not tell you."

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for three (#4, #6, and #11) of eight sampled residents who had experienced falls. Resident #6 experienced two falls in one month. With one of the two falls resulting in actual harm when the resident sustained [REDACTED]. The facility identified 22 residents who were at high risk for falls. Findings: 1. Resident #6 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/22/13, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident was independent with transfers, dressing, personal hygiene, was impaired on lower extremity, and had not experienced any falls. A fall risk evaluation, dated 05/25/13, documented a score of 13. This score indicated the resident was a high risk for falls. An annual assessment, dated 08/14/13, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident was independent with transfers, dressing, personal hygiene, was impaired on lower extremity, and had not experienced any falls. A fall care plan, dated 08/14/13, documented, "Problem: ...Right AKA and am at risk for falls. I transfer myself and use wheelchair for my travels...Goal: I will show no decline with my transfers and be free of falls for the next 90 days...Approach: I do transfer my self (sic) and bear weight on my left leg, I also slide from surface to surface. Offer assist if you see that I am in need..." An incident report, dated 08/16/13, documented, "Res stated she thinks she slipped out of w/c while asleep, hit her R ear on the stool. Redness to ear...Neuro (checks) started...Corrective measures implemented to prevent recurrence...Res has been (up) & about facility, self propelled in wc...Talkative & friendly...(no) c/o pain/discomfort..." The incident report did not address fall interventions to prevent further falls. The fall care plan, updated 08/19/13, documented, "...had a fall hitting her head neuro (checks) started..." The fall care plan had not been updated to address fall interventions to prevent further falls. A fall risk evaluation, dated 09/01/13, documented a score of eight. This score indicated the resident was not at a high risk for falls. An incident report, dated 09/01/13, documented, "...unwitnessed fall...res found on floor of her room...c/o severe L hip pain...unable to move L leg...has recent hx of falls...Corrective measures implemented to prevent recurrence...Sent...to ER for eval & tx. of pain in L hip..." The incident report did not address fall interventions to prevent further falls. The fall care plan, updated 09/02/13, documented, "...found on floor in her room...sent to ER for L hip pain c results L Femur Fx..." The fall care plan, updated 09/03/13, documented, "return c orders SNF c therapy..." The fall care plan had not been updated to address any fall interventions to prevent further falls. On 10/10/13 at 10:05 a.m., the resident was asked what had happened when she had fallen from her wheelchair. She stated, "I slid out of my wheelchair. I couldn't get up and finally got over to the door. My door was closed and they couldn't hear me." At 11:11 a.m., the DON was asked why no fall interventions had been addressed or implemented when the resident had fallen on 08/16/13. She stated, "She is a very independent woman. She doesn't use her call light." She was asked if any fall interventions had been implemented. The DON stated, "No." The care plan coordinator was asked if fall interventions should have been care planned after the resident's fall on 08/16/13. She stated, "Yes." The care plan coordinator was asked if the resident's independence should have been addressed. She stated, "Yes." At 11:35 a.m., the DON was asked why there were no fall interventions implemented when the resident had fallen on 09/01/13 and experienced a left hip fracture. She stated, "She doesn't want anything." The DON was asked if the resident was on the falling star program. She stated, "She doesn't want to be in the falling star program." The DON was asked if a fall assessment was completed after each fall to determine the root cause of the fall. She stated, "No." The care plan coordinator was asked if fall interventions should have been addressed on the care plan related to the fall the resident had experienced on 09/01/13. She stated, "Yes." 2. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 05/01/13, documented the resident had a BIMS score of four. This score indicated the resident was severely impaired with cognitive daily decision making. The assessment documented the resident required limited assistance through total dependence with activities of daily living. A fall care plan, dated 05/01/13, documented, "...at risk for falls r/t slow gait, and requires assistance when ambulating for safety...bed in lowest position...make visual checks on resident at least every 2 hours and as needed...toilet resident at least every 2 hours and as needed...provide teaching on wheelchair safety...fall mat placed next to bed..." An incident report, dated 07/05/13, documented, "...found sitting on the floor @ the foot of her bed...sitting c knees bent, feet flat on floor...'got down to get out of the water'...(no) obvious injury...corrective action taken (blank)..." The fall care plan, updated 07/05/13, documented, "...fall unknown..." No new interventions were documented to prevent further falls. An incident report, dated 07/09/13, documented, "...found sitting on the floor...reported she was trying to get up and slipped off the bed...no apparent injury...corrective action taken: see nurse notes...Initial investigation how (keep from happening again) pressure pad... The fall care plan, updated 07/09/13, documented "...fall slipped off bed (no) injury..." No new interventions were documented to prevent further falls. An incident report, dated 07/30/13, documented, "...staff responded to personal alarm & found res on the floor next to her bed...Initial investigation what? (nature of incident) res was going to bed by self...how? (keep from happening again) (blank)...final report: staff instructed to assist res into bed after she eats..." The fall care plan, updated 07/30/13, documented, "...fall unwitness she stated she was transferring herself (no) injury..." No new interventions were documented to prevent further falls. A quarterly assessment, dated 08/01/13, documented the resident had a BIMS score of two. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had falls since admission/entry or the prior assessment but documented zero for no injury and zero for injury and major injury. An incident report, dated 08/24/13, documented, "..sitting in the floor bed rails up...wanted up cause she was cold...no apparent injury...initial investigation: how? (keep from happening again) (blank)...environmental factors: pt climbed over rail and slept (sic) c her socks on the floor..." The fall care plan was not updated to address the fall out of bed on 08/24/13. No new interventions were documented to prevent further falls. An incident report, dated 08/27/13, documented, "...found sitting on floor in front of B/R door...no injuries noted...initial investigation: How? (keep from happening again) instruct resident use of call light... environmental/situational factors...urinated on floor..." The fall care plan, updated on 08/27/13, documented, "...unknown fall (no) injuries see NN 08/27/13..." No new interventions were documented to prevent further falls. A fall risk evaluation, dated 08/27/13, documented the resident had a score of 18 which indicated high risk for falls. A physician's orders [REDACTED]. A nurse's note, dated 08/30/13, documented, "...I just walked to bathroom...instructed resident to use call light when needing to go to the bathroom..." The fall care plan had not been updated to address the use of an alarmed seat belt. An incident report, dated 09/05/13, documented, "...ambulating to bathroom. fell and hit her head on roommates w/c...initial investigation: How? (keep from happening again) unsteady gait..." The fall care plan, updated on 09/05/13, documented, "...fall with head injury neuro (checks) started...has cognitive loss c no aware of safety..." No new interventions were documented to prevent further falls. An incident report, dated 09/10/13, documented, "...found on floor...unable to tell what happened...no apparent injury...corrective action taken see nurses note...initial investigation: How? (keep from happening again) unknown..." The fall care plan, updated on 09/11/13, documented, "...fall (no) injury See NN 9-10-13..." No new interventions were documented to prevent further falls. An incident report, dated 09/11/13, documented, "found sitting on floor by bathroom sitting on coccyx...no apparent injury...initial investigation: How? (keep from happening again) (blank). The fall care plan, updated on 09/12/13, documented, "...fall (no) injury See NN 9-11-13..." No new interventions were documented to prevent further falls. On 10/10/13 at 3:21 p.m., The DON and care plan coordinator were asked if the resident was able to use the call light. The DON stated, "She plays with it." The care plan coordinator stated, " I don't think she cognitively knows what it is." The DON was asked why she waited for the resident to have five falls before adding the alarms. She stated, "I thought we were adding one at a time." The DON was asked if she did a fall assessment after each fall to find the root cause. She stated, "No, I have not." The DON and care plan coordinator were asked why interventions were not put in place before the resident had five falls. The DON stated, "I honestly couldn't tell you." They were asked if interventions should have been implemented. The care plan coordinator stated, "Yes." She was asked if it should have been on the care plan. She stated, "Yes." The DON was asked if the resident was on a bowel and bladder program since three of her falls were related to going to the bathroom. She stated, "No, she is not." She was asked if she had tried one. She stated, "Not recently. I don't remember the last time." The care plan coordinator was asked if the resident wanted to be put in bed after all meals. She stated, "Yes." She was asked if it should have been addressed on the care plan. She stated, "Yes." She was asked why the intervention to assist to bed after meals not on the care plan. She stated, "I did not know that." The DON was asked why no interventions were in place after each fall. She stated, "I don't know." 3. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/05/13, documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with daily decision making. The assessment documented the resident required assistance of one person with activities of daily living. A fall care plan, dated 06/08/13, documented, "...at risk for falls with unsteady gait, balance deficits, gait disturbances, arthritis and osteoporosis and recommend that I use non slip socks and make sure my shoes are safe and well fitting...give me pt/ot...keep rooms and halls well lit and clutter free...monitor me while I am ambulating, while in bed, during transfers and in w/c for safety issues..." An incident report, dated 07/24/13 documented, "...resident in floor, reported by housekeeping... roommate stated she slipped out of lift chair...no apparent injury...corrective action taken...see nurse notes..." The fall care plan, updated 07/25/13, documented,"...fall...slid out of chair...no injury...see nurses note (sic). There were no new interventions documented on the care plan to prevent further falls. The fall care plan, updated 08/04/13, documented, "...rail is used to assist with positioning..." An incident report, dated 08/05/13, at 8:30 p.m., documented, "...resident was found on floor by CNA, lift chair raised to assist to standing position...my feet went from under me I didn't hit the floor hard, I just slid out of my chair...corrective action taken: see nurse notes...Immediate corrective action...use call light..." The fall care plan, updated 08/06/13, documented, "Fall...no injury..." There were no new interventions documented on the care plan to prevent further falls. An incident report, dated 08/13/13, documented, "...found on the floor, sitting on bottom...used lift to get resident off floor and in bed. Corrective action taken... see nurse note..." A nurse's note, dated 08/13/13, documented, "...resident found sitting on floor by CNA,...I came into room resident sitting on floor, no shoes, in plain socks...asked what happened...I was trying to get up by myself...Resident needs assist to stand, call light within reach, but won't use it..." The fall care plan, up dated on 08/14/13, documented, "...Fall no injury continues with therapy...see nurse's note..." No new fall interventions were added to the fall care plan. A fall risk assessment, dated 09/16/13, documented a score of 15. This score indicated the resident was a high risk for falls. A quarterly assessment, dated 09/24/13, documented a BIMS score of 9. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers, ambulation, and had not experienced any falls. On 10/10/13 at 4:15 p.m., the DON and care plan coordinator were asked why no new fall interventions had been addressed or implemented after each fall. The DON and care plan coordinator stated they did not know. They were asked if the care plan should have been updated with interventions to prevent further falls. They stated, "Yes." The DON was asked were appropriate interventions put in place when resident fell [DATE], she stated "No." There were no interventions for the fall on 08/13/13. "Because she was sliding out of chair, I don't know why we didn't. I felt it was more of a behavior." The DON was asked why no interventions were added to address the behaviors? She stated " Well, I should have. We need to put new plan in place, meeting and address it better."

Based on observation, interview, and record review, it was determined the facility failed to: a. provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for 1 (#10) of six sampled residents who had experienced eight falls in less than four months with the last fall that resulted in actual harm of a hip fracture. The Resident and Census and Condition identified 17 residents who needed assistance of one or more staff for transfers. b. ensure thickened liquids were provided for one (#3) of one sampled resident who had a physician's order for thickened liquids. The facility identified one resident received thickened liquids. Findings: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report, dated 07/03/12, documented, "...description of incident: Res fell to floor from bed onto bottom...no injury...suggested safety precautions to prevent recurrence: instructed to use call light..." An incident report, dated 07/04/12, documented, "...description of incident: res fell on to bottom then backwards hit back of head, goose egg swelling...suggested safety precautions to prevent recurrence: res needs walking shoes..." A nurse's note, dated 07/10/12, documented, "...Res found on the floor of main living room. res stated trying to get back into w/c from recliner..." An incident report, dated 08/10/12, documented, "...description of incident: found on floor, res transferring from bed to W/C, no shoes on only soxs (sic) slipped down onto bottom...suggested safety precautions to prevent recurrence: res instructed to wear shoes when getting up, use call light..." A fall care plan, dated 08/20/12, documented, "...Problem: Resident is at risk for falls related to resident's inability to sit up and history of falls as recent as 08/10/12...Interventions: Place call light close and answered promptly. Place a bed & chair monitor on resident to alert staff when she attempts to get up..." An incident report, dated 08/31/12, documented, "...description of incident: went to room res. was in (sic) floor beside bed laying on L side (parcially) (sic)...suggested safety precautions to prevent recurrence: use CL for assist..." An updated fall care plan, dated 08/31/12, documented the resident had a non-injury fall. No new interventions were addressed on the fall care plan to prevent future falls. An incident report, dated 09/02/12, documented, "...description of incident: resident stated 'I was trying to go from my w/c and get in bed. I slipped & fell . I held the bed & fell on my bottom'...suggested safety precautions to prevent recurrence: Instructed resident to use call light when needing assistance. (call light within reach) instructed resident to lock her w/c before getting up..." An updated fall care plan, dated 09/02/12, documented the resident had a non-injury fall. No new interventions were addressed on the fall care plan to prevent future falls. An incident report, dated 09/17/12, documented, "...description of incident: resident stood up in w/c and while attempting to sit back down, she missed w/c and sat on floor...suggested safety precautions to prevent recurrence: (blank)..." An updated fall care plan, dated 09/17/12, documented the resident had a non-injury fall. No new interventions were addressed on the fall care plan to prevent future falls. A fall care plan, dated 10/15/12, documented, "...Problem: Resident is at risk for falls and injuries due to resident history of falls...Interventions:...Visual checks on resident every 2 hours and PRN..." An incident report, dated 10/24/12, documented, "...description of incident: resident found sitting on floor in room in front of recliner. stated she slipped out of chair...scabbed wound opened from previous skin tear...suggested safety precautions to prevent recurrence: ask for part B therapy eval..." An incident report documented, "...incident date: unknown...relevant history...resident sustained [REDACTED]. Old scabbed over wound to R arm reopened from previous skin tear, no bleeding occurred, reported no complaints of pain or discomfort. On 10/25/12, resident had no complaints, up in wheelchair most of the day. On 10/26/12, c/o R arm pain, slight edema noted, pain medication given with effective pain management...On 10/28/12, resident refused to get up. Resident started to cry and scream when staff attempted to get her up in reclined (sic). Resident c/o L leg and hip pain and grabbed her L hip and upper leg. ROM attempted by RN, resident cried out in pain when L leg moved. Sent to ER for evaluation and X-ray. Staff interviews in process to determine when another fall may have occurred...Corrective measures implemented to prevent recurrence: Investigation of staff indicates no further fall between 10/24 and 10/28 when resident was taken to the ER and a R hip fracture was found and surgically repaired. New policy in place to obtain mobile exray (sic) for any falls in which a resident lands on their bottom to check for hairline fracture of pelvis or hip..." An updated fall care plan, dated 10/24/12, documented the resident had experienced a fall. No new interventions were addressed on the fall care plan to prevent future falls. An updated fall care plan, dated 10/28/12, documented, "...crying & screaming when CNA attempted to assist her up from bed. c/o pain & grabbed L hip & L leg..." No new interventions were addressed on the fall care plan to prevent future falls. An updated fall care plan, dated 11/07/12, documented, "...returned from hospital..." No new interventions were addressed on the fall care plan to prevent future falls when the resident returned from the hospital with a hip fracture. A care plan dated, 11/14/12, documented, "...Assessment:..I have fallen or slipped out of my wheelchair or recliner 7 times since my admit here...This last fall resulted in my right hip fracture and recent surgery... Problem/Situation/Need: History of numerous falls and risk for further falls related to use of mechanical lift and wheelchair and past history of sliding out of my wheelchair or recliner...interventions:..Use the mechanical lift to prevent injuries to me or yourself for transfers. Always make sure the battery to the lift is charged fully and the brakes are on before putting me up in the lift. Make sure the sling to the lift has no holes or tears in it and is in good condition. Monitor me when I am in my wheelchair for safety risks and appropriate use. Remind me to put the brake on when I am in my wheelchair and sitting still. Be sure my new pad is in my wheelchair or my recliner to prevent slipping...Monitor my medical conditions that may increase my risk for." An admission assessment, dated 11/20/12, documented the resident had severe impairment in cognitive skills for daily decision making, needed extensive assistance with transfers, did not ambulate, was always incontinent of urine, and had a fracture related to a fall in the six months prior to admission/entry or reentry. On 11/30/12 at 1:55 p.m., the resident was observed in her bed without a personal, bed, or chair alarm. At 3:39 p.m., the DON was asked if the resident used her call light. She stated, "You could tell her but she wouldn't remember to use the call light." She was asked if the call light was an appropriate intervention for this resident. She stated, "No." She was asked why there was an intervention for shoes when the resident was not ambulatory. She stated, "I don't know." She was asked if the shoes were an appropriate intervention for the resident. She stated, "No. We had an alarm for a while." She was asked when the alarms were instituted. She stated, "I don't know." She was asked when the alarms were discontinued. She stated, "I don't know." She was asked if she had completed a fall assessment after each fall to determine the root cause of the fall and appropriate interventions. She stated, "No." The DON was asked after the resident returned to the facility after her hip fracture, what interventions were put in place to keep her safe from falls. She stated, "We got a wedge for her wheelchair and we changed her room." She was asked if the care plan had been updated to reflect the resident's room change. She stated, "No." 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/02/12, documented a BIMS score of 2, which indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with one person assist while eating, experienced shortness of breath, received a mechanically altered diet, and had experienced a 5% weight loss or more in the last month or a 10% weight loss or more in the last six months. A nutritional care plan, dated 09/02/12, documented, "Problem: ...requires mechanically altered diet due to difficulty chewing...Goal: ...will consume adequate amount of each meal 75% - 100% x 90 days...Intervention: ...sitting up for all meals...encouraged to drink fluids with all meals...encouraged to eat slowly...meal intake recorded and monitored..." A dietitian note, dated 09/24/12, documented, "Diet (changed) 9/18 to Puree & House Supp now mixed c milk @ meals...Meal intake poor to fair...Wt 173# (down) 6#...Meal intake has improved...Rec weekly wts & f/u to see if new interventions had helped..." A physician's notification, dated 10/17/12, documented, "...resident has had alot of difficulty c swallowing, hospice notified on way to eval per dtr request..." A physician's order, dated 10/17/12, documented, "Honey thick liquids for 2 days then eval again..." A physician's order, dated 10/18/12, documented, "...Hospice evaluation..." A physician's notification, dated 10/19/12, documented, "...resident continues to have (no) swallowing difficulties c honey thick liquids. Would you like to continue honey thick liquids order after today?..." A physician's order, dated 10/22/12, documented, "...Continue honey thickened liquid..." The October 2012 weight records were reviewed for the recorded weekly weights. No weekly weights were recorded. A dietitian note, dated 10/22/12, documented, "...Wt [DATE]# (down) 6.1# (3.5%) (down) 7.79% x 6 m is sig. 10/12/12...started on Health Shakes c all meals...Puree food...Hospice...might benefit from Remeron...cont. to monitor wt & intervention..." A monthly nurses' summary, dated October 2012, documented, "...Weight: 166.4...Stable...Diet: ...Regular c 4 oz house supplement..." The nurses' summary did not address the resident's 27.1 pound weight loss in the last five months, the resident had experienced swallowing difficulities, the resident was to receive thickened liquids, or any new nutritional interventions for the prevention of further loss. The nutritional care plan had not been updated to address the resident's 27.1 pound weight loss, a puree diet, a house supplement to be mixed with milk at all meals, honey thicken liquids, the resident had experienced difficulties with swallowing, the weekly weights, the poor meal intake, the problem the resident experienced with her teeth or new interventions for the prevention of further weight loss. A current monthly physician's order, dated 11/01/12, documented, "...Diet: Puree with 4 oz house supplement mixed with 1/2 cup of milk with meals, health shake with meals d/t wt loss..." A dietary communication form, dated 11/06/12, documented, "...Honey thick liquids..." The November 2012 weight records were reviewed for the recorded weekly weights. No weekly weights were recorded. A dietitian's note, dated 11/19/12, documented, "Wt [DATE]#...[DATE]#...wt (down) 5# x 1m...(down) 7# x 3m...puree c 4 oz house supplement mixed c milk @ meals...Remeron started per rec 10/22/12 & noted in Nov...(no) new interventions @ this time...monitor wt for (change)..." The dietitian did not address the 32.2 pound weight loss in six months (16.6%) the resident had experienced from May through November 2012, the 17.2 pound weight loss in three months (9.6%) from August through November 2012, the Remeron had not been started until three weeks after the recommendation, the resident was to have honey thicken consistency with all liquids, and the resident was to have weekly weights. The nutritional care plan had not been updated to address the resident's 32.2 pound weight loss in six months (16.6%) the resident had experienced from May through November 2012, the 17.2 pound weight loss in three months (9.6%) from August through November 2012, a puree diet, a house supplement to be mixed with milk at all meals, honey thicken consistency for all liquids, the resident had experienced swallowing difficulties, the weekly weights, Remeron for an appetite stimulant, the poor meal intake, the problem the resident experienced with her teeth or new interventions for the prevention of further weight loss. The nutrition intake, dated November 2012, documented the resident received a supplement with her meals only 26 times out of 90 meals. A monthly nurses' summary, dated November 2012, documented, "...Weight: 161.8...Stable...Diet: ...Pureed c honey thick liquid..." On 11/26/12 at 11:40 a.m., the resident was observed during the lunch meal. The resident received a thickened supplement, regular milk, and regular water. Staff was observed assisting the resident with her meal. The resident was observed drinking the thickened supplement. The resident was not observed drinking the regular milk or the regular water. On 11/27/12 at 5:10 p.m., the resident was observed during the evening meal. The resident received a thickened supplement, thickened lemonade, and a regular milk. CNA #7 stated the resident was to have honey thickened milk. She stated she was going to have one of the aides bring her a honey thickened milk. On 11/28/12 at 9:54 a.m., the DON was asked if the resident was to receive thickened liquids. She stated, "Yes she is suppose to be on honey thicken liquids." The DON was asked why the resident was to receive the honey thicken liquids. She stated, "She was having some swallowing problems." She was asked why the November physician's orders did not address the honey thicken liquids. She stated, "I have no answer for that other than it was missed." She was asked who reviewed the current physicians' orders. She stated, "I review them." On 11/30/12 at 2:53 p.m., the DON was asked why the thickened liquids were not addressed on the resident's care plan. The DON stated the thickened liquids should have been addressed.

Based on observation, interview and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for three (#2, #3, and #7) of nine sampled residents who had experienced falls. A. Resident #2 experienced six falls in four months with five falls resulting in actual harm of a fractured collarbone, a dislocated finger, and three head injuries. B. Resident #3 experienced four falls in six months. With two of the four falls the resident sustained [REDACTED]. C. Resident #7 experienced four falls within one month, resulting in skin tears and bruising to her head. Findings: A facility's fall prevention program documented, "Purpose: To reduce the potential risk and injury to the Residents. Procedure: ...C. Develop & implement appropriate Plan of Care based on assessment..." A document titled, Interventions to reduce falls, documented, "...Establish frequent toileting rounds to reduce unassisted trips to the bathroom...Check high risk Resident frequently, particularly at high risk times...Keep residents active & ambulatory. Provide appropriate activities to engage the restless or agitated Resident...Seating aides such as wedge cushions & postural supports should be used for Residents likely to fall or slide from a chair...Search for causes. Establish a pattern of falls. Be sure to investigate." 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial assessment, dated 02/17/11, documented the resident had moderately impaired cognition as indicated by a BIMS score of 9, the resident needed limited assistance with setup help only for transfers, had an unsteady gait, and had not experienced any falls. An incident report, dated 03/31/11, documented, "...Head Injury: Yes...was going to sit on the edge of her bed, & missed the bed, sliding down onto her side, hitting her head on the floor...lg purple bruise c edema...bruise to R temple & eye 10cm x 12cm...Safety precautions to prevent recurrence: Encourage res to lay (down) after prn given...monitor..." A care plan for falls occurrence, dated 03/31/11, documented, "Problem: Fall with injury...lg hematoma R side of face...Goal: Resident will have no further falls or injuries x 30 days...Interventions: ...monitor for further injuries..." The fall care plan did not address how the injury occurred, or if the resident was to be on fall precautions and what the fall precautions were. There were no interventions addressed for the prevention of further falls. An incident report, dated 04/14/11, documented, "...Head Injury: Yes...Res urinated in floor & slipped & fell backwards...Goose egg size bump on back of head c/o L & R hip pain...Safety precautions to prevent recurrence: family & resident requested use of briefs..." A care plan for falls occurrence, dated 04/15/11, documented, "Problem: Fall with injury...Hematoma L side back of head c/o pain (L) & (R) hip...Goal: Resident will have no further falls or injuries x 30 days...Interventions: frequent visual checks (Q30min)...Briefs for incont..." The fall care plan did not address how the injury occurred, or the resident was to be on fall precautions and what the fall precautions were. A care plan for falls occurrence, dated 04/25/11, documented, "Problem: Fall without injury...Goal: Resident will have no further falls or injuries x 30 days...Interventions: ...assessment/document NN QS x 72hrs..." There was no other documentation of the fall on 04/25/11 in the clinical record. The fall care plan did not address how the fall had occurred, or the resident was to be on fall precautions and what the fall precautions were. There were no new interventions addressed for the prevention of further falls. A nurse's note, dated 05/04/11 at 9:35 p.m., documented, "...resident fell out of bed fell backwards and struck back of head at occiput on metal frame of bed. A large lump formed quickly c bleeding fr. (from) cut where back of head struck metal frame of bed Res was alert to self only which is usual for this res." The nurse's note documented the resident was sent to the hospital. A care plan, dated 05/04/11, documented, "Problem: Fall with injury...Goal: Resident will have no further falls or injuries x 30 days...Interventions: ...low bed...therapy eval...frequent visual checks (Q30min)...call light within reach/remind resident to use..." A nurse's note, dated 05/05/11, documented, "...returned to the facility DX of (1) fall c contusion Head, pelvis, chest. (2) scalp laceration...fall precautions...2 staples to small cut @ back of head..." A physician's note, dated 05/05/11, documented, "...Frequent falls...has fallen in her room several times..." A nurse's note, dated 05/05/11, documented, "...2 staples intact @ back of head...ambulates without difficulty to RR and back..." A nurse's note, dated 05/12/11, documented, "@2340 (11:40 p.m.) Res found on floor next to her bed...stated rolled out of bed, & landed c her left hand under her back. Middle finger of left hand bent abnormally to the side. lg purple bruise on knuckle..." The nurse's note documented the resident was sent to the hospital. A care plan for falls occurrence, dated 05/12/11, documented, "Problem: Fall with injury...Goal: Resident will have no further falls or injuries x 30 days...Interventions: ...low bed...call light within reach/remind resident to use..." The fall care plan did not address the resident was to be on fall precautions and what the fall precautions were. There were no new interventions addressed for the prevention of further falls. A nurse's note, dated 05/13/11, documented, "Returned to facility...splint on her finger...Dx of (1) fall (2) L 3rd digit dislocation...Orders received for...fall risk precautions..." A nurse's note, dated 05/15/11, documented, "...has balance problems when tries to stand or walk..." A fall risk assessment, dated 06/10/11, documented the resident had not experienced any fall in the past 3 months. The assessment documented the resident was at high risk for falls. A nurse's note, dated 07/27/11 at 3:00 p.m., documented, "Res c/o severe pain in R collarbone flinches when it is touched..." A physician's orders [REDACTED]. There was no documentation in the resident's clinical record to describe how the resident had sustained a fracture of the right collarbone. The incident was not addressed on the fall care plan and no interventions were addressed or implemented for the prevention of further falls and injuries. Monthly physician's orders [REDACTED]. A monthly nurses' summary, dated 08/09/11, documented, "...Geri chair...Ambulation: assist..." A physician's note, dated 08/25/11, documented, "...The patient did have a fracture of the distal clavicle on the right on x-ray recently...Atrial fibrillation. The patient is not anticoagulated due to fall risk and history of frequent falls with hemorrhage..." The resident was observed on 09/20/11 through 09/23/11 in a reclined geriatric chair. On 09/22/11 at 1:50 p.m., the DON, ADON, nurse consultant #1, nurse consultant #2, and nurse consultant #3 were asked how the resident had fractured her collarbone. They were informed there was no documentation in the resident's clinical record to describe what had occurred. The ADON stated in June or July the resident had fallen then complained of her collarbone. She stated, "Come to find out it was broken." The DON and ADON were asked why there were no interventions addressed on the care plan to prevent the resident from falling. The ADON stated, "I don't believe you will find them anywhere." She stated, "We were to give the information to the DON and she was to take care of it." The ADON was asked if they were to implement interventions at the time a fall. She stated, "No." The DON and ADON were asked if a fall risk assessment was completed after a resident experienced a fall. The ADON stated, "No." She was asked why the fall risk assessment, dated 06/10/11, documented the resident had not fallen within the last three months when the resident had fallen six times. She did not provide an answer. The DON, ADON, nurse consultant #1, nurse consultant #2, and nurse consultant #3 were informed the resident had sustained six falls and five injuries from 03/01/11 through 07/27/11 and no interventions had been implemented to prevent further falls. No comments were made. The care plan did not address the fall that occurred in June or July, that the resident was at high risk for falls, was on fall precautions or identify what the fall precautions were. The care plan did not address the collar bone fracture or that the resident was in a geriatric chair. There were no new interventions addressed for the prevention of further falls. 2. Resident #3 had a current [DIAGNOSES REDACTED]. A care plan, dated 01/05/11, documented, "Problem: High risk for falls related to imp mobility Goal: Resident will be without falls or injury daily x 90 days Intervention:...Assist resd c all transfers..." An incident report, dated 02/16/11 documented, "...Description of incident: Resident found on floor in front of recliner c R arm extended back said she 'tumped forwards' (sic) no c/o pain no redness does not want to go to ER...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE: use call light for help c transfers..." The care plan, updated on 04/07/11, documented, "Cont POC..." The care plan did not address the resident's fall on 02/16/11. No new interventions were addressed on the care plan to prevent another fall. An incident report, dated 04/28/11, documented, "...Description of incident: Res was in dinning (sic) room standing up to leave and fell res hit face on ground large bump on right side of face and cheek swollen...Describe extent of Injury: right cheek under the eye swollon (sic) right upper arm & shoulder sore complaint of res. no outward signs of reddness (sic) or swelling...treatment: seen in ER no injury...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE: (blank)..." An Oklahoma State Department of Health Incident Report Form, dated 04/28/11, documented, "...Initial and Final report checked...Description of Incident: Resident fell out of w/c in dining room trying to stand up c assist. Resident hit face large bump on R side of face sent to ER...corrective measures: (no preventive measures documented)..." The incident report documented the resident was standing up and fell and the Oklahoma State Department of Health Incident Report documented the resident fell out of her wheelchair. An incident report, dated 05/26/11, documented, "...Description of incident: Res. was found face down on the floor of her room. Bleeding coming from top of R eye (sic)...describe extent of injury: above right eye area swallon (sic) & bleeding Swallon (sic) approx 1 1/2 inchs. (sic) in width cut to top of right hand bleeding...cut approx 1 in long...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE : possible use of seatbelt and more visual checks by staff.." The report documented the resident was sent to the hospital. An Oklahoma State Department of Health Incident Report Form, dated 05/26, documented for the final report portion of the form which was to include a summary of the investigation and corrective measures implemented to prevent recurrence, "Resident returned from ER c sutures to forehead...Resident refuses seatbelt to help prevent falls. Started frequent visual checks." A care plan for falls occurrence, dated 05/26/11, documented, "...Problem: FALL WITH INJURY Describe injury: head...GOAL: Resident will have no further falls or injuries x 30 days...INTERVENTIONS:...medication review by DR...non slip footwear...proper shoes...frequent visual checks (Q 30 min)...call light within reach / remind resident to use..." The fall care plan did not address the reason the resident had fallen or the previous falls the resident sustained [REDACTED]. A quarterly assessment, dated 07/07/11, documented the resident had short term memory problems with modified independence in cognitive skills for daily decision making; the activity of walking did not occur; for balance during transitions from sitting to standing or from surface to surface, the resident was only able to stabilize with human assistance; was totally dependent on staff for dressing; and had a limitation in range of motion of upper and lower extremities on one side of her body. The assessment documented the resident was occasionally incontinent of urine and had 2 falls with injuries that were not major since the last significant change assessment on 04/07/11. No medication review by the physician, and no documentation of visual checks every 30 minutes were found in the resident's medical record. An incident report, dated 09/05/11, documented, "...Description of incident: resident in w/c reaching for something on floor when fell fwd. hitting head...describe extent of injury: Hematoma on forehead 7 cm x 5 cm...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE: (blank)..." The documentation of the four falls on 02/16/11, 04/28/11, 05/26/11, and 09/02/11, revealed the resident had head injuries with three of the four falls, and there were no new interventions documented to prevent another fall for two of the four falls. On 09/21/11 at 4:00 p.m., nurse consultant #2 was asked if an investigation was done regarding why the resident had four falls since February. The nurse consultant stated, "No." She was asked what new interventions were in place to prevent the resident from falling. She stated, "I guess just what was documented." 3. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurse's note, dated 06/27/11 at 5:00 p.m., documented, "New Res admitted from home...Need max assist c getting in and out of bed. Res has bruising around R eye family states res has fell ,[DATE] times n past 30 days..." A nurse's note, dated 06/28/11 at 9:20 p.m., documented, "...has alarm attached for alert to falls res removes it and shuts it off tries to standup and walk constantly had 1 fall out of bed onto mat on floor no injury..." There was no incident report for this fall. A nurse's note, dated 06/29/11 at 3:15 a.m., documented, "...resident is removing alarm to get up..." At 9:00 p.m., a nurse's note, documented, "...res removes or turns off fall alarm tries to do things by self..." A nurse's note, dated 07/02/11 at 5:45 a.m., documented, "...res up and amb in hall way...holding bed alarm." An incident report, dated 07/05/11, documented, "...Description of incident: Resident was found sitting in floor in west hallway. Reopened wound to left hand. Denies hitting head. Resident stated 'I fell on my butt." No nurses' notes were found in the resident's clinical record documenting the fall on 07/05/11. A care plan for falls occurrence form, dated 07/05/11, documented the resident had a fall with injury with a reopened wound on the left hand. Interventions marked were low bed, personal alarm and call light within reach/remind resident to use. An admission assessment, dated 07/10/11, documented the resident had severe cognitive impairment based on their BIMS score of 0, needed limited assistance with transfers, dressing, toilet use, and personal hygiene and needed supervision with walking and eating. The assessment documented the resident had a fall since admission and had two or more falls with an injury. A care plan for falls, dated 07/11/11, documented, "...Problem: High risk for falls related to generalized weakness, dementia, severe weight loss, fatigue...Intervention:...Address fall risk factor for resident: identify resident as fall risk with staff...Frequent visual checks on resident if unable to utilize call light while in bed..." The care plan did not address the previous fall on 06/28/11, or that the resident removed the alarm or turned the alarm off. A nurse's note, dated 07/14/11 at 11:45 p.m., documented, "...Roommate to hallway to report res had 'fallen on her butt'. Res found sitting on the floor next to her BSC. Stated she got up to pee & landed on her bottom. Small skin tear to L wrist & upper forearm....Bed alarm replaced. Pommel cushion placed. Res reminded not to get up unassisted. Staff instructed to make frequent visual checks..." A care plan for falls occurrence form, dated 07/14/11, documented the resident had a fall with injury with a skin tear to the right wrist and upper forearm. Interventions marked were personal alarm, pommel cushion and call light within reach/remind resident to use. The care plan for falls was not updated to include the reason the resident had fallen or the previous fall on 06/28/11. A nurse's note, dated 07/28/11 at 2:30 a.m., documented, "Res fell at 0200 (2:00 a.m.) striking her head on roommates bed while attempting to dress herself and she states came down to breakfast. Has a contusion to R side of forehead c swelling and bleeding also has skin tear on L elbow. States pain 10 of 10 in head...transferred to hospital (name withheld)" A nurse's note, at 5:20 a.m., documented, "Res returned from hospital...new orders for wheelchair and bed check alarm..." A nurse's note at 10:00 a.m., documented, "Bed alarm found on floor in resident closet still attached to nightgown..." A care plan for falls occurrence, dated 07/28/11, documented, "...Fall with injury...Describe injury: Contusion to R forehead c bleeding skin tear to L elbow c bleeding...INTERVENTIONS: Monitor injury for s/s of infection...monitor resident for further injuries...low bed...personal alarm...non slip footwear...frequent visual checks (Q30min)...call light within reach...remind resident to use...new alarm pad..." The care plan did not address how or why the resident was falling. On 09/19/11 at 10:00 a.m., during the initial tour of the facility, LPN #3 was asked about the resident's chair alarm. She stated, "When she gets up she is steady on her feet and tells staff she needs to go to the bathroom." On 09/22/11 at 3:40 p.m., the resident was observed sitting in her wheelchair in the lobby watching television. The resident stood up and her chair alarm sounded. The resident was observed for 4 minutes as she walked across the lobby and most of the way down the main entrance hallway before the DON responded and reached the resident. The resident told the DON, "I need to go to the bathroom." On 09/23/11 at 3:30 p.m., the DON was asked what was the facility's system when a resident falls. He stated, "A fall risk assessment is to be completed." The DON and ADON were asked if a fall risk assessment was competed after a resident experienced a fall. The ADON stated, "No." Nurse consultant #1 was asked if the facility had updated resident's care plans after each fall. She stated, "No." The DON was asked if the system the facility had in place for resident falls was effective. He stated, "No."

Based on observation, interview, and record review, it was determined the facility failed to prevent severe weight loss for three (#2, #5, and #10) of six sampled residents with weight loss. This resulted in actual harm for: ~ resident #2, who had a severe weight loss of 11.6% in six months, 9.5% in 3 months, and 5.2% in 1 month; ~ resident #5, who had a severe weight loss of 8.6% in 3 months; and ~ resident #10, who had a severe weight loss of 7.67% in 1 month, 10% in 3 months. Six residents were identified with weight loss within the last 180 days. Findings: A policy titled, Nursing supervision of nutrient intake, documented, "Policy: Nursing service is responsible for supervision of nutrition intake, will be aware of the nutritional status of each resident and will in meeting their nutritional needs. Procedure:...2. Nursing service will be responsible for preparing the resident for meals and assisting residents who are unable to feed themselves...5. Nursing personnel will be in the dining area during meal service and will observe intake and document acceptance of diet. Deviations from normal will be recorded in the medical record as well as the replacements offered for food refused. 6. Nursing service will contact the resident's designated physician when intake of nutrients is less than 75% of normal diet for two consecutive days..." A policy titled, Meal service, documented, "...Purpose:...2. To provide adequate nutrition for the well-being of all residents...4. To assure that each resident receives the amount of assistance necessary...6. To record percentage of food resident consumed...General guidelines for assessment may include, but are not limited to: Condition of mouth and teeth...Difficulty in chewing or swallowing...Nutritional status...Reason for food or fluid refusal...Weight..." 1. Resident #2 was admitted to the facility on [DATE], with diagnoses which included [MEDICAL CONDITION]. An initial assessment, dated 02/17/11, documented the resident had moderate cognitive impairment based on a BIMS score of 9, was independent with eating with setup help required. The assessment documented the resident weighed 129 pounds and had not experienced a weight loss. A nutritional care plan, dated 02/17/11, documented, "Problem: Requires a therapeutic diet related to: Health Maintenance...Goal: Resident will consume adequate daily nutrition (at least 75% of meals daily) without complications related to health maintenance x 90 days...Interventions: ...Document meal percentages consumed...weigh resident at least monthly...offer supplements and replacements as needed and appropriate to diet...Dietician to evaluate diet for adequacy and make recommendations prn...monitor lab values...document any dietary non compliance..." A nutritional recommendation, dated 02/24/11, documented, "Diet order: low fat, low sodium, low chol (cholesterol) Meal intake is poor Rec: (Change) diet to regular house supp (supplement) 4 oz TID c meals." The facility's weight record documented the following 2011 weights: March - 129 pounds, April - 133 pounds, May - 133 pounds, June - 126 pounds, July - 115 pounds, August - 118 pounds, and September - 114 pounds. A monthly nurses' summary, dated 03/09/11, documented the resident's weight was "132...Loss: # of lbs?... Blank..." A physician's order, dated 03/17/11, documented the resident was to receive a regular diet with a 4 ounce house supplement three times a day with meals. A monthly nurses' summary, dated 04/09/11, documented the resident's weight was "131...Loss: # of lbs?...1..." A nurse's note, dated 04/12/11, documented, "...appetite continues to be diminished, along c mental status x 2wks..." A nurse's note, dated 04/27/11, documented, "...If staff feeds res she eats well if queded (sic) otherwise drifts off into own world or sleeps..." A monthly nurses' summary, dated 05/09/11, documented the resident's weight was "125...Loss: # of lbs?... 6..." There were no dietary interventions documented that were implemented regarding the six pound weight loss. The nutritional care plan, updated 05/17/11, documented, "Cont. poc..." The care plan failed to address the resident's "diminished appetite", poor meal intake, the weight loss of 6 lbs documented in the nurses's monthly summaries from 04/09/11 through 05/09/11, the resident's need to be fed and assisted by the staff, and new interventions to prevent further weight loss. A dietary note, dated 05/24/11, documented, "Weight 133lbs. Weight stable x 2 months. Appetite poor. Feeder at feeding room. No changes in diet. Will cont. to monitor weight loss." The nutritional meal intake records for 05/01/11 through 05/31/11 revealed the resident's meal percentages had not been documented for 24 of 93 meals and the resident was not offered the house supplement for 68 of 93 meals. The resident refused the supplement five times when it was offered and refused one meal. The dietary notes did not address the meal percentages which had not been documented, the resident's refusal of one meal or supplements five times or that the supplement had not been provided to the resident three times daily with meals as ordered by the physician. A doctor's notification, dated 06/07/11, documented, "...current weight 122...This resident is below their ideal body weight range, has or is having a weight loss...April wt. 133...May 133...June 122...The average percentage of meal acceptance is: 25-50%...Interventions we have taken to hopefully improve appetite and food intake are: House supplement...May we have order for Appetite stimulant?...Doctor: Dementia...refer to hospice..." A physician's order, dated 06/07/11, documented, "Per family et Nursing home request may we evaluate and admit if appropriate to ...Hospice?...Yes" The physician's order failed to address the [DIAGNOSES REDACTED]. A monthly nurses' summary, dated 06/09/11, documented the resident's weight was "123...Loss: # of lbs?... 2..." A medication regimen review, dated 06/14/11, documented, "...Patient weight June 122...Down from 133 in May...Would patient benefit from addition of [MEDICATION NAME] 40mg/ml 10cc po daily for appetite stimulant..." Doctor's response, "Has been referred to hospice" A dietary note, dated 06/27/11, documented, "Weight 126 lbs (down) 7 lbs x 1 month. No new labs. No changes to diet. Resd is a feeder now at the feeder table. Seems to be going good." An RD note, dated 06/28/11, documented, "Weight (change) -5% x 1month, however only (down) 2% from 3 months ago. Regular diet. House supplement c meals. Overall meal intake is poor. Meds. noted. Now on hospice. Weight loss likely related to disease progression. TF/appetite stimulant (not) desired. Lab noted. No recs @ this time." The dietitian failed to address the resident's need to be fed during all meals and failed to address any new recommendations to prevent further weight loss. The June 2011 Nutrition Intake Sheet failed to document meal intake for 15 of 90 opportunities. The sheet documented a supplement was not offered to the resident for 49 of 90 times it was to be offered. The resident refused the supplement eight of the times it was offered and refused one meal. The dietary notes did not address the meal intake percentages which had not been documented, the resident's refusal of one meal or supplements eight times or that the supplement had not been provided to the resident three times daily with meals as ordered by the physician. The nutritional care plan had not been updated to address the resident's "diminished appetite", poor meal intake, the weight loss of 7# (5.2%) in one month, the resident's need to be fed and assisted by the staff, the residents refusal of her meals/supplement and the house supplement not given. There were no new interventions to prevent further weight loss. An RD note, dated 07/28/11, documented, "Weight 115. Hospice nurse confirmed weight. Sig loss 8% x 1 month. Meal intake fair. Regular diet c house supplement TID c meals. No new labs. TF (not) indicated. Appetite stimulant requested by nsg. and pharmacist. Nothing else to suggest @ this time..." The DON was asked for the July 2011 nutritional intake sheets. None were provided. The nutritional care plan had not been updated to address the resident's significant weight loss of 8% in one month, the resident's need to be fed during meal times, and any new dietary interventions to prevent further weight loss. A monthly nurses' summary, dated 08/09/11, documented the resident' weight was "118...Gain: # of lbs?...3..." A physician's hospice note, dated 08/25/11, documented, "...if she remains stable, there may need to be consideration given to discharging her from hospice for now..." A dietary note, dated 08/26/11, documented, "Weight 118...continues to gain...meal intake fair...regular diet and house supplement TID meals..." An RD note, dated 08/30/11, documented, "Sig wt (loss) of 11% x 3 months...meal intake fair...receiving palliative care...no new recs..." The dietitian's notes failed to address any recommendations for the prevention of further weight loss. The DON was asked for the August 2011 nutritional intake sheets. None were provided. On 09/20/11 at 12:07 p.m., the resident was observed sitting at the dining room table in the assisted dining room. At 12:15 p.m., the resident was removed from the dining room. At 12:21 p.m., nurse consultant #2 was asked where the resident was going. She stated to an eye doctor appointment. At 12:25 p.m., LPN #3 was asked what time the appointment was. She stated, "The appointment is at 1 (1:00 p.m.)." At 12:26 p.m., a dietary aide was observed delivering the resident's lunch tray. The aide was informed the resident was gone and the kitchen would need to prepare a new tray for the resident when she returned. At 3:08 p.m., the resident was observed returning from the appointment. The resident was placed in the lobby area in a reclined geriatric chair. At 3:10 p.m., the office manager asked the resident if she wanted something to eat. The resident was taken to the dining room. At 3:30 p.m., the resident was given a meal tray. On 09/22/11 at 2:02 p.m., the DON and the ADON were asked what the resident's [DIAGNOSES REDACTED]. The ADON stated, "Lots of falls? I don't remember what her [DIAGNOSES REDACTED]. At 2:10 p.m., nurse consultant #3 stated the [DIAGNOSES REDACTED]. At 2:50 p.m., the ADON was asked why the resident did not receive her lunch meal early since she had a doctor's appointment at 1:00 p.m. She stated, "I told them to pack a snack to take with her." She was asked why nursing did not take care of the resident's food situation before the resident left for the appointment. She stated, "They should have. The charge nurse is to check the schedule for appointments. Nurse consultant #2 stated, "We need to work on this system." The DON, ADON, and the nurse consultants were asked why there were no dietary interventions or recommendations from the dietitian in place to prevent further weight loss. Nurse consultant #1 stated, "I don't know." The nurse consultant was asked if anyone was following up on the dietitian's notes and recommendations. She stated no one was following up on the dietitian right now. On 09/23/11 at 2:00 p.m., the dietary manager was asked what the procedure was for a resident to receive a meal if they had an appointment during a meal time. She stated, "Nursing is to notify us if they are to leave before their meal so we can give them a meal before they leave or fix them something when they get back." She was asked if nursing had informed the kitchen the resident would be leaving before lunch and would need to eat early. She stated, "No. They asked her to fix her a tray when she came back." Did anyone ask the kitchen to prepare the resident a snack before she left for her appointment. She stated, "No." The resident had not received any nutrition since her breakfast meal until 3:30 p.m., when her tray was served after her return from the appointment. The resident had experienced a 7# (5.2%) severe weight loss in one month, a 12# (9.5%) severe weight loss in three months, and a 15# (11.6%) severe weight loss in six months. 2. Resident #5 had diagnoses which included [MEDICAL CONDITION] and [MEDICAL CONDITION]. An annual assessment, dated 12/06/10, documented, the resident was unable to complete the cognition interview and the cognitive patterns for short term memory problems and long term memory problems were left blank, the resident required limited assistance with eating with a one person physical assist, and the resident's weight was 144 pounds, with no weight loss experienced. A physician's order, dated 02/16/11, documented the resident was to receive a regular puree diet with a 4 ounce supplement during the lunch and evening meals. A quarterly assessment, dated 03/08/11, documented, the resident was unable to complete the cognition interview and the cognitive patterns for short term memory problems and long term memory problems were left blank, the resident required limited assistance with eating with a one person physical assist, and the resident's weight was 134 pounds, with no weight loss experienced. A nutritional care plan, dated 03/08/11, documented, "Problem: Resident c problem r/t puree diet wt stable march wt was 135# will continue care plan...Goal: Resident will consume at least 75% of meals daily without complications x 90 days...Interventions: ...Assist resident with meals as needed...weigh resident at least monthly...monitor resident for increased chewing or swallowing difficulties...Dietician to evaluate diet for adequacy and make recommendations prn...Allow resident ample time to eat...Prevent feeling rushed...Document meal percentages consumed daily..." The facility's weight record documented the following 2011 weights: June - 138 pounds, July - 135 pounds, August - 126 pounds, and September - 126 pounds. The nutritional meal intake records for 05/01/11 through 05/31/11 revealed the resident's meal percentages had not been documented for 19 of 93 meals, the resident had refused 6 meals, and did not receive the house supplement for 34 of 93 meals. The record revealed when the resident had received the house supplement the intake was 100%. The dietary notes did not address the 19 times the meal percentages had not been recorded, that the resident had refused 6 meals, and the resident had not received the house supplement 34 times. A quarterly assessment, dated 06/08/11, documented the resident was unable to complete the cognition interview and the cognitive patterns for short term memory problems and long term memory problems were left blank, the resident required supervision while eating with setup help only, and the resident's weight was 135 pounds with no weight loss experienced. The nutritional care plan had not been updated on 06/08/11 to address if the goal had been met or new interventions to prevent weight loss. A dietary note, dated 06/27/11, documented, "Weight 138 lbs. (up) 3 lbs x 1 month. New labs noted...no changes is diet..." The nutritional meal intake records for 06/01/11 through 06/30/11 revealed the resident's meal percentages had not been documented for 7 of 90 meals,the resident had refused 7 meals, and did not receive the house supplement for 31 of 90 meals. The record revealed when the resident had received the house supplement the intake was 100%. The dietary note did not address the 7 times the meal percentages had not been recorded, that the resident had refused 7 meals, and the resident had not received the house supplement 31 times. An RD note, dated 07/28/11, documented, "Weight 135. Wt (change) not significant. Eats fair. Regular, puree diet, supp 4 oz BID...No recs @ this time..." The RD note did not address the nutritional intake records for the months of May and June 2011. The RD did not address why the resident had not received the supplement as documented as an intervention to prevent weight loss. The July and August 2011 nutritional intake records were not in the resident's clinical record. A dietary note, dated 08/16/11, documented, "Weight 159 (up) 24 x last month, labs noted...Regular Puree diet supp 4 oz BID...Appetite good..." There were no dietitians' notes for the month of August 2011 in the resident's clinical record. A physician's order, dated 08/23/11, documented the resident was to receive hospice care. No [DIAGNOSES REDACTED]. A nurse's note, dated 08/30/11, documented, "1430 (2:30 p.m.) New orders received (sic) for [MEDICATION NAME] Swish & Swallow 1 tsp QID x 10 days for red & painful areas in mouth..." A doctor's notification, dated 09/02/11, documented, "...current weight 126...This resident is below their ideal body weight range, has or is having a weight loss...Resident has had 9 lb weight loss in 1 month...Interventions we have take to hopefully improve appetite and food intake are: Hospice pt. on comfort care...Method of feeding: Self c assist...Doctor: No change. Only do monthly weights..." A dietary note, dated 09/03/11, documented, "Wt 126#. 8/11 Wt. 135#..." The dietary note did not address the resident's sore mouth, the 9 lb. weight loss in one month, the resident's severe weight loss of 12 lbs. in three months, why there were no nutritional intake records for July and August 2011, and new interventions to prevent further weight loss. The resident had experienced a 12# (8.6%) severe weight loss in three months from June through September 2011. A physician's notification, dated and faxed 09/08/11, documented, "Problem/Information: Pt has had wt loss in last 2 mos may we have order for [MEDICATION NAME] to enhance appetite..." The notification had not been signed by the physician and no follow-up to the notification had been documented. The nutritional meal intake records for 09/01/11 through 09/30/11 revealed the resident's meal percentages had not been documented for 15 of 65 meals, the resident had refused 1 meal, and did not receive the house supplement for 31 of 65 meals. The record revealed when the resident had received the house supplement the intake was 100%. On 09/20/11 at 12:30 p.m., the resident was observed during the lunch meal. The resident had received her meal and was attempting to take a bite of her dessert. No one assisted her with her meal. The DON and the ADON were walking around the dining room but no one stopped to assist the resident with her meal. At 12:33 p.m., LPN #1 asked the resident if she could help her. The resident did not respond. The resident was drinking her house supplement and looking around the room. The LPN set in a chair next to the resident. She attempted to give the resident a bite of food. The resident shook her head no. The LPN got up from her chair and left. The resident continued to drink the house supplement. No bites of food had been taken. At 12:42 p.m., the DON asked the resident, "Are you going to eat?" The DON offered the resident a bite of the dessert. The resident put her hand up. The DON left. At 12:48 p.m., the ADON stated, "You don't want any lunch?" The resident shook her head no. The ADON left. At 12:53 p.m., the resident was still at the dining room table and observed falling asleep. LPN #1 walked over to the resident and asked the resident if she wanted to eat. The resident shook her head yes. The LPN offered no encouragement and no attempts were made to assist the resident with the meal. At 12:54 p.m. the resident was removed from the dining room. No staff offered the resident an alternative to her meal, an additional house supplement, or encouragement to eat her lunch. The resident did not eat any of her lunch meal and drank 100% of her house supplement. On 09/21/11 at 12:24 p.m., the resident received her meal tray. The aide placed the tray in front of the resident and walked away. The resident picked the juice glass up and attempted to drink the juice. The plastic wrap was on the glass and the resident was unable to remove the wrap from the glass. She continued to attempt to drink the juice with the plastic wrap attached and finally set the glass down. The resident took a bite of the dessert. At 12:30 p.m., LPN #1 sat down beside the resident. She asked the resident if she could help her. The LPN attempted to feed the resident. The resident shook her head no, but then she took a bite of the food offered. The LPN stated, "She doesn't have a very big appetite." The LPN did not offer the resident any more bites of food. The LPN offered no more encouragement and no attempts were made to assist the resident with the rest of the meal. No staff offered the resident an alternative to her meal or encouragement to eat her lunch. The resident drank two house supplements and ate a few bites of dessert. On 09/22/11 at 3:25 p.m., the DON, ADON, nurse consultant #1, and nurse consultant #3 were asked who reviewed the dietary notes. The ADON stated she had just started to review the notes. They were asked why the resident's severe weight loss had not been addressed in the nurses' notes. The DON stated, "It should be." The ADON stated, "I'm doing it now." They were asked for the nutritional intake records for the months of July and August. Nurse consultant #1 stated, "We'll look for them." The DON, ADON, and nurse consultants were asked why there were no nutritional interventions addressed in the dietary notes or in the care plan when the resident had experienced a severe weight loss of 12# in three months. No one answered. They were asked if the dietitian had completed a dietary progress note for the month of August 2011. The ADON stated, "No." Nurse consultant #1 stated the person that was updating the care plans was no longer there and no one had followed up. The nutritional intake records for the months of July and August 2011 were not provided. 3. Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia, depression, and muscle weakness. Throughout the survey on 09/19/11 through 09/23/11, the resident was observed during meals. The resident was observed eating alone at a table in the corner of the dining room. At no time was the resident spoonfed or assisted with her meals. The facility's weight record documented the following 2011 weights: January - 119 pounds, February - 117 pounds, March - 108 pounds, April - 107 pounds, May - 110 pounds, June - 113 pounds, July - 108 pounds. August - 114 pounds, September - 105.33 pounds. A dietary note, dated 01/21/11, documented, "...Wt: 119# Resd stable c wt x 3 months. Diet puree c H.S. tid c meals...no signs of problems." An RD note, dated 01/27/11, documented, "See annual assessment." A dietary note, dated 02/28/11, documented, "Wt: 117 lbs. down 2 lbs x 1 month. Resd has her days. past few days she has refused to get up to eat..." The dietary note did not address the 2# weight loss and the resident's refusal to eat. A dietary progress note, dated 03/30/11, documented, "Weight 108 lbs. down 9 lbs x 1 month. Appetite fair...No new labs..." A RD note, dated 03/31/11, documented, "Resident has had significant weight loss of 7.67% x 1 month and 10% x 3 months...House supp tid c meals. Reported meal intake is poor. [MEDICATION NAME] ordered 3/24 for appetite. Agree c current intervention to help appetite. Will monitor for progress..." The dietitian did not address the resident's severe weight loss for 1 month, severe weight loss for 3 months, and the resident's refusal to eat. A dietary note, dated 04/20/11, documented, "...weight 107 lbs. down 1 lb. x 1 month. -10.08% x 3 months. Resd continues to lose weight. Appetite poor. [MEDICATION NAME] order but doesn't seem to work. Will speak c DON..." An RD noted, dated 04/21/11, documented, "...Weight 107. Sig wt loss 10% x 3 months. Diet puree - intake poor, house supp tid - intake good. No new lab. Skin intact. If no sig improvement in appetite, may benefit from trying [MEDICATION NAME] ES. Will follow to monitor wt/intake..." No physician's order was found in the resident's medical record for [MEDICATION NAME] ES. The RD did not address the severe weight loss for 3 months, the lack of benefit from [MEDICATION NAME], the poor intake, and any new recommendations to prevent further weight loss. A doctor's notification, dated 04/23/11, documented, "...Interventions we have taken to hopefully improve appetite and food intake are: [MEDICATION NAME] 4 mg po bid. HS c meals..." Signed by physician. The doctor's notification did not address the resident had [MEDICATION NAME] since 03/25/11 without results. The resident had experienced a 12# (10.08%) severe weight loss in 3 months. A dietary note, dated 06/27/11, documented, "...weight 113 lbs..." The dietary note did not address the 5# weight loss the resident had in 1 month or any recommendations to prevent further weight loss. A nutritional intake dated 07/01/11 through 07/31/11, documented the resident refused 9 out of 93 meals, refused 7 out of 93 supplements, no intake for 28 of 93 meals, and no intake for 44 of 93 supplements. The dietary progress notes and the care plan failed to address the resident's meal intake. A quarterly assessment, dated 07/07/11, documented the resident had severe cognitive impairment with a BIMS score of 4, had a weight of 108 lbs., and had a weight loss of 5% or more in the last month and 10% in the last 6 months. A care plan, dated 07/08/11, documented, "...Problem: At risk for [MEDICAL CONDITION] weight loss R/T poor appetite...Goal: Resident will exhibit no weight loss x 90 days...Intervention: Spoon feed...Weigh resident weekly...Report significant changes in weight or appetite to the physician...House supp tid c mls. [MEDICATION NAME] 4mg po bid...notify PCP of any wt loss..." An RD note, dated 07/28/11, documented, "...weight 108 wt decreased 9 % x 6 months...cont current interventions. will follow..." A dietary note, dated, 08/30/11, documented, "Weight: 114..." A nutrition intake record, dated 08/01/11 through 08/31/11, documented the resident refused 7 out of 93 meals. There was no intake documented for 11 of 93 meals, or for 64 of 93 supplements. The dietary progress notes and the care plan failed to address the resident's meal intake. A dietary note, dated 09/02/11, documented, "...there appears to be discrepancy c the wt documented 08/30/11. Resident has not gained wgt instead she has lost 2 lbs. since 7/28/11 upon reweigh..." The dietary note did not address the continued weight loss of the resident and recommendations to prevent further weight loss. A physician's notification dated, 09/06/11, documented, "...REs. has small round bumps under the tongue and one large bump on roof of mouth. c/o tongue hurting. tongue white in color on top..." The bumps and tongue hurting was not addressed in the dietary notes and the care plan as a potential problem for the resident's continued weight loss. The resident had experienced a 8.67# (7.67%) severe weight loss in one month, a 12# (10.08%) severe weight loss in three months, and 13.67# (11.48%) weight loss in eight months. On 09/22/11 at 5:00 p.m., the DON was asked if he was aware the resident had a significant weight loss. He stated, "I knew she had a weight loss but did not think it was a significant weight loss." He was asked what interventions were in place to prevent weight loss. He stated, "I did do some this month." He was asked before this month, what were the interventions. He stated, "I was not aware of a previous weight loss." The DON was asked what was the procedure for weighing residents. He stated, "I write down the previous month's weight for a resident and give the paper to a CNA to weigh that resident. The CNA writes the weight on the same paper and returns it to me then I enter the weight into the computer. He was asked if he was aware the resident had a significant weight loss. He stated, "No, I did not." He was asked if he was aware the resident had a significant weight loss when he entered her weight into the computer. He stated, "No."

Based on observation, record review, and interviews, it was determined the facility failed to have a quality assessment and assurance program in place to identify problems and develop and implement plans of action to correct quality deficiencies, which would in turn ensure the nursing staff provided nursing and related services to enable residents to achieve and maintain their highest practicable well-being. The facility failed to identify and implement a plan of action to correct systems failures related to: a. prevention of severe weight loss for three (#2, #5, and #10) of six sampled residents who had experienced a severe weight loss; and b. supervision and implementation of measures to prevent falls for 3 (#2, #3, and #7) of 9 sampled residents with falls. This had the potential to affect 52 of 52 residents who resided in the facility. Findings: 1. The facility failed to prevent severe weight loss for three (#2, #5, and #10) of six sampled residents with weight loss. This resulted in actual harm for: ~ resident #2, who had a severe weight loss of 11.6% in six months, 9.5% in 3 months, and 5.2% in 1 month; ~ resident #5, who had a severe weight loss of 8.6% in 3 months; and ~ resident #10, who had a severe weight loss of 7.67% in 1 month, 10% in 3 months. Six residents were identified with weight loss within the last 180 days. Refer to F-325. 2. The facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for three (#2, #3, and #7) of nine sampled residents who had experienced falls. A. Resident #2 experienced six falls in four months with five falls resulting in actual harm of a fractured collarbone, a dislocated finger, and three head injuries. B. Resident #3 experienced four falls in six months. With two of the four falls the resident sustained [REDACTED]. C. Resident #7 experienced four falls within one month, resulting in skin tears and bruising to her head. Refer to F-323. 3. A facility policy and procedure titled Quality Assessment and Assurance Program documented, "It is the policy...to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems..." On 09/22/11 at 2:00 p.m., the DON was asked if the facility had an established QA committee. He stated, "No." The DON, ADON, nurse consultant #1, nurse consultant #2, and nurse consultant #3 were asked what systems were in place to identify residents who were at risk for severe/significant weight loss. The DON stated, "None." The DON was asked if the facility had a system to ensure treatments were done as ordered. He stated, "No." On 09/23/11 at 3:36 p.m., the DON, nurse consultant #1, nurse consultant #2, and nurse consultant #3 were asked what systems were in place to identify residents who were at high risk for falls. The DON stated, "The fall risk assessments." He was asked if it was an effective system. He stated, "No."