Every finding on record at Community Health Center

Based on observation, record review, and interview, the facility failed to ensure:a. wounds with an infection were covered during meal time to prevent spread of infection for 1 (#5); andb. wound care was provided in a manner to prevent contamination for 1 (#10) of 3 sampled residents reviewed for wound care; andc. proper glove usage during colostomy care for 1 (#8) of 1 sampled resident for ostomy care.The administrator identified one resident with an ostomy and four residents with wounds resided in the facility. Findings: 1. On 04/07/26 at 7:22 a.m., Resident #5 was observed seated in the dining room with wounds on their legs uncovered. On 04/07/26 at 7:35 a.m., RN #1 was observed to don a gown and gloves and applied Silvercel (an anti-microbial wound medication) to Resident #5's right leg wound. RN #1 wrapped Resident 5's right leg with kerlix and Coban, then changed gloves. RN #1 applied Silvercel to Resident 5's left leg wound and wrapped with Kerlix and Coban (wound dressing wraps). RN #1 did not cleanse Resident #5's wounds before applying treatment. An undated Infection Control Policy, read in part, Community Health Center's intent is to prevent and control the transmission of disease and provide maximum protection for our residents, visitors, and staff from the spread of diseases and infections and viruses. A comprehensive assessment, dated 02/16/26, showed Resident #5 was admitted to the facility with multiple drug-resistant organisms and a chronic non pressure ulcer to their right leg. A physician's order, dated 04/07/26, showed Resident #5 was prescribed a midline catheter placement for intravenous antibiotics. The indication for antibiotics was a pseudomonas wound infection. On 04/07/26 at 7:44 a.m., RN #1 stated Resident #5 had a shower before breakfast, so they did not cleanse the wound prior to applying the wound medication. On 04/07/26 at 12:24 p.m., the DON stated Resident #5 was positive for pseudomonas (a bacterial infection) in their wound. They stated Resident #5 was to have a midline intravenous catheter placed for antibiotics. On 04/08/26 at 8:24 a.m., the infection preventionist stated Resident #5 should have never been out of their room without dressings on their wounds. The infection preventionist stated Resident #5 could spread the pseudomonas to others. 2. On 04/07/26 at 8:33 a.m., RN #1 was observed to don a gown and gloves, removed Resident #10's left sock, and cleansed Resident #10's inner left ankle wound with cleanser. RN #1 applied Silvercel to Resident #10's left ankle wound and applied a bandage. RN #1 changed gloves and cleansed Resident #10's outer left ankle wound with cleanser. RN #1 applied Medihoney (a sterilized honey used to treat wounds) with their gloved fingers. RN #1 applied gauze to the wound, and wrapped Resident #10's left foot with Kerlix and Coban. RN #1 applied Resident #10's sock to their left foot, picked up a book and cards from the floor, and handed them to Resident #10. RN #1 doffed their gown and gloves and washed their hands with soap and water. RN #1 did not change their gloves after applying Medihoney to Resident #10's wound. A quarterly assessment, dated 02/14/26, showed Resident #10 was admitted to the facility with multiple drug-resistant organisms and a stage 3 pressure ulcer to their left ankle. On 04/07/26 at 8:45 a.m., RN #1 stated they did not change their gloves after applying Medihoney to Resident #10's wound. RN #1 stated they touched Resident #10's sock, book, and cards with the same gloves they used to apply the wound treatment. They stated they should have changed their gloves or doffed them before touching the items to prevent contamination. 3. On 04/07/26 at 12:26 p.m., the DON was observed providing colostomy care to Resident #8. The DON cleansed the colostomy site and doffed a pair of gloves. The DON was observed to have a pair of gloves on underneath the pair they doffed. The DON prepared the colostomy wafer, then doffed their gloves. The DON was observed to have a pair of gloves on underneath the pair they doffed. The DON applied the colostomy wafer and bag to Resident #8's abdomen. The DON doffed their gloves. The DON had a total of four pairs of gloves on at one time. On 04/08/26 at 8:27 a.m., the infection preventionist stated it was not acceptable practice to wear multiple pairs of gloves at one time while providing colostomy care or any direct care. They stated staff must only wear one pair at a time to prevent spread of infection.

Based on observation, record review, and interview, the facility failed to ensure accurate comprehensive assessments for 3 (#10, 18, and #21) of 12 sampled residents reviewed for accurate assessments.The administrator identified 32 residents resided in the facility. Findings: 1. On 04/06/26 at 11:21 a.m., Resident #18 was observed lying in bed with oxygen on at two liters. A physician's order dated 09/03/25, showed Resident #18 was to have oxygen at two liters per nasal cannula to keep oxygen levels greater than 89%. A significant change assessment, dated 03/23/26, showed Resident #18 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of breast, Lewy bodies neurocognitive disorder, atrial fibrillation, and asthma. Resident #18's assessment did not show they used oxygen. 2. On 04/07/26 at 12:35 p.m., Resident #21 was observed seated in a geriatric chair participating in a music activity in which they were holding a drumstick. Resident #21 was observed having difficulty holding the drumstick due to contractures in their bilateral hands. A quarterly assessment, dated 03/15/26, showed Resident #21 was admitted on [DATE] with diagnoses which included cerebral palsy, profound intellectual disabilities, and speech and language disorder. The assessment showed no impairment to Resident #21's upper extremities. On 04/08/26 at 12:43 p.m., the MDS coordinator stated they should have checked oxygen use on the comprehensive assessment for Resident #18 and impairment to upper extremities for Resident #21's quarterly assessment. 3. On 04/06/26 at 1:17 p.m., Resident #10 was observed to have a bandage on their left lower extremity. On 04/07/26 at 8:33 a.m., RN #2 was observed providing wound care to Resident #10's left ankle. A skin evaluation, dated 02/13/26, showed Resident #10 had a stage three pressure ulcer on their left lateral foot that was present on admission. An annual assessment, dated 02/14/26, showed Resident #10 was admitted to the facility on [DATE]. The assessment did not show a pressure ulcer was present for Resident #10. On 04/08/26 at 12:49 p.m., the MDS coordinator stated they should have documented Resident #10's wound on their comprehensive assessment.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 2 (#18 and #21) of 12 sampled residents reviewed for care plans. The administrator identified 32 residents resided in the facility. Findings: 1. On 04/06/26 at 11:21 a.m., Resident #18 was observed lying in bed with oxygen on at two liters. An undated Care Plan Policy, read in part, Community Health Centers' interdisciplinary team will conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity .This care plan will include measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs .Each resident will be assessed on a quarterly basis and necessary revisions of the care plan will take place with each quarterly review/assessment. A significant change assessment, dated 03/23/26, showed Resident #18 was admitted on [DATE] with diagnoses which included neurocognitive disorder with Lewy bodies, malignant neoplasm of breast, asthma, and atrial fibrillation. A physician's order dated 03/23/26, showed Resident #18 was admitted to hospice services. 2. On 04/07/26 at 12:35 p.m., Resident #21 was observed seated in a geriatric chair participating in a music activity in which they were holding a drumstick. Resident #21 was observed to be having difficulty holding the drumstick due to contractures in their bilateral hands A care plan, updated 12/29/25, showed Resident #21 required total assistance with all activities of daily living. The care plan did not show contractures were present in both hands. A diagnoses report, dated 04/08/26, showed Resident #21 was admitted on [DATE] with diagnoses which included cerebral palsy, developmental speech disorder, profound intellectual disabilities, and dystonia. On 04/08/26 at 12:43 p.m., the MDS coordinator stated they should have included a hospice care plan for Resident #18 and should have included interventions for contractures on Resident #21's hands.

Based on record review and interview, the facility failed to ensure an as needed psychotropic medication was not used for more than 14 days for 1 (#4) of 3 sampled residents reviewed for unnecessary medications.The DON identified 27 residents utilized psychotropic medications. Findings: A physician's order, dated 01/12/26, showed Resident #4 was prescribed lorazepam (an anti-anxiety medication) oral concentrate 2 mg/ml. The directions for administration were to give 0.5 ml by mouth every four hours as needed for anxiety, restlessness, and/or agitation. There was no end date for this order. A medication administration record, dated 03/2026, showed Resident #4 was given lorazepam oral concentrate 2 mg/ml on 03/06/26, 03/08/26, and 03/14/26. An annual assessment, dated 03/19/26, showed Resident #4 was admitted to the facility with diagnoses which included depression and seizure disorder. On 04/08/26 at 11:59 a.m., certified medication aide #1 stated Resident #4 received lorazepam as needed for anxiety. On 04/08/26 at 12:06 p.m., the DON stated to ensure a resident was free from unnecessary medications, a psychotropic medication would be limited to a 14-day use. The DON stated Resident #4's lorazepam order from 01/12/26 should have had a stop date of 01/26/26 and a new order obtained. They stated, It has fallen through the cracks.

Based on observation, record review, and interview, the facility failed to ensure a resident received the correct insulin dosage for 1 (#24) of 1 sampled resident reviewed for insulin administration.The administrator identified two residents in the facility received insulin. Findings: On 04/07/2026 at 8:50 a.m., RN #1 was observed to obtain Resident #24's finger stick blood sugar with a result of 190. RN #1 was observed to administer Fiasp FlexTouch Pen-injector 100 unit/ml (insulin) 9 units subcutaneously to Resident #24's right lower abdomen. An annual assessment, dated 01/14/26, showed Resident #24 had a diagnosis of diabetes mellitus. A physician's order, dated 01/31/26, showed Resident #24 was prescribed Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/ml, inject as per sliding scale: if 70 - 140 = 0; 141 - 180 = 3u; 181 - 220 = 6u; 221 - 260 = 9u; 261 - 300 = 12u; 301 - 340 = 15u; 341 - 500 = 18u. If greater than 341 give 18 units. On 04/07/26 at 8:57 a.m., RN #1 stated they did not know they administered 9 units of insulin instead of 6 units. They stated they would notify the DON of the medication error.

Based on record review and interview, the facility failed to ensure informed consent was obtained for the use of an psychotropic medication for one (#29) of five sampled residents reviewed for unnecessary medications. The DON identified 27 residents were prescribed psychotropic medication. Findings: The facilty's Initiation of a Psychotropic Drug policy policy, dated 11/21/22, read in part, The family is to be notified .Explain our effects and inquire about their feeling toward the use if a psychotropic medication and explain the risk involved. Resident #29 was admitted on [DATE] with diagnoses which included major depressive disorder and dementia unspecified with other behavioral disturbances. A physician order, dated 12/26/23, documented Resident #29 was prescribed buspirone HCI oral tablet 15 mg .Give one tablet by mouth two times a day .Citalopram Hydrobromide Oral Tablet 10 mg. Give one tablet in the morning. A quarterly assessment, dated 4/9/24 documented Resident #29's cognition was significantly impaired. The clinical health record did not contain documentation an informed consent had been signed for the use of buspirone and citalopram. On 07/09/24 at 2:26 p.m., the IP was asked if they could provided consents for psychotropic medications for Resident #29. The IP stated they had a form they previously used, cant locate consents and education in the clinical health record. On 07/09/24 at 2:27 p.m., the DON was asked what psychotropic medications Resident #29 was prescribed. The DON stated the Resident#29 was prescribed buspirone and citalopram. The DON was asked to provide the consents and education for the prescribed psychotropics. The DON stated, No, I cant find them at this time. I don't think they had been doing them.

Based on observation, record review, and interview, the facility failed to ensure a resident who was physically restrained has a physician order, was assessed, and monitored for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: An undated facility policy titled Restraint Policy, read in part, All residents will have an assessment performed to determine the safety and protective needs of the resident prior to the application of the restraints. The policy also read, .restraints may be applied only on a physician's written order and shall identify the type and reason for the restraint .A restrained resident shall have their restraints released every two hours for at least ten minutes. Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, documented Resident #1 had severe cognitive impairment and required extensive assistance with ADL's. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:56 a.m., Resident #1 was observed sitting in the common area. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:57 a.m., RN #1 stated Resident #1 has a lap belt on their wheelchair because they moved a lot and they were fidgety. On 07/10/24 at 10:01 a.m., RN #1 stated there was no physician order for the use of the lap belt and no documentation Resident #1's wheelchair lap belt use was monitored. On 07/10/24 at 10:05 a.m., Admin stated Resident #1 can undo the wheelchair seat belt on their own. On 07/10/24 at 10:06 a.m., the DON and Infection Preventionist instructed Resident #1 to undo the seat belt. Resident #1 was unresponsive to the instructions given. On 07/10/24 at 10:16 a.m., the DON was unable to locate a resident assessment for the use of the wheelchair seat belt.

Based on observation, record review, and interview, the facility failed to ensure physical restraints were coded accurately on MDS assessments for one (#1) of one sampled resident reviewed for the use of physical restraints. The Administrator identified 35 residents resided in the facility. Findings: Resident #1 had diagnoses which included cerebral palsy and dystonia. An annual resident assessment, dated 05/06/24, did not document Resident #1's use of chair restraint. On 07/09/24 at 8:51 a.m., Resident #1 was observed in their wheelchair. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 9:56 a.m., Resident #1 was observed their wheelchair in the common area. There was a black belt around their waist with a quick release buckle. On 07/10/24 at 10:06 a.m., the DON and Infection Preventionist instructed Resident #1 to undo the seat belt. Resident #1 was unresponsive to the instructions given. On 07/10/24 at 10:20 a.m., MDS Coordinator #1 stated it was considered a restraint if a resident is not able to undo their wheelchair seat belt. On 07/10/24 at 10:23 a.m., the DON stated the use of the wheelchair seat belt was not coded in Resident #1's annual resident assessment.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was labeled and dated, per the facility policy and professional standards of care, for one (#20) of one resident sampled for respiratory care. The DON identified one resident used supplemental oxygen. Findings: The facility's OXYGEN THERAPY policy, undated, read in part, Change device tubing every 30 days on the 15 th of the month on night shift and store the tubing in a bag when not in use. Tubing is to be dated. Resident #20 was admitted on [DATE] with diagnoses which included acute respiratory failure and major depressive disorder. A annual assessment, dated 04/01/24, documented Resident #20's cognition was intact. A physician order, dated 05/07/24, read in part, O2 via nasal cannula PRN to keep sats above 89% every shift. On 07/08/24 at 2:17 p.m., Resident #20 observed in bed wearing O2 with a nasal annual. There was no date observed on the O2 tubing or O2 saturator. On 07/10/24 at 1:39 p.m., CNA #1 went in Resident #20's room. They were asked to observe the date the O2 tubing was changed. They stated there was no date on the tubing or saturator. On 07/10/24 at 1:42 p.m., RN#1 was asked to look at the Resident #20s O2 tubing and saturator. They stated there was no date and have an order to change it monthly. They stated the tubing should be labeled with date. On 07/10/24 at 1:50 p.m., the DON was aked what the policy was when changing O2 tubing and humidifier on the O2 saturator. The DON stated the O2 tubing needed to be labeled with the date it was changed and put in a bag when not in use.

Based on record review and interview, the facility failed to ensure a medication regimen review gradual dose reduction was responded to timely for one (#35) of five sampled residents reviewed for unnecessary medications. The administrator identified 35 residents resided in the facility and received medication. Findings: The facility's Drug Regimen Review policy, dated 11/21/22, read in part, The consultant pharmacist documents potential or actual medication therapy problems, and communicates them to the primary physician and the Director of nursing. A written report is provided to the physician within seven working days. Resident #35 had diagnoses which included major depressive disorder and peripheral vascular disease. A physician order, dated 05/17/24, documented to administer tramadol 50 mg HCI oral tablet every 6 hours as needed for pain. A monthly medication review, dated 05/22/24, documented the pharmacist request to attempt a gradual dose reduction of the residents tramadol 50 mg every six hours as needed. The medication review was not documented as sent to the physician or responded to by the physician in the clinical health record. On 07/10/24 at 10:40 a.m., the Medical records personal was shown the GDR attempt dated 05/22/24 and asked to locate the physician response. They stated it was never sent to the physician due to finding it in a stack of paperwork. They were asked what the policy was when a GDR from a monthly medication regimen review was received . They stated the staff give them to me and I send them to the doctor. When they come back signed, we review and update chart. On 07/10/24 at 11:22 a.m., the DON was asked what the policy was when a monthly medication pharmacy review GDR was requested. The DON stated the GDR should of been sent sent to the physician within 7 days and nursing personnel should of provided a response within two weeks. The DON stated the physician should of provided a report to the facility within one month after the report was sent. The DON was asked if the policy was followed. They stated the policy was not followed.

The facility failed to ensure resident assessments accurately reflected the residents status for two (#5 and #6) of three sampled residents. The administrator stated the facility census was 35. Findings: 1. Resident #5 had diagnosis to include Alzheimer's disease. A physician order, dated 03/15/23, documented Resident #5 was to be provided a regular diet with a mechanical soft texture. A quarterly assessment, dated 01/14/24, documented Resident #5's proportion of total calories received through a parenteral or tube feeding was 25% or less; and the average fluid intake per day by tube feeding was 500 cc or less during seven days of the assessment. On 01/30/24 at 12:15 p.m., Resident #5 was observed in the dining room for the noon meal. Resident #5 had been served a mechanically soft diet and a family member was assisting with the meal intake. 2. Resident #6 had a diagnosis to include Barrett's esophagus and abnormal weight loss. A physician order, dated 05/12/22, documented Resident #6 was to be provided a regular diet with pureed texture and pudding thickened liquids. A quarterly assessment, dated 12/27/23, documented Resident #6's proportion of total calories received through a parenteral or tube feeding was 25% or less; and the average fluid intake per day by tube feeding was 500 cc or less during seven days of the assessment. On 01/30/31 at 12:15 p.m., Resident #6 was observed to have been served a pureed diet and staff assist with the meal intake. On 01/31/24 at 12:35 p.m., the MDS coordinator was asked if Residents #5 and #6 had tube feedings or other alternates for nutritional intake. They stated Residents #5 and #6 had never had tubes. They stated the assessments were not accurate.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to ensure residents had the right to unrestricted visitation. The Resident Census and Conditions of Residents report, documented 33 residents resided in the facility. Findings: The Centers for Medicare and Medicaid Services (CMS) guidance titled In-Person Nursing Home Visitation, dated 03/16/21, documented , .visitation should be allowed at all times .regardless of vaccination status .visitors should be able to adhere to core principles .if fully vaccinated, a resident may choose close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand hygiene before and after . On 06/01/21 at 10:31 a.m., during the entrance conference, the administrator was asked how visitation was being conducted. She stated they used a visitation room. She was asked how visits were scheduled. She stated family called the facility and got put on the calendar for the day they requested to come visit. She was asked how long they were allowed to visit. She stated they scheduled visits for an hour they they could stay longer if another family member was not waiting. The ADM was asked if only one resident could have a visitor at a time. She stated, Yes, inside. She stated they also had outdoor visitation.

Based on observation, record review and staff and resident interviews, it was determined the facility failed to ensure residents had informed of their right to receive visitors. The Resident Census and Conditions of Residents report, documented 33 residents resided in the facility. Findings: The Centers for Medicare and Medicaid Services (CMS) guidance titled In-Person Nursing Home Visitation, dated 03/16/21, documented , .visitation should be allowed at all times .regardless of vaccination status .visitors should be able to adhere to core principles .if fully vaccinated, a resident may choose close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand hygiene before and after . On 06/01/21 at 10:31 a.m., during the entrance conference, the administrator was asked how visitation was being conducted. She stated they used a visitation room. She was asked how visits were scheduled. She stated family called the facility and got put on the calendar for the day they requested to come visit. She was asked how long they were allowed to visit. She stated they scheduled visits for an hour they they could stay longer if another family member was not waiting. The ADM was asked if only one resident could have a visitor at a time. She stated, Yes, inside. She stated they also had outdoor visitation.

Based on record review and staff interview, it was determined the facility failed to ensure grievances made by residents/family representatives were documented, investigated and resolved and the documentation was maintained. The Resident Census and Condition of Residents report, documented 33 residents resided in the facility. Findings: A grievance policy, dated 10/24/18, documented, .that each resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal .will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with the residents throughout the process to resolution .objective of the grievance policy is to ensure .prompt efforts to resolve grievances a resident may have .to support each resident's right to voice grievances .and to assure that after receiving a grievance .actively seeks a resolution . A grievance log documented three grievances had been made in 2018 and 2019. There was no documentation of grievances for 2020 or 2021. On 06/02/21 at 8:50 a.m., the administrator (ADM) was asked who was responsible for handling grievances. She stated, Usually [social service director] or whoever they come to. She was asked how residents and family representatives put in a grievance. She stated, They just come up and talk to you. She stated several came to her or the social service director. The ADM was asked if the grievance log they had provided contained all the grievances since the past recertification survey. She did not respond. She was asked if staff documented grievances on a grievance form or log. She stated, Not always. She stated, We just try to fix the problem. The ADM was asked what she would consider a grievance. She stated if a resident was missing clothes they would just go through closets and the laundry room, find the items and return them. She stated the nurses sometimes documented a nursing communication in the electronic medical record (EMR) if a resident had something missing. At 9:56 a.m., the assistant director of nursing informed the ADM that there was no documentation of grievances in the nurses communication in the EMR. She stated the social service director did not have any documentation of grievances.

Based on observation, interview, and record review, it was determined the facility failed to: ~ ensure the ice machine was cleaned and ~ensure dishes and utensils were cleaned under sanitary conditions. The administrator identified 33 residents who received their meals from the kitchen. Findings: 1. On 06/3/21 at 11:10 a.m., the dietary manager (DM) was asked to unlock the ice machine located in the dining room. The ice machine drop was wiped with a clean white cloth in the presence of the dietary manager. Pink slime substance was observed on the cloth. The DM stated the ice machine was cleaned twice a year by maintenance. She stated maintenance would be notified and the ice machine would not be utilized. At 11:15 a.m., dietary aide #2 was stopped by this surveyor from serving residents prefilled ice water to residents seated in the dining room for lunch. At 11:20 a.m., the DM stated the ice machine was last cleaned March 2021. At 12:40 a.m., the administrator was notified and acknowledged the findings. A request was made for the ice machine cleaning logs. On 06/07/21 at 10:35 a.m , a hand written document titled Ice machine/ cleaned and sanitized, documented 03/29/21 was the last date the ice machine was cleaned. At 10:36 a.m., the administrator reported bagged ice would be utilized to replace use of the ice machine. She stated maintenance could not clean ice machine. 2. On 6/03/21 at 12:27 p.m., Dietary aide #1 was asked to perform the dish machine sanitizing check. The DM was observe to run the dish machine and dietary aide #1 placed test strip with no reading observed. The DM changed the heavy duty rinse additive and the concentrated dish machine detergent. The DM was observed to make three more attempts to test the chemical reading of the dish machine. All three test strips observed with no indication the dish machine was functioning properly. At 12:34 p.m., the DM stated the test strip utilized not good. The test strip was observed with expiration date of September 2022. At 12:36 p.m., the DM was asked if the dishes and utensils were cleaned under sanitary conditions. The DM stated she could observe the chemicals dispensing into the dish machine. She was asked how she could verify the proper chemical sanitization since the test strips had no readings after four separate attempts. She stated she would notify [named company] to report concern.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were resting in their bed in a dignified manner for one (#25) of one sampled resident. The Resident Census and Condition of Residents identified seven residents that required total assistance in dressing. Findings: 1. Resident #25 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 04/19/21, documented the resident had severe cognitive impairment for daily decision making, was rarely/never understood, and required extensive assistance with dressing and bed mobility/transfers. On 06/01/21 at 02:25 p.m., resident #25 was observed in his bed. The door from his room into the hallway was opened. The resident was dressed in an adult diaper and shirt. He was uncovered, and exposed to hallway. Several residents, staff and surveyors were in the hallway. On 06/09/21 at 8:56 a.m., the DON was informed of the observation of the resident exposed from his room into the hallway. She stated, The resident sometimes kicks the covers off but he should not have been left that way.

Based on observation, record review, and interview, it was determined the facility failed to ensure residents were educated in reporting information to Ombudsman and OSDH and the information were readily accessible. This affected five of five residents who attended the group interview. It had the potential to affect 33 residents and the family representatives. Findings: On 06/02/21 at 10:00 a.m., five alert/oriented attended the resident interview. The residents were asked if they knew how to file a grievance. They reported they would talk to the activities/social services director or the facility administrator. The residents were asked if they knew where the Ombudsman contact information was posted. They stated they did not know. The residents were asked if they knew how to report a complaint to the Oklahoma State Department of Health. They stated they were not sure but if they could find out from the activities/social services director or the facility administrator. Following the group interview, the signage for Ombudsman information and OSDH reporting was observed on the bulletin board near the 300 hall. The information for both, were approximately 5 feet from floor level. On 06/09/21 at 11:05 a.m., the administrator was asked to observe the bulletin board containing the signage of Ombudsman contact information and OSDH reporting information. The administrator was asked if the Ombudsman contact information was posted in a manner that was readily accessible to the residents. She stated, Its a little high. The administrator was asked if the information to file a complaint to OSDH was readily accessible to the residents. She stated, We will need to get it moved down.

Based on observation and interview, it was determined the facility failed to make survey results readily accessible/available to residents. The facility census was 33. Findings: On 06/02/21 at 10:00 a.m., five alert/oriented residents attended the resident council interview. The residents were asked if they could review the results of the state inspection without having to request to see the report. They stated the administrator would have the reports. Directly after the meeting, the bulletin board near the 300 hall was observed to have a small binder clip which contained multiple documents: ~The top document was labeled .Fire Department - Fire Procedure; ~Behind the Fire Department document, were reports of a COVID focus survey completed on 10/21/20; and desk audit for a follow up for the COVID focus survey, dated 01/25/21. The re-certification/re-licensure survey reports were not located. On 06/09/21 at 11:05 a.m., the administrator was asked to review the items on the bulletin board. While observing the signage and posting of reports, the administrator was asked if the state survey results were readily available with easy access for residents. She stated a resident has been taking the survey results from the bulletin board and the reports are now in a different place and not easy to find.

Based on record review and interview, it was determined the facility failed to include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive in the clinical record for three (#7, 11 and #36) of three sampled residents reviewed for Advance Directive. The census and condition, dated 06/01/21, identified 33 residents who resided in the facility. Findings: 1. Resident #7 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/04/21, documented the resident was severely impaired in cognition and required no assistance with most activity of daily living. The care plan, last updated 03/11/21, documented, .I have advance directive .guardian and DNR (do not resuscitate) . The current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record did not include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive. 2. Resident #11 was readmitted to the facility on [DATE] from skilled to long term care. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual assessment, dated 03/16/21, documented the resident to have severe cognitive impairment for daily decision making; was rarely/never understood; required limited to extensive assistance for ADLs; and received nutrition via [MEDICATION(S)] tube feedings. The care plan, last updated 04/02/21 documented .Special Instructions: Code Status --DNR [Do Not Resuscitate] . The care plan did not address any details of the DNR or if an Advance Directive had been initiated or offered. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record did not include documentation an Advance Directive had been formulated or that information had been provided to formulate an Advance Directive. 3. Resident #36 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 05/26/21, documented the resident was severely impaired in cognition and required total assistance with most activity of daily living. The care plan, last updated 06/03/21, documented, I have signed a DNR and it is on my chart . The current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/21 at 9:41 a.m., the DON was asked if advance directives was discussed with residents on admission. She said, Yes. She further stated the social worker reviews all the advance directives with residents on admission, the documents are scanned into the electronic medical records and a copy placed in the resident's chart. At 9:52 a.m., the social service director was asked to show the where the documentation advance directive was reviewed with residents on admission. She said, There is not one. She was asked if advance directive should be discussed with each resident on admission. She said, Yes.

Based on observations, record reviews, and interviews it was determined the facility failed to notify the physician and/or the resident representative for four (#2, #14, #25, and #35) of 16 sampled residents. This had the potential to affect 33 residents who resided in the facility. Findings: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 02/05/2021 at 9:01 p.m., documented, .while transferring with sit to stand res'd [resident's] knees bent and he began to slide down, lowered easily to floor by staff without difficulty or injury. Alert, denies pain/discomfort. VSS [vital signs] staff instructed to use full body lift for transfers . A nurse's Monthly Summery report for February 2021, dated 03/26/2021 at 00:29 a.m., documented, .on 02/05/21 resident had a fall in his room (slid out of Sit-to-Stand.) . The clinical record did not contain documentation the physician or the resident's representative was notified of the fall. On 06/08/21 at 3:23 p.m., the DON was asked if the physician or family representative had been notified of the resident's fall from the sit-to-stand lift as documented on 02/05/21. She stated she would have to look but had not considered it a fall so an incident report was not completed. No further information was provided. 2. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 03/25/21 at 1:24 p.m., documented, .right thumb is purple in color and 'boggie' He denies pain . A nurse note, dated 03/26/21 at 2:08 p.m., documented, .he was kicking his feet. CNAs noted that he had kicked a toenail off .Triple antibiotic applied with band aid. A quarterly assessment, dated 04/19/21, documented the resident had severe cognitive impairment for daily decision making; required extensive assist for bed mobility, transfers and dressing; was totally dependant of staff for locomotion; did not walk; and had not experienced any falls. The care plan, last updated on 05/19/21, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician orders documented weekly skin evaluations every Wednesday had been initiated on 10/09/19. There was no physician's order documented for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/09/21 at 8:50 a.m., the DON was asked if the physician and/or family representative had been notified of the change of condition. She stated, No. 3. Resident #14 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 04/19/2021 4:10 a.m., documented, Open area on coccyx measures 2cm [centimeters]x 2.5cm. Protective cream applied . There was no documentation the family and/or physician had been notified of the open area to the coccyx and an order was obtained for the protective cream. On 06/07/21 at 4:28 p.m., the assistant director of nursing (ADON) was asked if the resident's physician and family were notified of the open area to the coccyx and an order obtained for treatment. She stated, She didn't write that, no. 4. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 01/15/21 at 5:00 a.m., documented the resident had a FSBS (finger stick blood sugar) of 58 a peanut butter and jelly sandwich was given and consumed. A progress note, dated 01/18/21 at 1:24 a.m., documented the resident had blood glucose reading of 44 and consumed milk, peanut butter and jelly sandwich and a cup of juice. The blood sugar was rechecked with a result of 53. A progress note, dated 01/20/21 at 5:50 a.m., documented the resident had a finger stick blood sugar reading of 50 and a snack was provided. A progress note, dated 01/22/21 at 6:18 a.m., documented the resident FSBS was 47. There was no documentation the physician had been notified of the low FSBS. A progress note, dated 05/07/21 at 1:38 p.m., documented staff alerted the charge nurse resident right pinky toe was bleeding .resident had ripped off .toe nail .area cleansed and bandaged. A progress note, dated 05/23/21 at 12:33 a.m., documented the resident was observed with an injury to the back of his head and the area was treated with triple antibiotic. There was no documentation the physician was notified of the right toe and/or the injury to the back of head. A progress note, dated 05/24/21 at 5:21 a.m., documented the resident had a FSBS reading of 52 at 4:00 a.m. and consumed a protein shake. There was not documentation the physician was notified. A progress note, dated 05/24/21 at 9:02 p.m., documented the resident was confused and had a FSBS of 403 at 3:30 p.m. and a FSBS of 483 at 6:00 p.m. There was no documentation the physician was notified of the elevated FSBS. A care plan, last updated 05/27/21, documented .FOCUS .Diabetes .Goal .I want my FSBS (finger stick blood sugar) level to be WNL (within normal limits) throughout this review .Interventions .Notify my PCP (primary care physician) of any abnormal FSBS .or s/s (sign/symptom) of high/low blood sugars and follow through . A facility document, titled weights and vitals summary, documented a blood sugar reading on 05/29/21 at 6:50 a.m. of 51. There is no documentation physician was notified. On 06/08/21 at 3:39 p.m., the DON was asked what was the facility's policy for notification of a resident change in condition. She stated the facility did not have one. She was asked to review the progress notes of abnormal finger stick blood sugar reading for the dates 01/15/21, 01/18/21, 01/20/21, 01/22/21 and 05/24/21. She was asked if physician was notified of change in condition. She said, No. In reference to the progress note dated 05/07/21 of an injury to resident right pinky toe nail ripped off and bleeding. The DON was asked if the physician and family was notified. She said, No. In reference to the progress note dated 05/23/21 of an injury to resident head which required a treatment, the DON was asked if the physician and family was notified. She said, No.

Based on observations, record reviews, and interviews, it was determined the facility failed to: a. provide supervision to prevent falls, failed to investigate falls to determine the root cause and to consistently identify and implement interventions to aide in the prevention of recurrent falls for three (#3, 27 and #33) of four sampled residents reviewed for falls. Resident #33 had 17 falls from 02/02/17 through 10/12/17. She experienced a fall with a facial laceration followed by a second fall four days later on 02/06/17 resulting in a 2.5 cm (centimeter) scalp laceration which required emergency intervention of three sutures for closure. The facility director of nursing (DON) identified 36 residents were at risk for falls and; b. ensure potentially hazardous chemical substances were securely stored out of reach of residents on one hall (Cherry hall) of three halls observed. The facility DON identified 6 residents who wandered the facility hallways. Findings: A facility policy titled, Repeated Fall Protocol documented: Any resident that has more then one fall in a 7 day period or more than 3 falls in a 90 day period will be considered to be at risk for 'Repeated Falls' .physician will be notified .family will be notified of each fall once it has been established as a trend .clinical record will reflect this .all falls will continue to be reviewed with interventions identified to prevent further falls .plan of care will reflect these interventions and staff will be aware of their part in resident individualized interventions .there will be ongoing meetings between nursing and therapy staff of all residents to identify further resident with potential for falls .staff will be involved in ongoing training to assure knowledge to meet interventions . A facility policy titled, Charting Guidelines documented: .chart on falls according to the fall protocol . A facility policy titled, Q (every) Shift Charting Rotation documented: .Reasons to chart Q shift IR (incident reports) X (times) 72 HRS (hours) . A facility policy titled, Neurologic Checks documented: Policy .neurological checks are a combination of objective observations and measurements done to evaluate neurological status that includes consciousness, orientation, pupillary changes, neuromuscular function and neurosensory perception .purpose to assist nurse in identification of change indicating progressive improvement or deterioration in neurological status, correct and through neurologic checks . procedure .frequency of checks is every 15 minutes for 1 hour, every thirty minutes for next hour, every 60 minutes for 4 hours then every 8 hours for a total of 72 hours . 1. Resident #33 had [DIAGNOSES REDACTED]. A nurse's progress note, dated 01/23/17, documented, .admitted to facility .Alert but confused .Difficulty putting thoughts together .ambulates with stand by assistance and wheelchair for distances . An admission fall assessment, dated 01/23/17, documented the following instructions for use: complete on admission, quarterly, at change of condition, and after a fall. Moderate fall risk scare range was identified as a score of 25-44. The resident scored a 40. The clinical record contained no documentation of an admission care plan having been developed for the resident: who had been assessed as a moderate fall risk. A facility incident report, dated 02/02/17 at 8:00 a.m., documented, .Alerted to the res (resident's) room by housekeeping she is in the fetal position (sic) on the floor near the end of her bed. There is a bruise on the left thigh .approx. (approximately) three inches long. It does appear to be a healing bruise. She is in pain in her back .Assisted off the floor and to the restroom by staff x 2 (times two). Res (resident) denies hitting her head but she is confused of the time . Immediate Action Taken .Staff to do more freq. (frequent) checks . Level of Consciousness .Alert . The clinical record contained no documentation of how often checks were to be conducted, who was to conduct them, and where the observations were to be documented. A nurse's note, dated 02/02/17 at 9:00 p.m., documented the resident was found on the floor next to her bed. She was found on her right side with a one inch laceration above her left eye. The resident was bleeding from the laceration and complained of right hip and neck pain. A facility incident report, dated 02/02/17 at 8:00 p.m., documented, .Resident was found lying on right side beside her bed in her room . Immediate Action Taken .Injuries noted (one) inch laceration noted above left eye bleeding large amount appears to slightly deep pressure applied resident assisted up off the floor and into a w/c (wheelchair) and brought to the nurses station neuro checks done .received orders to transfer resident to (named emergency room ) . Level of Consciousness .Lethargic (Drowsy) . Predisposing environmental factors .rugs/carpeting . Predisposing situation factors .ambulating without assist .improper footwear . A nurse progress note, dated 02/03/17 at 1:28 a.m., documented, .Resident returned from hospital via EMSA (ambulance) around 0045 (12:45 a.m.), no new order received .no bleeding noted to laceration on left side of forehead, assisted resident to bed, will monitor for any ill effects. The note contained no documentation of how the laceration was repaired. The clinical record contained no documentation of neurological (neuro) checks having been conducted. The incident report contained no documentation of new interventions having been developed and/or implemented. The record contained no documentation of a new fall assessment having been conducted after the resident had sustained two falls within a thirteen hour period, one fall with injury. There was no documentation neurological examinations were completed for 72 hours after the resident had a fall with a head injury. A care plan, initiated on 02/05/17, documented, .Focus .I have had an actual fall with Unsteady gait . Goal .I will resume usual activities without further incident through the review date . Intervention .toilet every two hours and prn (as necessary) .staff to anticipate need to go to restroom .initiated 02/02/17 . There was no record of the interventions, dated 02/02/17, having been documented and/or initiated until the care plan had been created on 02/05/17. The clinical record contained no documentation of staff assisting the resident to the toilet every two hours or as necessary or of frequent visual checks having been conducted. An admission assessment, dated 02/05/17, documented the resident was severely impaired in cognition for daily decision making. The resident was usually understood and usually made herself understood. The resident required limited assistance of one staff member for transfers and required the use of an assistive device for stability during transfers. A nurse's note, dated 02/06/17 at 8:28 a.m., documented the resident was found seated on the floor of her room. She was observed to have a laceration, of approximately one inch, on the back of her head. The note documented the laceration would probably require sutures. The note also documented the resident's pupils were dilated but reactive to light. The resident was transferred to a local hospital. A facility incident report, dated 02/06/17, documented, .Alerted to the res room. She was sitting on her bottom with her back to the wall. There is a laceration approximately (one) inch on upper posterior scalp. Bruising noted to the back of her head. Neuro checks wnl (within normal limits) as her normal. Pupils dilated but reactive to light .pressure applied. It appears that the laceration will need sutures, glue, or staples. Call to (named physician) and to her daughter .orders to send to ER (emergency room ) .(7:40 a.m.) loaded in ambulance and sent to (named emergency room ) . Immediate Action Taken .Sent to ER . Predisposing situation factors .improper footwear . The incident report contained no documentation of a new intervention having been developed. A hospital record, dated 02/06/17, documented, .Patient fell and sustained a laceration to her head. She had a fall last week as well and sustained a laceration to the left side of her face. She has only been in the nursing home for the past (two) weeks. She suffers from dementia which seems to be accelerating . Physical Exam .2.5 cm (centimeter) laceration right parietal-occipital scalp . Laceration Repair .2/6/2017 9:32 AM .Anesthesia method: Local .Repair method: Sutures .Number of sutures .3 . A nurse progress note, dated 02/06/17 at 12:20 p.m., documented the resident returned from the emergency room with three sutures to her head. A care plan, updated on 02/06/17, documented, .Focus .I have had an actual fall with Unsteady gait . Goal .I will resume usual activities without further incident through the review date . Intervention .Upon return to facility staff member to stay with resident through night .to assure safety, until closer room could be made available. Date initiated: 02/06/2017 . The clinical record documented the resident experienced a fall on 02/02/17 while wearing improper footwear and received a facial laceration. She experienced a second fall wearing improper footwear on 02/06/17 and received a head laceration which required emergency intervention of sutures. The resident's care plan, updated on 02/06/17, documented the resident would be monitored overnight until a closer room was made available. There was no documentation of overnight monitoring or that the resident was moved to a closer room. There was documentation of neurological assessments completed at 2:00 p.m., 4:00 p.m., and 8:00 p.m. on 2/6/17. Neurological checks were documented as completed on 02/07/17 at 12:00 a.m. and on the night shift. Neurological assessments were not completed every shift on 02/07/17 and 02/08/17. The resident's continued use of improper footwear was not addressed on the resident's care plan. A facility incident report, dated 02/07/17, documented, .alerted to the dining room res was playing cards with fell ow res and her boyfriend. She attempted to get up from the table and lost her footing. She fell striking the back of her head. Pupil dilated and sluggish to light, grips are equal. She is alert to person but not to place time. Appropriate response to pain. Very large knot on the posterior skull. Call to (named physician) orders to send to (named emergency room ) for CT (computed tomography scan) of the head .EMS in route . Immediate Action Taken .send to (named emergency room ) for eval (evaluation) and tx (treatment) . Injury .hematoma .back of head . A nurse progress note, dated 02/07/17 at 7:08 p.m., documented the resident returned to the facility from the emergency room . A CT scan had been completed and the physician did not give new orders for the resident. The resident was confused to situation but recognized family and friends. The resident required frequent reminders to not get up from the chair without help. A chair alarm was placed. A care plan, updated on 02/07/17, documented, .Focus .I have had an actual fall with Unsteady gait . Goal .I will resume usual activities without further incident through the review date . Interventions .2/7/2017 0950 (9:50 a.m.) resident was in the dining room playing cards with other resident and volunteer-staff heard chair alarms sound, but was unable to reach resident before she stood up from w/c (wheelchair) and attempted to transfer into dining room chair-resident stated 'people keep telling me what to do' continue to assure resident that we have her well-being in mind, continue to anticipate needs and continue bed and chair alarm . The care plan documented no new interventions had been initiated. Neurological examinations were documented as completed on 02/07/17 at 12:00 a.m. and during the 10:00 p.m. to 6:00 a.m. shift. There were no further neurological assessments documented. A facility incident report, dated 02/08/17 at 9:33 p.m., documented, .This LPN (licensed practical nurse) noticed resident sliding out on the floor before I could get to her resident was on the floor bed alarm was on . Immediate Action Taken .Resident was assisted to her w/c small skin tear on right elbow and on right arm above elbow cleansed and band aid applied . A care plan, initiated on 02/08/17, documented, .Focus .I have had an actual fall with Unsteady gait . Goal .I will resume usual activities without further incident through the review date . Intervention .2/8/2017 2133 (9:33 p.m.) lpn (licensed practical nurse) noticed resident sliding out onto the floor from her bed-fall mat was in place as well as bed alarm-continue to anticipate needs-check resident frequently-for needs and correct bed positioning .date initiated 02/22/17. A facility incident report, dated 02/10/17 at 7:00 a.m., documented, .Incident Location .Resident's room .Res found laying on the floor . Immediate Action Taken .Resident rolled from her side to her back No external rotation noted c/o (complained of) some pain in back which is from previous fall. Hips and legs palpated without gross abnormality found. Returned res to bed with assist x 2 . Predisposing Situation Factors .Recent room change . A nurse progress note, dated 02/10/17 at 7:41 a.m., documented the resident was found on the floor in her room. She was not on her fall mat. The resident's bed was in the low position and the bed alarm was in place. The resident had taken a few steps prior to the fall. A care plan, initiated on 02/10/17, documented, .Focus .I have had an actual fall with Unsteady gait . Goal .I will resume usual activities without further incident through the review date . Intervention .Resident found laying on her floor in her room. She states 'I fell , not I sure did not want to do that again' .Resident was assessed with [REDACTED]. Continue fall mat, bed and chair alarm, frequent positioning, PT evaluation, frequent toileting. Date initiated: 02/10/2017 . A care plan, initiated on 02/12/17, documented, .Focus .(Named resident) is high risk for falls r/t cognitive loss, weakness, and inability to recognize unsafe situation . Goal .(Named resident) will be free of falls . Interventions .Anticipate and meet (Named resident) needs .Be sure (named resident) call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Ensure that (named resident) is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) .Pt (physical therapy) evaluate and treat as ordered and PRN (as needed) .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (intra disciplinary team) as to causes . A care plan, initiated on 02/12/17, documented, .Focus .(Named resident) has an ADL (activities of daily living) self-care performance deficit [DIAGNOSES REDACTED]. Goal .(Named resident) will improve current level of function . Interventions .HS (bedtime) routine .At this time she uses a fall mat and a bed alarm related to recent falls . A physical therapy note, dated 02/13/17, documented the resident was evaluated and placed on physical therapy services through 06/14/17. The physical therapy note documented, .(Named resident) has been falling a lot and has injured her hip and lacerations on her head. Pt (patient) has severe Dementia and has been to the ER several times .Pt (patient) safety awareness is limited due to severe Dementia and Alzheimer's . A fall risk assessment, dated 02/15/17, documented the following instructions for use: complete on admission, quarterly, at change of condition, and after a fall. The type of assessment completed was a post fall assessment. A high fall risk score range was identified as a score of 45 or higher. The resident scored a 105. The resident had experienced six falls from her admission date of [DATE] through 02/10/17. The clinical record did not contain any further post fall assessments which had been completed following the five other falls the resident had. The clinical record contained no documentation the resident's fall had been investigated to determine a root cause. A facility incident report, dated 03/05/17 at 9:00 p.m., documented, .Heard chair alarm sound, resident found sitting on the floor in the hallway next to the time clock with her wheelchair next to her, no injuries noted at this time . Immediate Action Taken .Assisted resident up times two person assist .resident voiced mild pain to left arm/elbow area and left leg, prn pain medication administered for relief, will continue to monitor for any ill effects from fall . Predisposing Environmental Factors .Fall Alarm . Predisposing Situation Factors .Ambulating without assist . There were no new interventions identified or implemented to prevent further falls. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 03/15/17, documented, .Incident Location .Resident's room .This nurse heard bed alarm sound and went into residents room observed resident laying on her back slightly to the left side holding the back of her head .also complaint of lower back pain .full range of motion of all extremities .pupils equal and reactive .no swelling noted to back of head . Immediate Action Taken .Neurochecks (sic) per policy-assessment completed-assisted resident with dressing and toileting-assisted resident out to lobby in wheelchair . Predisposing Environmental Factors .Fall Alarm .Poor Lighting . Predisposing Situation Factors .Improper Footwear . There were no new interventions identified or implemented to prevent further falls. The resident's care plan was not followed for the use of proper footwear. A post fall risk assessment was not completed. Neurological assessments were not documented as completed every shift on 03/17/17 and 03/18/17. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 03/21/17, documented, .Resident was found on the floor lying on her back in the dining room in front of her w/c tab (unknown abbreviation) alarm was on . Immediate Action Taken .Resident assisted from the floor to her w/c per two assist . There were no new interventions identified or implemented to prevent further falls. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 03/22/17, documented, .Resident was in her w/c in the lobby where she was picking up magazines when she was witnessed by (named registered nurse) resident slipped out of the w/c sitting on her buttocks on the floor . Immediate Action Taken .Resident was assisted back in her chair small skin tear on right little finger cleaned and band aide (sic) applied . There were no new interventions identified or implemented to prevent further falls. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 04/06/17, documented, .Resident found lying on her right side on the floor in the lobby able to move all extremities chair alarm was sounding but time staff could get there resident was on floor no injuries noted . Immediate Action Taken .Resident assisted off the floor into her w/c . There were no new interventions identified or implemented to prevent further falls. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 04/06/17, documented, .Resident found sitting on her bottom in front of her recliner in her room able to move all extremities no apparent injuries noted . Immediate Action Taken .Resident assessed for injuries none found able to move all extremities resident assisted to her w/c chair alarm was on and was sounding . There were no new interventions identified or implemented to prevent further falls. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A nurse progress note, dated 04/07/17 at 7:43 p.m., documented, .FOLLOW UP CHARTING SP (status [REDACTED]. RESIDENT IS CONFUSED AND IS UNAWARE OF OWN SAFETY AND CAN'T ALWAYS MAKE NEEDS KNOWN. USES A PERSONAL SAFETY ALARM AND SOUNDS IT OFF FREQUENTLY REQUIRING REDIRECTION OR ASSIST WITH NEEDS. PT TEACHING PROVIDED BUT RESIDENT HAS POOR MEMORY RETENTION. STAFF ANTICIPATING NEEDS AND ATTENDING PROMPTLY . A nurse progress note, dated 04/11/17 at 11:59 a.m., documented, res is very restless today. wondering. (sic) standing up and down setting off the chair alarm. she also is noted to take the alarm off the chair and shut it off. or hide it from staff. unable to redirect . The residents ability to remove her chair alarm was not updated on the care plan. A facility incident report, dated 04/16/17 at 6:45 p.m., documented, .Overhead alarm coming from resident's room, resident found sitting on her bedroom floor next to her wheelchair, no injuries noted, resident denied pain from fall . Immediate Action Taken .Assisted resident up times two person assist .will continue to monitor for any ill-effects . Predisposing Situation Factors .Ambulating without assist . A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A nurse progress note, dated 04/18/17 at 6:52 p.m., documented the resident frequently got up unattended and ambulated. She was very unsteady on her feet. A facility incident report, dated 04/26/17, documented, .Alerted to the dining room, (named resident) was lying on her right side crying out in pain. She was holding her right side of her head. Staff reports she got up to go after (unknown abbreviation). Her gait was unsteady and staff started to move twds (towards) her but before they could reach her she fell striking the right side of her head very hard. Pupils are equal, pin point and sluggish to react. She did not lose consciousness. There is a large knot on the back, right side of her head. Ice applied .She is alert but slow to respond. Confused . Immediate Action Taken .(named physician) and family notified. Received new orders to send to (named emergency room ) for a head CT to r/o (rule out) brain injury . Predisposing Situation Factors .Ambulating without assist . A nurse progress note, dated 04/26/17 at 9:13 p.m., documented the resident returned to the facility. She did not have any fractures from her fall. She had no new orders. Her CT showed no new changes since her most recent CT. There was no documentation neurological examinations were completed for 72 hours after the resident had a fall with a head injury. There was no root cause analysis completed following the resident's fall as care planned. A nurse progress note, dated 05/17/17 at 1:18 p.m., documented the resident was very noncompliant with the use of her wheelchair. She had a chair alarm in place but she often turns the alarm off. She often pushed the wheelchair around. A facility incident report, dated 06/06/17, documented, .Resident was observed ambulating in the halls-this nurse heard her call out from her room-when this nurse entered room she noted that resident was bent over at the waist-with her pants around her ankles-this nurse attempted to grab back of pants or shirt to break fall, but only slowed down fall-resident struck top of head on wall of bathroom-no swelling noted-no complaint of pain, but did state that she hit her head-neuro checks negative-range of motion normal-states she had to go to the bathroom . Immediate Action Taken .Neuro checks per policy-assisted resident to the bathroom and into night clothes . Neurological assessments were conducted on 06/06/17 every 15 minutes during the first hour and every 30 minutes during the second hour. Neurological assessments should then have been completed every hour for four hours, then once a shift for a total of 72 hours of monitoring. The resident's neurological assessments were completed three more times during the first 24 hours. There were no further assessments documented after the first 24 hours. A fall risk assessment, dated 08/15/17, documented the resident was a high fall risk. A facility incident report, dated 09/22/17, documented, .Heard resident yell out, upon entering resident's bathroom she was on the floor on her hands and knees in front of her toilet, started losing her balance and falling forward, no injuries noted at time, resident denied hitting her head, c/o some body pain all over .assisted resident up time two person assist, and back into her bed .Resident started losing her balance and falling forward upon getting up off the toilet . Immediate Action Taken .assisted resident up times two person assist, prn pain medication given for c/o body pain, will continue to monitor for any ill-effects . Predisposing Situation Factors .Improper footwear .Ambulating without assist . The resident's care plan was not followed for the use of proper footwear. A post fall risk assessment was not completed. There was no root cause analysis completed following the resident's fall as care planned. A facility incident report, dated 10/12/17, documented, .Resident found on floor in front of toilet with knee to her chest laying on side . Immediate Action Taken .Assisted to sitting position and elvaluated (sic) .right pupil sluggish, right sided weakness and facial droop noticed. (named physician) notified and family notified to send by ambulance to (named emergency room ) . Predisposing Situation Factors .Ambulating without assist . A care plan, updated on 10/12/17, documented, .10/12/17 (8:15 a.m.) I was found on the floor in front of my toilet with my knees to my chest-I was sent to hospital and admitted related to s/s (signs and symptoms) stroke . A nurse progress note, dated 10/13/17 at 10:10 p.m., documented the resident returned from the hospital. The resident had right sided weakness and required extensive assistance with transfers. A significant change assessment, dated 10/29/17, documented the resident was severely impaired in skills for daily decision making. She required total assistance from staff with bed mobility, locomotion, dressing, toileting, and personal hygiene. She required extensive assistance from staff with transfers. She was occasionally incontinent of bowel and/or bladder. She had upper and lower range of motion limitations on one side. She utilized a wheelchair for mobility. On 11/08/17 at 3:00 p.m., the DON was asked how many falls the resident had since her admission to the facility in January 2017. She stated the resident had fallen 17 times since admission. She was then asked if the facility had determined the root cause of the resident's falls. She said, Not really. She was asked if each fall was listed on the resident's care plan and the care plan was updated with new interventions after each fall. She did not answer the question but stated falls were not indexed on the care plan. She was asked if the facility kept a log of the resident's falls. She said, No. She was asked what was done when a resident experienced a fall. She did not answer the question but instead stated what they had been doing with falls had not been working. She said, It was too complicated. She then stated they had identified falls as an area of concern for the QA (quality assurance) committee for next year because they were not happy with how things had been and the system was not working. She was asked what system they had been using for falls which she had considered too complicated. She stated they would fill out an Individualized Fall Trending form. She was asked to provide the resident's fall trending form. She located the form in the chart, but the form was blank. She was asked why the form was blank, and she stated it was blank because they had already determined the system wasn't working so they did not fill it out. The DON was asked if she knew why the resident had a period of no falls around June. She stated the resident got better because she liked the physical therapist. She stated she enjoyed working with him and was determined to walk. She stated the resident was able to walk again and got back to her normal pleasantly confused self. She was then asked to describe what action she had taken to prevent the resident or other residents from experiencing falls. She stated she had increased the number of nurses so she could spend more time in the office to work on things like falls. On 11/13/17 at 10:13 a.m., CNA (certified nurse assistant) #1 was asked how did you know which residents were at risk for falls. She stated they almost all are. She named 25 residents who were at risk for falls including resident #33. She was asked how would you know if a new resident was at a risk for falls. She stated she would be given a verbal report. She was asked if there was written documentation of who was at a risk for falls that she could refer to if needed. She stated she did not know of any. She stated she knew which residents were fall risks by watching them. She then stated the resident would try to pick things off of the ground, even little specks, and she would try to walk on her own which made her a fall risk. She was asked what interventions were implemented when a resident was identified as a fall risk. She stated they kept the resident stable by placing them in a recliner or bed. She stated everyone watched the residents. She was asked if residents who had fallen required frequent observations and were there certain time frames the resident must be observed. She said, No. She was then asked if the frequent observation checks were documented. She said, No. At 10:20 a.m., CNA #2 was asked how did she know if a resident was a fall risk. She said, When they fall a lot. She further stated she mostly helped with showers and made sure the floors were safe and she held onto the residents. She was asked if there was documentation available to identify which residents were a fall risk. She stated it was probably in their care plan. At 10:31 a.m., CNA #3 was asked how did she know if a resident was a fall risk. She stated the nurse lets us know and she mentioned six residents (on resident #33's hall) who were at risk for falls including resident #33. She was asked what extra precautions were put in place when a resident had a fall. She stated they did periodic checks and would peep in on the residents and would answer the alarms as soon as they sounded. She was asked if checks were done at certain times. She

Based on observations, record reviews, and interviews, it was determined the facility failed to have an effective quality assessment and assurance program (QAA) in place to identify, develop and implement corrective plans of action for residents' multiple falls. Three (#3, 27 and #33) of four sampled residents reviewed for falls had multiple falls without indication of increased supervision or effective interventions that had been implemented. Resident #33 had 17 falls with one that required sutures to the scalp. The director of nursing (DON) identified 36 residents in the facility that were at risk for falls. Findings: A facility policy titled, Quality Assurance policy, documented: .(Named facility) Quality Assurance program represents our facility's commitment to continuous quality improvement . .The committee shall maintain written minutes and activity of various departments. These reports will be used to improve quality of care and track improvements . Resident #33 had 17 falls from 02/02/17 through 10/12/17. She experienced a fall with a facial laceration followed by a second fall four days later on 02/06/17 resulting in a 2.5 cm (centimeter) scalp laceration which required emergency intervention of three sutures for closure. See F-323 for further details. On 11/14/17 at 12:32 p.m., the DON was asked about concerns related to resident falls. She stated the facility had identified a problem with fall investigations and documentation and an inservice was held in August to remedy the situation. She then stated, It looks as through it did not take care of the problem. On 11/15/17 at 10:52 a.m., the DON, and administrator were asked if the issues identified with falls had been identified through the facility QAA process. The DON stated it had. She was asked how effective the QAA was with correcting the problems identified with falls. She stated, It was not effective. It was not followed up on and the problem was not corrected.

On 02/24/14 at 2:47 p.m., an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to ensure hot water temperatures were maintained in a safe range and residents were not exposed to hazardous water temperatures. The existence of the IJ was verified with the Oklahoma State Department of Health (OSDH). At 3:05 p.m., the administrator was notified of the existence of the IJ. At 6:40 p.m., an acceptable plan of removal was received. The facility's plan of removal documented the following: 1. On 02-24-14 at 3:30 p.m. (approximately) the facility maintenance worker checked the mixing valve & hot water heater & adjusted both the valve & the heater. 2. On 02-24-14 at 4:30 p.m., the facility ran large amounts of hot water thru the system to immediately bring down the water temperatures and allow the system to lower its temps. 3. On 02-24-14 at 6:20 p.m., a facility employee started taking temps on all halls & they were coming down. The reading was 118 degrees. All rooms with concerns were below safety numbers. 4. On 02-24-14 at 7:30 p.m., an in-service was posted at the time clock & nursing station regarding safety of residents concerning water temps. An attachment to the in-service posting documented: "In service 02-24-14 All staff please use extra caution to check water for residents care and check all rooms routinely for excessive hot water. If any sink or tub feels hot or you are concerned ask maintenance, housekeeping, or charge nurse to check or report it immediately. This could seriously harm someone so please all take part in this plan of correction. If you are aware of a room having to (sic) hot a water you need to report it call the administrator or supervisor of nursing immediately regardless of the time. We are working on this and need all here to be good overseers of these peoples safety. Thank you for this help. If you have any question ask your immediate supervisor or call the Assist adm or DON." This was signed by the administrator. 5. On 02-25-14 at 2:00 p.m., all staff was to read & sign the in-service, or to be contacted by phone & reviewed one on one. 6. On 02-24-14 at 6:00 p.m., & continuing, water temps would be taken daily in all resident rooms X 1 week & if not over the safety limit checking would be reduced to 3 X a week in 5 rooms on all halls & recorded. 7. On 02-24-14 at 5:57 p.m., the maintenance was in serviced as to guidelines for safety of water temps & contractors were called to check out the water heater & mixing valve. Another in-service form presented to the surveyors, dated 02/24/14 at 5:57 p.m., documented, "In service one on one: Administrator and maintenance reviewed policy (attached) and set guidelines for immediate safety of residents during findings of water temps being too high for resident safety. Water temp logs will be filled out on all rooms X 1 week and 3 X a week after. Contractors will be available for consults as needed till new maintenance person is comfortable with this system & the regulations for safety of residence." This form was signed by both the administrator and the maintenance man. On 02/24/14 at 6:45 p.m., the following water temperatures were obtained by the surveyors: Room 101 - 110.6 degrees Fahrenheit, Room 213 - 110.1 degrees Fahrenheit, Room 301 - 111.9 degrees Fahrenheit, Room 302 - 109 degrees Fahrenheit, Room 308 - 104 degrees Fahrenheit, Room 309 - 111.7 degrees Fahrenheit, and Room 310 - 114.9 degrees Fahrenheit. The Immediate Jeopardy (IJ) was removed on 02/25/14 at 2:00 p.m., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. On 02/24/14 at 6:45 p.m., after interviews with staff, review of inservices, and observations of water temperatures in rooms 101, 213, 301, 302, 308, 309 and 310, the administrator was informed the immediacy had been lifted on 02/25/14 at 2:00 p.m. Based on observations, resident and staff interviews, and review of the facility policy and procedure, it was determined the facility failed to ensure the residents' environment was free of accident hazards and failed to provide supervision to prevent accidents for one (#5) of one resident identified by the facility as cognitively impaired and who wandered around the facility. The facility failed to: ~ ensure hot water temperatures did not reach hazardous temperatures on three of three halls; and ~ ensure potentially hazardous materials were properly stored and secured in one of one closets and out of reach for resident #5. Findings: The facility 'Water Temperature Policy' documented: "(Facility name deleted) policy is to ensure the proper maintenance of water temperatures at a level safe for the resident's safety and needs. Bathing Temperature 115 degrees F. (Fahrenheit) ..." 1. On 02/24/14 at 11:15 a.m., an environmental tour was conducted to check water temperatures. At 11:20 a.m., the water temperatures at the lavoratory sinks in resident rooms were obtained. In room #301 the water temperature was 133.8 degrees Fahrenheit. In room #302 the water temperature was 132.3 degrees Fahrenheit. At 11:55 a.m., the water temperatures at the lavoratory sink in resident room room #213 was 131.1 degrees Fahrenheit. At 12:10 p.m., the water temperature at the lavoratory sink in resident room #101 was 130.2 degrees Fahrenheit. On 02/24/14 at 12:35 p.m., an interview was conducted with a contracted plumber in the facility there to check a water leak. He stated "More than likely if the water temperatures are high, that wouldn't have a thing to do with what I am doing. That's tempering." On 02/24/14 at 1:55 p.m., the DON was asked if she had any residents identified as cognitively impaired and who wandered in the facility. She identified one resident on hall 200 (resident #5) and stated the resident walked up and down the halls. At 2:00 p.m., CNA #1 was asked if resident #5 was confused and if she had observed the resident wandering anywhere in the facility. She stated the resident was confused a lot and didn't know which room was hers until staff showed her. She stated, "Most of the time she wanders all around and she wanders into others room. We found her in (resident #17's) room. She was going to get in her bed." CNA #1 was asked if the resident was able to drink on her own without assistance and if she could unscrew a cap. She stated, "(Resident #5) drinks on her own and yes, she could unscrew a cap." On 02/24/14 at 2:10 p.m., an interview was conducted with the administrator. She was asked if she had monthly water temperature logs for the facility. She stated the previous maintenance man had been out of the facility and did not have logs for the months of January 2014 or February 2014 and the last recorded water temperatures she could find were for December 2013. On 02/24/14 at 2:15 p.m., an observation was made of resident #5 sitting in the lobby. She rose from a sitting position and was attempting to exit a coded door off of the dining room area. She stated "I couldn't get in that door." She ambulated away from the door holding on to handrails and using furniture also as support. The surveyor asked the resident where she was going and she stated "I was gonna try to go in and see the little fell a." The surveyor asked the resident who the little fell a is and she stated "I don't know." On 02/24/14 at 2:25 p.m., the administrator produced a hand-written document on a legal pad with the following information: "daily Report 2-14-14...Room 207 water temp - 80 degrees left side Room 204 water temp - 97 degrees right side Hosp (hospital) End Room 101 - 119 degrees Room 100 - 114 degrees Hopper West Hall - 116 degrees Med Room - 83 degrees Laundry room - 161 degrees hopper room - 115 degrees North hall Room 309 - 116 degrees Room 306 - 111 degrees..." The administrator stated this was the only documentation she could find from the previous maintenance man for this year. At 2:50 p.m., CNA #2 was asked if resident #5 was confused and if she had observed the resident wandering anywhere in the facility. She stated, "Sometimes she gets confused and at times tries to get out of the facility. When she is trying to find her room, she goes into someone else's room. She is usually laying on the bed or about to get into it." On 02/24/14 at 2:55 p.m., observation was again made of resident #5. She was sitting in the dining room area and was asked if she could tell the surveyor where she was (facility or city). She stated, "I don't know." The resident was asked if she could state the date that day (day, month, year). She stated "I know some of em dates." She was again asked if she could state that day's date and she did not respond. The resident was asked if she could name the president currently in office. She stated "Not right now, won't you tell me." At 3:20 p.m., the resident was assisted down the hall to her room by staff. The resident was observed to turn the water on and off when asked. At 4:20 p.m., the administrator stated to the surveyor, "The mixer was turned up way too high." Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan for resident #5, dated 5/28/13, documented: "Category Problem: At times I get confused and refuse to participate with care... Category Problem: I have short and long term memory problems. My short term appears to be worse than the long term according to staff. I do take medication for this... Category Approach:...The staff will reinforce to me where I need to go and when I need to go somewhere... Category Problem: There are times when I have trouble communicating to my care givers... Category Approach:...You may need to tell me more than once where I need to go and what I need to do so please be patient with me. I need the staff to understand that my memory causes me to forget and I will need them to frequently remind me where I need to go and what I need to do." A resident assessment for resident #5, dated 12/22/13, documented the resident was moderately impaired in cognitive skills for daily decision-making. The assessment documented she had disorganized thinking that came and went and changed in severity. The assessment documented she was independent for transfers and ambulation, required set-up help only for eating, and required limited assist with one person physical assist for dressing and hygiene. The assessment documented she required physical help with one person assist in part of bathing. A form titled 'Care Plan Continuation For New Problem', dated 12/24/13, documented "Problem: At risk for elopement per assessment... Approaches:... 3. When visitors are in the facility monitor resident closely so she doesn't try to follow visitors out the door." The February 2014 monthly physician's orders documented the resident had the following medications ordered by the physician: Sertaline 75 mg q (each) day for depression, Risperidone 0.5 mg TID (three times a day) for dementia with behavior, Donepezil 10 mg at HS (hour of sleep) for Alzheimer's disease, Buspirone 5 mg q day for dementia with behaviors, and Buspirone 10 mg at HS for dementia with behaviors. On 02/24/14 2:10 p.m., LPN #1 was asked if the resident was confused, wandered about the facility and able to drink with out assistance. She stated the resident drank on her own and sought out food and drinks. She stated she wandered around usually looking for a bathroom. On 02/25/14 at 1:40 p.m., the surveyor asked CNA #7 if resident #5 was confused or wandered. She stated, "She is confused most of the time. She wanders to the living room and dining room and sometimes in others rooms." The surveyor asked the CNA if the resident was able to eat and drink without assist. She stated, "She can feed herself and she picks up liquids and drinks them." At 4:45 p.m., the maintenance man reported the water tanks on the hospital side had been turned down and the water on the units was adjusting more accordingly within range. On 02/26/14 at 10:00 a.m., observation was made of resident #5 lying in her bed. The surveyor asked the resident to state her name. Resident #5 stated her first name. She was asked her last name and she stated, "I don't even know I guess." The surveyor asked the resident if she could name the facility or town she was currently in. She stated, "I don't know." The surveyor asked the resident if she knew and could state that day's date. The resident stated, "I don't know." The surveyor informed the resident of the date and the resident stated, "That's my birthday." The resident was asked if she had any family that came to visit her and she stated, "I don't know, I can't think of them." At 10:20 a.m., CNA #4 was asked to tell the surveyor about resident #5. She stated "(Resident #5) is starting to need more help. She gets up in the night and wanders a lot and tries to get up at bedtime. She can answer questions, is kinda confused, she can't start a conversation. She wanders to the dining room, into the front lobby, into other residents' rooms, and heading down the halls." At 11:20 a.m., CNA #3 was asked to tell the surveyor about resident #5. She stated "She is confused. She has known me my whole life and in the last six months she doesn't know me at all. She doesn't know her daughter-in-law anymore and that is kinda sad." 2. On 02/24/14 at 10:45 a.m., during an environmental tour of the facility, a room/closet off of hall 200, with the door placket labeled "J3" was observed to have the following chemicals on a shelf within reach of the surveyor: (1) One gallon germicidal labeled 'Pure Bright Ultra Bleach' with a cap that unscrewed and was not a childproof cap. The label had a warning "Keep out of reach of children DANGER." (2) One bottle with a green colored solution labeled 'Drain Care Build Up Remover. The label had a warning "Keep Out of Reach Of Children & Pets. Eye irritant, sensitizer, May be harmful if swallowed." (3) One bottle labeled 'Enforcer Buildup Remover' with a warning label "Keep Out Of Reach Of Children - Warning Causes Eye Irritation." (4) One spray bottle labeled 'Workout - The Muscle Cleanser' with a warning label of "Keep Out Of Reach Of Children - Avoid Contact With Eyes and Skin." (5) One can of 'Bab-O Cleanser' with the warning label "Keep Out OF Reach Of Children - Harmful If Swallowed - Do Not Induce Vomiting - Call a physician or the poison control center." The room was unlocked. Observation was made on 02/24/14 of the unlocked door to the 'J3' room/closet at 11:45 a.m., 12:50 a.m., and 2:45 p.m. At 2:00 p.m., CNA #1 was asked if resident #5 was confused and if she had observed the resident wandering anywhere in the facility. She stated the resident was confused a lot and didn't know which room was hers until staff showed her. She stated, "Most of the time she wanders all around and she wanders into others' rooms. We found her in (resident #17's) room, she was going to get in her bed." CNA #1 was asked if the resident was able to drink on her own without assistance and if she could unscrew a cap. She stated, "(Resident #5) drinks on her own and yes, she could unscrew a cap." At 2:50 p.m., CNA #2 was asked if resident #5 was confused and if she had observed the resident wandering anywhere in the facility. She stated, "Sometimes she gets confused and at times tries to get out of the facility. When she is trying to find her room, she goes into someone else's room. She is usually laying on the bed or about to get into it." CNA #2 was asked if the resident could drink liquids unassisted. She stated, "She drinks liquids without any problem."

On 05/30/12 at 10:15 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents with a history of elopement were adequately supervised to prevent elopement from the facility. The Oklahoma State Department of Health (OSDH) was contacted and verified the existence of the IJ. At 10:21 a.m., the administrator and DON were notified of the IJ situation regarding the lack of adequate supervision for residents who were at risk for elopement from the facility. An acceptable plan of removal was received on 05/30/12 at 6:15 p.m. The plan of removal documented, "There has been a resident identified at risk for Elopement and has put this facility in an I.J. status. We will be doing these intervention (sic) to ensure that this resident and no others will be harmed by this action in the future. 1) We have adopted an appropriate Elopement Policy for our facility, and it will be implemented into our policy and procedures by 1:00 p.m. on 05-30-2012. 2) All staff have been inserviced on our new policies for Elopement and wandering and the ones that have not been to the facility today have been notified by phone and have been in serviced concerning this matter and the new policies by 6:00 p.m. on 05-30-2012. 3) We found and adopted an assessment risk form that will be done on each and every resident in the facility, and those will be done quarterly or on a significant change after this. These risk assessments will be completed on current residents by 8:00 p.m. on 05-30-2012. 4) Residents that have been found to be at risk for elopement will be monitored one on one, and diversional activities will be used to redirect her or others away from the front door/exit. The facility will be reviewing bids for a contract for a new security system and this will done and in place by 12:00 noon on 06-30-2012. 5) The maintenance staff will check each of the 8 door alarms daily and make sure they are in working order, and he started the documentation in a log at 3:00 p. m. on 05-30-2012. 6) We will implement the Standards of Practice for Risk Assessment for all of our residents, which is... on admit, after 30 days, quarterly, and for a significant change of condition. This was done and in place by 1:00 p.m. on 05-30-2012. 7) Any resident that is found to be at risk for elopement will be identified in their care plan. Those care plans were updated and put in the care plan book by 4:00 p. m. on 05-30-2012." The IJ was removed on 05/30/12 at 8:00 p.m., when the facility provided evidence that all components of their plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on observation, clinical record review, review of policies and procedures and staff interviews, it was determined the facility failed to: - provide adequate supervision to prevent elopement for one (#3) of three sampled residents who were at risk for elopement from the facility. This had the potential to affect four residents identified by the facility who were at risk for elopement; and - ensure hot water temperatures were maintained at a safe temperature in 12 (#204, 205, 206, 207, 208, 209, 213, 301, 302, 303, 308 and #312) of 27 resident rooms. This had the potential to affect all 34 residents who resided in the facility. Findings: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, with an assessment reference date, 07/24/11, documented the resident was moderately impaired in her cognitive skills for daily decision making. The assessment also documented the resident did not have any wandering behaviors. A nurse's note, dated 07/25/11 at 8:40 p.m., documented, "Resident wandered outside et across the street 2 houses down et sat on front porch of (private citizen). (Private citizen) brought resident back to the facility... Resident placed on 15 minute walking rounds." A care plan, titled, "Care Plan Continuation for New Problem", dated 07/25/11, documented, "... Problem: I have left the building a couple of times recently. I didn't leave the facility grounds. But the facility also had a blue van like my daughters. Goal: I will not leave the facility without the staff knowing where I am at thru the next review. Approaches: (1) When I head to the front door, please stop me and ask me politely where I am going - If I appear to be leaving the facility, please re-direct me (2) I will need the staff to monitor my where abouts @ all times. (3) I like to sit in the front lobby by the front door - If the alarm goes off the staff will need to check immediately to make sure it wasn't me going out." The annual assessment was signed by the DON as complete on 07/26/11. The assessment was not modified to reflect the resident had wandered outside the facility. A nurse's note, dated 07/27/11 at 6:00 p.m., documented, "Attempting to leave facility." A nurse's note, dated 08/15/11 at 1:15 p.m., documented, "resident sitting on front porch napping woke her up + assisted into the facility s difficulty." A nurse's note, dated 08/28/11 at 7:15 p.m., documented, "Resident ambulated outside unassisted..." Documentation was missing on fifteen minute checks for the following: On 09/08/11 from 10:00 a.m. to 6:00 p.m. On 10/05/11 from 12:00 noon to 1:45 p.m. On 10/10/11 from 7:00 p.m. to 10:00 p.m. A nurse's note, dated 10/20/11 at 5:30 p.m., documented, "res found crossing street in front of center c walker, 15 minute checks continue... brought back to center by nurses." Documentation was missing on fifteen minute checks for the following: On 11/04/11 from 1:00 p.m. to 2:15 p.m. An undated form, from 4:30 a.m. to 5:45 a.m. and from 10:00 a.m. to 2:15 p.m. On 11/10/11 from 7:45 a.m. to 2:00 p.m. On 11/17/11 from 2:15 p.m. to 6:15 p.m. On 11/18/11 from 3:00 p.m. to 6:15 p.m. On 12/06/11 from 3:00 p.m. to 5:00 p.m. A nurse's note, dated 12/10/11 at 6:00 p.m., documented, "Resident finished dinner, got (up) from table and walked to front door of building. She opened the door and began to walk out..." Documentation was missing on fifteen minute checks for the following: On 12/14/11 from 9:45 a.m. to 2:15 p.m. and 9:15 p.m. to 11:00 p.m. On 01/31/12 from 6:45 a.m. to 2:00 p.m. On 02/01/12 from 1:30 p.m. to 2:15 p.m. On 02/05/12 from 2:30 p.m. to 10:00 p.m. On 02/13/12 from 2:00 p.m. to 11:45 p.m. On 02/16/12 from 10:45 a.m. to 2:25 p.m. On 02/23/12 from 10:45a.m. to 12:00 noon and from 12:30 p.m. to 2:15 p.m. On 03/01/12 from 7:00 a.m. to 2:15 p.m. An undated form, from 7:00 a.m. to 2:15 p.m. On 03/04/12 from 7:00 a.m. to 2:15 p.m. On 03/05/12 from 7:00 a.m. to 11:30 a.m. and 2:00 p.m. to 2:15 p.m. On 03/07/12 from 10:00 a.m. to 2:00 p.m. On 03/09/12 from 7:00 a.m. to 10:00 p.m. On 03/10/12 from 7:00 a.m. to 2:15 p.m. On 03/12/12 from 9:00 a.m. to 10:00 a.m. and 1:30 p.m. to 4:15 p.m. On 03/13/12 from 10:45 p.m. to 6:15 a.m. On 03/16/12 from 7:00 a.m. to 2:00 p.m. On 03/22/12 from 9:30 a.m. to 10:00 p.m. On 03/23/12 from 12:00 noon to 12:15 p.m., it was documented the resident was "in chair in lobby" and from 12:30 p.m. to 12:45 p.m., "Not in room." There was no documentation in the clinical record which indicated the facility was searched to locate the resident when she was not in her room. An Unusual Occurrence Report, dated 03/23/12 at 12:45 p.m., documented, "Private citizen came inside facility & notified staff that an older woman c walker was on far side of park & had fallen. Found res sitting on ground in street. She stated 'my feet slipped out from under me.' She was able to stand & ambulate into van c walker initially are (s)teps taken to prevent recurrence attempts to re-orient & notify staff before going outside (unsuccessful) Able to amb into facility & into room. (Checked) on 30min later & she was sitting in her recliner on her R hip. C/O L hip pain. Was barely able to bear wt. to (L) LE. Assisted into bed abrasion & bruise noted to (L) elbow & (L) pinky & ring fingers. Softball size hematoma noted to (L) hip was hard, warm to touch called (physician) back & will send res to ER ..." An OSDH Incident Report Form, dated 03/23/12, documented, "... On March 23, 2012 at approximately 12:45 pm a private citizen came to the facility and notified staff that a resident was outside by the park and had fallen. Staff members found (resident) on the ground. She stated 'my feet slipped out from under me'. Resident was assessed. She was able to stand and ambulate with walker into van, facility, and into room...Approximately 30 minutes later, she was sitting in her recliner on her (R) hip. (Resident) complained of (L) hip pain and was barely able to bear weight. Resident assisted into bed. Abrasion & bruise noted to (L) elbow & pinky & ring fingers. Softball size hematoma noted to (L) hip was hard, warm to touch. Physician notified and resident sent to (name deleted) Hospital ER for further evaluation... (Resident's) fall risk assessment score is 12, which is considered high risk for falls to occur. (Resident) does not have a history of falls; her last fall being Nov. 30, 2010. (Resident) suffers from both short and long term memory loss, and is occasionally confused. She is ambulatory with a walker. Staff assists with her ADL's as needed. (Resident) has a been an elopement risk. She likes to sit by the front door and view the outdoors. The facility's blue van is a reminder of her daughter's van which is also blue... Resident (name deleted) returned to the facility following X-ray and evaluation in (name deleted) ER. X-ray showed that there was not a fracture. (Resident) is currently on a 15 minute elopement risk assessment check. Charge nurse reinforced to staff the importance of re-orienting (resident) and reminding her to notify staff before going outside. Staff reminded to continuously monitor (resident's) presence when in the front lobby. Maintenance supervisor is to perform daily checks on all alarms to make sure they are functioning properly." Documentation was missing on fifteen minute checks for the following: On 04/03/12 from 1:00 p.m. to 2:00 p.m. On 04/07/12 from 8:30 p.m. to 10:15 p.m. On 04/09/12 from 2:30 p.m. to 7:45 p.m. On 04/14/12 from 9:15 a.m. to 2:00 p.m. On 04/19/12 from 11:45 a.m. to 2:00 p.m. On 04/22/12 from 10:00 p.m. to 6:00 a.m. On 04/27/12 from 10:15 a.m. to 2:00 p.m. On 04/28/12 from 3:30 p.m. to 10:15 p.m. On 05/05/12 from 2:00 p.m. to 10:00 p.m. On 05/06/12 from 11:15 p.m. to 6:00 a.m. On 05/07/12 from 5:00 a.m. to 6:45 a.m. On 05/11/12 from 6:30 p.m. to 10:15 p.m. On 05/13/12 from 1:15 p.m. to 2:15 p.m. and 3:30 p.m. to 10:15 p.m. On 05/14/12 from 8:30 p.m. to 10:00 p.m. On 05/19/12 from 7:00 a.m. to 1:30 p.m. On 05/20/12 from 7:00 a.m. to 1:30 p.m. On 05/25/12 from 11:45 a.m. to 1:45 p.m. and 8:00 p.m. to 10:00 p.m. On 05/27/12 from 2:30 p.m. to 10:15 p.m. On 05/28/12 from 9:15 p.m. to 10:00 p.m. On 05/29/12 at 4:15 p.m., the resident was observed lying on the couch in the front lobby next to the front door. On 05/30/12 at 8:46 a.m., the maintenance supervisor was asked about alarms on the doors. He stated two doors to the outside, the North door and the West door, do not have a doorbell. He was asked about the staff entrance. He stated the staff entrance never had a bell. At 8:50 a.m., the restorative aide was asked how the resident was monitored. She stated, "We do a fifteen minute check on (resident)." At 8:55 a.m., CNA #2 was asked what intervention was in place to ensure the resident would not elope from the building. She stated, "We checked her every fifteen minutes." At 9:00 a.m., RN #1 was asked what she did for wandering residents. She stated, "One lady fifteen minute checks because she has wandered outdoors." At 9:10 a.m., the ADON was asked what was done to ensure the resident does not leave the building. She stated, "We do every 15 minute checks. She was shown the missing documentation for monitoring the resident's whereabouts. She was asked if she could determine if the resident was monitored based on the missing documentation. She stated, "No I can't." 2. The facility policy for water temperatures documented, "Water Temperature Policy:" Community Health Center's policy is to ensure the proper maintenance of water temperatures at a level safe for the resident's needs and safety...Temperature...Bathing 115 degrees F. Hot water temperatures were observed on 05/29/12 at 3:25 p.m. through 5:05p.m. in the following residents' rooms: Room 208- 120.5 degrees F. Room 301- 123.3 degrees F. Room 302- 122.9 degrees F. Room 303- 123.7 degrees F. Room 308- 120.4 degrees F. Room 312- 122.1 degrees F. Hot water temperatures were observed on 05/30/12 at 9:15 a.m.through 12:30 p.m., in the following residents' rooms: Room 204- 120.4 degrees F. Room 205- 121.4 degrees F. Room 206- 124.8 degrees F. Room 207- 123.0 degrees F. Room 208- 121.4 degrees F. Room 209- 123.4 degrees F. Room 213- 123.5 degrees F. Room 301- 122.4 degrees F. On 05/29/12 at 4:15 p.m., The maintenance supervisor was asked at what temperature the hot water in the residents rooms was to be maintained and how often he checked the hot water temperatures in the residents' rooms. He stated the hot water temperatures were not to be over 120 degrees F in the residents' rooms and he checked them weekly.