Every finding on record at Cordell Nursing and Rehabilitation

Based on observation and interview, the facility failed to ensure:a. showers were cleaned between each use, andb. the walls of residents' rooms were not damaged during 2 of 2 observations made for a clean, sanitary, and home like environment.The administrator identified 53 residents resided in the facility.Findings:1. On 09/04/25 at 9:40 a.m., Resident #52's room was observed to have two areas 6 inches by 18 inches of damaged sheetrock and missing paint on the wall where the bed was against the wall. Resident #52 quarterly assessment, dated 07/10/25, showed their cognition was intact with a BIMS score of 15. The assessment showed Resident #52 was dependent for transfers. On 09/03/2025 at 9:40 a.m., Resident #52 stated the wall has been damaged like that for 6 years caused by the bed reclining up and down. Resident #52 stated the facility replaced the floor recently and were aware of the damage to the wall but did not repair the wall. Resident #52 stated the wall damage has been reported to multiple staff, but it has never been repaired. Resident #52 stated they did not like the wall being damaged. 2. On 09/04/25 at 9:45 a.m., Resident #9's room was observed to have one area 6 inches by 8 inches of damaged sheetrock and missing paint on the wall where the bed was against the wall. 09/04/25 at 10:05 a.m., work orders were reviewed. There were no open work orders for sheetrock/wall repair in Resident #9 and Resident #52's rooms. On 09/04/5 at 10:05 a.m., the maintenance supervisor was asked if they had any open work orders. The maintenance supervisor stated there were two work orders for air conditioners on e-wing and did not have any open work orders for anything else. On 09/04/2025 at 10:39 a.m., the administrator was shown the walls in room for Resident #9 and Resident #52. The administrator stated Resident #52 refused for days upon days to get out of the bed to make the repairs. The administrator stated the attempts to repair the wall in Resident #9's room were not documented. The administrator stated the damage to the wall in Resident #53's room was just forgotten. The administrator stated they do not have a policy for maintaining a safe home like environment. The administrator stated they did not have a maintenance person for over a month. The administrator stated the damaged walls did not reflect a homelike environment. 3. On 09/04/25 at 11:15 a.m., the following observations were made with HK #1 in the whirlpool bathroom on the A hall:a. a fan and fake plant hanging next to the whirlpool were covered in dust,b. green algae, hair, and soap scum were on the panel controls for the whirlpool bath,c. debris, a wet blanket, and a soiled glove was on the floor against the walls, d. soap scum, dust, and debris were on the shelves used to store supplies, ande. there was a missing access panel for the whirlpool bath with visible soiled floors and plumbing pipes covered in dust and debris behind the whirlpool bath. On 09/04/25 at 11:25 a.m., the following observations were made with HK #1 in the shower/bath on C hall:a. pink mold was observed on the floor in the corner;b. dust and debris were on the shower head and pipe overhead; and c. a plastic cabinet used to store shower supplies was open with shelves that were soiled with soap scum and debris. On 09/05/25 at 11:39 a.m., the following observations were made on the memory care whirlpool bathroom:a. there was an access panel for the whirlpool bathtub leaning against the wall with tape from a previous repair and not covering the whirlpool access;b. there was dirt, debris, hair ties, and resident hair on the floor around the perimeter; andc. a broom laying on the floor. Resident #29's quarterly assessment, dated 07/11/25, showed their cognition was intact with a BIMS score of 13. The assessment showed Resident #29 required partial to moderate assistance with showers and supervision or touching assistance for shower transfers. Resident #9s significant change assessment, dated 08/19/25, showed their cognition was moderately impaired with a BIMS score of 12. On 09/03/25 at 10:08 a.m., Resident #29 stated the bathrooms/showers were very dirty and needed to be cleaned. On 09/04/25 at 11:29 a.m., HK #1 was asked about the three bathrooms observed. HK#1 stated they were not responsible for cleaning the showers and the shower aide, CNA #1, was responsible for cleaning the showers. HK #1 stated the shower/bathrooms were not clean and sanitary. On 09/04/25 11:51 a.m., CNA #1 stated they were responsible for maintaining (cleaning) the showers on A hall and C hall. CNA #1 was shown the three bath/showers on hall A, hall C, and the memory care hall. CNA #1 stated they did not realize how dirty and dusty they were. CNA #1 stated they had not wiped the controls down in a few days and the whirlpool room on A hall needed to be deep cleaned. CNA #1 stated at the end of the day, they get tired and did not clean the bathrooms like they should be cleaned. On 09/04/25 at 12:25 p.m., the DON was shown the three shower/whirlpool baths on hall A, hall C, and the memory care halls. The DON stated the bath/showers used by residents were not clean and sanitary. 09/04/25 at 12:26 p.m., the administrator was shown the three shower/whirlpool baths on hall A, Hall C, and the memory care halls. The administrator stated the shower/baths were not clean, sanitary, and did not reflect a clean and sanitary homelike environment.

Based on record review and interview, the facility failed to have an effective quality assessment and assurance program that identified concerns and implemented actions to correct the concerns. The DON identified 53 residents resided in the facility. An undated policy provided by the facility titled Quality Assurance and Performance Improvement Program, read in part, The primary purpose of the Quality Assurance and Performance Improvement program is to establish data-driven, facility-wide processes that improve quality of care.On 09/05/25 at 11:55 a.m., the administrator was asked for quality assurance and performance improvement meeting documentation for the past year, from August 2024 thru August 2025.The administrator stated they did not have a book, or any documentation, for that time period. The administrator stated they had looked for it and had not been able to locate it. The administrator stated they had the meetings, but do not have any documentation available.

Based on record review and interview, the facility failed to ensure a PRN psychotropic medication was limited to 14 days for 1 (#40) of 5 sampled residents reviewed for PRN psychotropic medications.The DON identified 53 residents resided in the facility and 41 were taking psychotropic medication.Findings:An undated policy titled Initiation of Psychotropic Drugs, read in part, PRN psychotropic medication orders are limited to 14 days.A Physician's Order, dated 07/23/25, read in part, Lorazepam (a psychotropic drug) oral tablet 0.5mg Give one tablet by mouth every 6 hours as needed for anxiety.A MAR for August 2025 showed Resident #40 was given Lorazepam 0.5mg two times on 08/09/25 and once on 08/14/25.On 09/05/25 at 12:20 p.m., the DON was asked what the policy was for PRN psychotropic medications. The DON stated, We have to have a stop date. They were asked what the stop date should b. They stated, 14 days. Resident #40's PRN Lorazepam order was shown to the DON and asked what the stop date was for the medication. They stated, [They] are on hospice, so we don't put stop dates on hospice residents. The DON was asked to read the facility's policy. The DON stated, I guess we should have a stop date on it. The DON was asked what the stop date should have been since the order was written on 07/23/25. They stated, August 6th.

Based on observation, record review, and interview, the facility failed to accurately code MDS assessment for a resident's mobility device for 1 (#3) of 14 sampled residents reviewed for MDS accuracy The administrator identified 53 residents resided in the facility.Findings:On 09/03/25 at 9:13 a.m., Resident #3 was observed in a power wheelchair moving down the hall independently. On 9/05/25 at 10:36 a.m., Resident #3 was observed ambulating with power wheelchair in the hall independently. An admission record for Resident #3, dated 12/11/24, showed they were admitted with diagnoses which included cerebral infarction and spinal stenosis. A quarterly assessment for Resident #3, dated 06/26/25, showed their cognition was intact with a BIMS score of 15. The assessment showed in section GG0115, Resident #3 did not use any mobility devices. The assessment showed they were dependent for chair to bed transfers. The assessment showed Resident #3 was unable to walk. On 09/03/25 at 9:13 a.m., Resident #3 stated they used a power wheelchair to move around the facility. On 09/05/25 at 10:39 a.m., CMA #2 was asked how Resident #3 ambulated. CMA #2 stated Resident #3 used a power wheelchair to move around the facility. On 09/05/25 at 10:45 a.m., MDS coordinator #1 was asked how Resident #3 ambulated. MDS coordinator #1 stated Resident #3 did not walk and used a power wheelchair to move around the facility. MDS Coordinator #1 was asked what does Resident #3's quarterly assessment, dated 06/25/25, document in section GG on question GG0115. MDS Coordinator #1 stated the quarterly assessment, dated 06/25/25, did not document Resident #3 used a wheelchair. MDS Coordinator #1 was asked if the assessment was accurate. MDS coordinator #1 stated, No sir. MDS Coordinator #1 stated the assessment was miscoded. MDS Coordinator #1 stated the facility follows the RAI manual and did not have a policy on accurately coding assessments.

Based on record review, and interview, the facility to ensure a level II PASARR was completed after a new mental health diagnosis for 1 (#41) of 5 sampled residents reviewed for PASARR's.The administrator identified 53 residents resided in the facility. Findings:On 09/04/25 at 10:14 a.m., Resident #41 was observed in the resident council meeting. The resident was dressed and participating in discussions. Resident #41's PASARR level I, dated 09/09/22, showed Resident #41 did not have evidence, history, or a diagnosis of a serious mental illness. The electronic health record for Resident #41, dated 11/12/24, showed Resident #41 was diagnosed with unspecified psychosis not due to a substance or known physiological condition. An annual assessment for Resident #41, dated 07/25/25, showed their cognition was intact with a BIMS score of 15. The assessment showed they had diagnoses which included depression and psychotic disorder. The electronic health record for Resident #41 was reviewed. There was not a new PASARR level II completed after the new diagnosis on 11/12/24 of unspecified psychosis not due to a substance or known physiological condition. On 09/04/25 at 9:51 a.m., MDS coordinator #1 stated Resident #41 had a PASARR level I completed on 09/13/22. MDS Coordinator #1 stated Resident #41 had a new diagnosis of unspecified psychosis not due to a substance or known physiological condition on 11/12/24. MDS Coordinator #1 stated a PASARR level II was not completed after the new diagnosis of unspecified psychosis not due to a substance or known physiological condition. MDS Coordinator #1 stated a PASARR level II should have been completed after the new diagnosis on 11/12/24. On 09/04/25 at 9:55 a.m., the DON was asked about Resident #41's new diagnosis of unspecified psychosis not due to a substance or known physiological condition on 11/12/24 and the PASARR policy. The DON stated there should have been another PASARR completed because the resident had a new diagnosis of psychosis. The DON stated a PASARR level II was not completed after the new diagnosis on 11/12/24. The DON stated they did not have a policy on PASARRs.

Based on observation, record review, and interview, the facility failed to ensure:a. an oxygen nasal cannula was placed in a bag when not in use to prevent infections for 1 (#29) of 20 sampled residents reviewed for infection control practices, andb. staff changed gloves while performing catheter care for 1 (#4) of 2 sampled residents reviewed for catheter care.The DON identified 20 residents received oxygen therapy and two residents had catheters. Findings:1.On 09/05/25 at 10:18 a.m., CNA #2 donned gloves and unfastened Resident #4's brief. CNA #2 removed one wet wipe from a package and used it to wipe Resident #4's peri-area front to back. CNA #2 repeated this process three times. CNA #2 then removed another wet wipe and cleaned Resident #4's catheter from their urinary meatus down the catheter tubing approximately five inches. On 09/05/25 at 10:21 a.m., CNA #2 and CNA #3 rolled Resident #2 to their left side. CNA #2 removed Resident #2's brief and disposed of it in the trash can. CNA #2 then used a clean wet wipe to cleanse Resident #2's buttocks. CNA #2 then tucked a clean brief under the resident. CNA #2 and CNA #3 rolled Resident #2 to their right side. CNA #3 pulled the clean brief under the resident and then rolled the resident to their back. CNA #2 and CNA #3 each fastened the brief. CNA #2 used the bed remote to raise Resident #4's head of bed and lower the bed back down to the lowest position. CNA #2 then moved the resident's bed back against wall. On 09/05/25 at 10:23 a.m., CNA #2 doffed their gown and gloves and disposed of both in the trash. CNA #2 utilized hand sanitizer. An undated policy titled Catheter Care, Urinary, read in part, Maintain clean technique and isolation precautions as indicated. On 09/05/25 at 10:25 a.m., CNA #2 was asked how many times they changed their gloves during catheter care. They stated, I didn't. I forgot about that. They were asked when they should have changed their gloves. CNA #2 stated, After I cleaned [Resident #2] the first time, before placing the clean brief under [them]. 2.On 09/03/25 at 10:15 a.m., Resident #29's room, was observed to have an oxygen concentrator with the oxygen tubing and a nasal cannula coiled up on top of the concentrator. The nasal cannula was not in a bag. On 09/04/25 at 7:00 a.m., Resident #29s room was observed to have an oxygen concentrator with the oxygen tubing rolled up with a nasal cannula laying on top of the concentrator. The nasal cannula was not in a bag to prevent infections. An admission record for Resident #29's, dated 03/28/25, showed they were admitted with diagnoses which included encounter for orthopedic fracture and dementia. A physician order for Resident # 29's, dated 06/17/25, read in part, Oxygen: Continuous at 4L/min via N/C. A care plan for Resident # 29's, dated 06/17/25, read in part, Oxygen: Continuous at 4L/min via N/C at bedtime for SOB [shortness of breath] while sleeping. A quarterly assessment for Resident #29's, dated 07/11/25, showed their cognition was intact with a BIMS score of 13. The assessment showed Resident #29 was receiving oxygen therapy. On 09/03/25 at 10:15 a.m., Resident #29 stated they wear oxygen every night at bedtime. On 09/04/25 at 7:18 a.m., CMA #1 stated Resident #29 wears oxygen every night and they take it off in the morning. CMA #1 stated, When I take it off, I roll up the tubing and the nasal cannula and put in on the concentrator handle rolled up. On 09/04/25 at 7:30 a.m., the infection preventionist stated all oxygen tubing and nasal cannulas should be bagged when not in in use. The infection preventionist was shown the oxygen tubing and nasal cannula rolled up on the oxygen concentrator and placed under the handle. The infection preventionist stated the tubing and nasal cannula was not in a bag and was laying on top of the oxygen concentrator which could cause infection. The infection preventionist stated they did not have a policy on bagging the nasal cannula when not in use to prevent infections. 09/04/25 at 7:31 a.m., the DON was shown the oxygen concentrator and tubing. The DON stated the tubing and nasal cannula was not in a bag and was rolled up on top of the oxygen concentrator.

Based on observation, record review, and interview, the facility failed to ensure an antibiotic for a wound was justified and a wound culture had been obtained for one (#2) of two sampled residents reviewed for wounds. The Administrator identified 51 residents resided in the facility. The Resident Matrix, dated 04/22/24, documented two residents with wounds. Findings: An undated Antibiotic Stewardship-Review and surveillance of Antibiotic Use and Outcomes policy, read in part .The IP, or designees, will review all antibiotics starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified .Therapy is not justified if .The organism is not susceptible to antibiotic chosen .Therapy was started awaiting culture, but no organism was isolated after 72 hours . Resident #2 had diagnoses which included, depressive disorder, high blood pressure and stage three pressure ulcer. A Health Status Note, dated 04/19/24, read in part .Received order from [name of hospice nurse and hospice] for Keflex 500 mg TID x 7 days for coccyx wound . Resident #2's RESIDENT INFECTION REPORT, dated 04/19/24, was blank where the culture results should have been documented. An attachment titled, Infection Criteria Checklist did not contain documentation it had been completed. A weekly wound observation tool, dated 04/21/23, documented Residents #2's wound measurements as 30 mm x 16 mm x 0 with 20% slough to center of the wound and a small amount of serosanguineous drainage noted to the old dressing. The clinical health record did not contain documentation a wound culture had been obtained. On 04/25/24 at 10:39 a.m., the IPC nurse was asked if a wound culture had been completed on Resident #2's coccyx wound. They stated, no hospice had got the order. On 04/25/24 at 11:57 a.m., the IPC nurse was shown the policy for antibiotic stewardship and asked if the antibiotic had been reviewed after 48 hours to determine if it was justified. They stated there was no culture and they were not sure if it had infection or not but the wound had been worsening. The IPC nurse was asked why the wound had not been followed up on in 48 hours and why the infection Criteria Checklist was blank. The IPC nurse stated, the nurse was supposed to fill out the resident infection report and infection criteria checklist, and turn it in to them. They would then follow up to ensure the antibiotic was sensitive. The IPC nurse was asked if the policy had been followed. They stated No.

Based on record review and interview the facility failed to ensure annual competency reviews were completed for two (CNA #2 and CNA #3) of three sampled staff reviewed for annual competency skills checks. The Administrator identified 52 residents resided in the facility. Findings: CNA #2's date of hire was 10/21/21. The personnel file did not contain documentation an annual competency review had been completed. CNA #3 date of hire was 09/21/20. The personnel file did not contain documentation an annual competency review had been completed. On 04/25/24 at 2:21 p.m., the Administrator was asked if there were any annual competency reviews for CNA #2 and CNA #3. They reviewed the personnel files and stated there was not any documentation of competency reviews. On 04/25/24 at 4:09 p.m., the DON stated there was no facility policy for annual competency reviews for CNA's. They were asked if CNA #2 and CNA #3 had competency reviews they stated they should be in the personnel files.

Based on observation, record review and interview, the facility failed to ensure food was labeled, dated, and not kept beyond the Use by Date. The Administrator identified 52 residents resided in the facility. The DON identified 50 residents who received nutrition from the kitchen. Findings: A Dietary Services Food Storage policy, revised 01/20/14, read in part .Leftovers that are potentially hazardous foods shall be used, or disposed of, within 24 hours. Non-potentially hazardous leftovers that have been heated or cooked may be refrigerated for up to forty-eight (48) hours .All food is dated as to time received or cooked to ensure timely us (sic) and/or disposal . On 04/22/24 at 3:17 p.m., a brief initial kitchen observation was completed with [NAME] #1. The following observations were made in the walk in refrigerator: a. Two tubs of opened sour cream that were stamped best if used by 04/12/24, b. A clear container with green beans was, dated 04/18/24, and c. A package of hot dog buns in the original package did not have a date when they were received. Cook #1 was shown the two tubs of out of date sour cream. They removed the tubs and discarded in the trash. Two stainless steel containers with saran wrap and clear covers were observed without any date or time when prepared in the door of the black refrigerator. [NAME] #1 was asked what was the food in the containers. They stated ground and pureed sausage. They were asked when the food had been prepared. They stated they did not know. [NAME] #1 was asked if the containers had a date on them. They stated No. [NAME] #1 was asked how long they kept prepared food. They stated they usually get rid of the food after the meal is completed. [NAME] #1 was asked how long food is kept after it is prepared. They stated it depends on what it is.

Based on record review and interview, the facility failed to ensure the information submitted on the Payroll Based Journal was accurate for 24 hour staffing. The Administrator identified 52 residents resided in the facility. Findings: A PBJ Staffing Data Report, dated 10/01/24 through 12/31/24, documented the facility did not have 24 hour licensed nursing coverage on the following dates: 12/16/24, 12/17/24, 12/22/24, 12/23/24, and 12/31/24. On 04/25/24 at 11:05 a.m., documentation for 24 hour licensed staff for the dates in question were requested from the Administrator. On 04/25/24 at 1:00 p.m., the Administrator provided documentation of coverage for the dates. The Administrator stated they thought it was agency staff that had not been reported correctly.

Based on record review and interview, the facility failed to ensure a physician had been notified for a change in condition for one (#7) of three sampled residents reviewed for notification. The administrator identified 51 residents resided in the facility. Findings: Resident #7 had diagnoses which included atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia. A Physician's Order, dated 02/01/24, documented to administer Zofran 4 mg every six hours as needed Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. An Administration Note, dated 04/15/24, at 10:38 p.m., documented Zofran 4 MG had been administered for nausea. An Administration Note, dated 04/16/24 14:16 p.m., documented Zofran 4 MG had been administered for nausea An Administration Note, dated 04/16/24 at 8:20 p.m., read in part, .Resident threw up around 1830 [6:30 p.m.] and said stomach is still upset doesn't want to take [their] HS medication. A Health Status Note, dated 04/17/24 6:04 a.m., read in part, .Resident vomited mod. Amount brown liquid emesis .CMA instructed to give prn Zofran . There was no documentation the physician had been notified. An Administration Note, dated 04/18/24 12:40 p.m., documented Resident #7 complained of nausea and was given Zofran 4 mg for complaints of nausea. A Health Status Note, dated 04/18/24 at 3:25 p.m., documented Resident #7 refused supper because they weren't feeling good. Resident #7 refused to go to the emergency room . The note documented blood pressure 102/54, pulse 83, respirations 8, lungs clear to auscultation, and oxygen saturation of 95%. A Health Status Note, dated 04/18/24 at 10:13 p.m., documented Resident #7 was confused and had not eaten all day. It documented Resident #7 refused to go to the hospital for evaluation. There was no documentation the physician had been notified. A Health Status Note, dated 04/19/2024 at 6:25 a.m., read in part, .Resident pale, increase weakness, abdomen distended and discomfort noted when palpated .Resident c/o nausea during incontinent care .Resident not eating or drinking well. A Health Status Note, dated 04/19/24 at 7:05 a.m., documented Resident #7 was sent to the emergency room via ambulance. A review of health status notes contained no documentation staff had assessed Resident #7 for bowel sounds from 04/15/24 at 10:25 a.m. when Resident #7 complained of abdominal discomfort to 04/19/24 at 6:55 a.m. On 04/24/24 at 12:43 p.m., LPN #2 stated Resident #7 had been nauseated and vomiting throughout the week. They stated they assessed Resident #7's abdomen to be distended and Resident #7 complained of nausea. LPN #2 stated they sent Resident #7 to the emergency roiagnom on [DATE]. LPN #2 was asked who they would notify when a resident had a change in condition. LPN #2 stated the doctor had been notified on 04/19/24 On 04/24/24 at 1:19 p.m., the DON reviewed the nurses' notes and stated staff should have notified the physician due to the change in condition. The DON was asked if there was documentation the physician had been notified. The DON stated they did not see any.

Based on record review and interview, the facility failed to ensure staff reported an allegation of misappropriation of property for one ( #36) of one sampled resident reviewed The Administrator identified 51 residents resided in the facility. Findings: An undated, 'Abuse Investigation policy, read in part, .Should an incident or suspected incident of resident abuse .misappropriation .the Administrator, or his/her designees, will appoint a member of management to investigate the alleged incident . Resident #36 had diagnoses which included heart failure, and high blood pressure. An OSDH, Incident Report form, dated 04/20/24, read in part .Resident stated to Administrator 04/22/24 at 5:30 p.m. a personal vape was missing from [their] bag kept in the smoking locked file box . On 04/23/24 at 9:16 a.m., Resident #36 was asked if they had any property missing that had not been found. They stated, I have had two vape's stolen since I have been here. One was this weekend, I told the girls on Saturday morning. They were unsure who they told, and stated I told everyone since then except [the Administrator]. On 04/23/24 at 9:34 a.m., this surveyor notified the Administrator of the allegation of the missing vape product. On 04/23/24 at 11:32 a.m., the Administrator stated they spoke to housekeeper #1 who reported Resident #26 said their vape was gone on Saturday. The Administrator stated it had not been reported to them on Saturday. On 04/24/24 at 1:35 p.m., the Administrator was asked if housekeeper #1 had followed the policy to report the allegation of misappropriation of property. They stated it should have been reported to them or the DON in their absence.

Based on record review and interview, the facility failed to ensure bowel sounds had been assessed when a resident complained of abdominal discomfort for one (#7) of one sampled residents reviewed for hospitalization . The administrator identified 51 residents resided in the facility. Findings: Resident #7 had diagnoses which included atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia. A Physician's Order, dated 02/01/24, documented to administer Zofran 4 mg every six hours as needed Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. An Administration Note, dated 04/15/24, at 10:38 p.m., documented Zofran 4 MG had been administered for nausea. An April 2024 task record documented Resident #7 had a bowel movement on 04/16, 04/17, and on 04/18/24. An Administration Note, dated 04/16/24 14:16 p.m., documented Zofran 4 MG had been administered for nausea A Health Status Note, dated 04/16/24 at 6:18 p.m., read in part, .Resident c/o pain and cramping in LLQ, n/o to obtain UA with reflex to culture . An Administration Note, dated 04/16/24 at 8:20 p.m., read in part, .Resident threw up around 1830 [6:30 p.m.] and said stomach is still upset doesn ' t ' want to take [their] HS medication. A Health Status Note, dated 04/17/24 6:04 a.m., read in part, .Resident vomited mod. Amount brown liquid emesis .CMA instructed to give prn Zofran . An Administration Note, dated 04/18/24 12:40 p.m., documented Resident #7 complained of nausea and was given Zofran 4 mg for complaints of nausea. A Health Status Note, dated 04/18/24 at 3:25 p.m., documented Resident #7 refused supper because they weren't feeling good. Resident #7 refused to go to the emergency room . The note documented blood pressure 102/54, pulse 83, respirations 8, lungs clear to auscultation, and oxygen saturation of 95%. A Health Status Note, dated 04/18/24 at 10:13 p.m., documented Resident #7 was confused and had not eaten all day. It documented Resident #7 refused to go to the hospital for evaluation. A Health Status Note, dated 04/19/2024 at 6:25 a.m., read in part, .Resident pale, increase weakness, abdomen distended and discomfort noted when palpated .Resident c/o nausea during incontinent care .Resident not eating or drinking well. A Health Status Note, dated 04/19/24 at 7:05 a.m., documented Resident #7 was sent to the emergency room via ambulance. A review of health status notes contained no documentation staff had assessed Resident #7 for bowel sounds from 04/15/24 at 10:25 a.m. when Resident #7 complained of abdominal discomfort to 04/19/24 at 6:55 a.m. A hospital CT scan result, dated 04/19/24, documented Resident #7 had distended loops of small bowel, concerning for bowel obstruction. On 04/24/24 at 12:43 p.m., LPN #2 stated Resident #7 had been nauseated and vomiting throughout the week. They stated they assessed Resident #7's abdomen to be distended and Resident #7 complained of nausea. LPN #2 stated they sent Resident #7 to the emergency roiagnom on [DATE]. LPN #2 was asked if Resident #7 was having bowel movements. They stated Resident #7 would tell staff when they had a bowel movement. LPN #2 was asked if they had assessed bowel sounds on the 04/18/24 at 3:25 p.m. LPN #2 stated they had, but did not chart it. LPN #2 was asked if bowel sounds had been assessed on 04/18/24 at 10:13 p.m. LPN #2 reviewed the note and stated no. LPN #2 was asked who they would notify when a resident had a change in condition. LPN #2 stated the doctor had been notified on 04/19/24. On 04/24/24 at 1:19 p.m., the DON reviewed the nurses' notes and stated staff should have notified the physician due to the change in condition. The DON was asked if there was documentation the physician had been notified. The DON stated they did not see any.

Based on observation, record review, and interview, the facility failed to follow their policy and procedure to ensure a smoking assessment was completed quarterly for one (#47) of one sampled resident reviewed for smoking. The Administrator identified 51 residents resided in the facility and three residents smoked or used vape products. Findings: An undated Smoking Policy, read in part, .The nursing staff ensures that a safe smoking assessment evaluation is completed at the time of admission, quarterly and with significant change in condition . Resident #47 had diagnoses which included, high blood pressure and high cholesterol. Resident #47's clinical health record documented a Smoking Safety Evaluation, was completed on 08/29/23. On 04/24/24 at 10:40 a.m., Resident #47 was observed out under the patio smoking, wearing a smoking apron. On 04/25/24 at 9:31 a.m., the DON was shown the smoking policy and asked how often a smoking assessment should be completed. They stated, an assessment should be completed quarterly. They were asked asked when the last time an assessment had been completed. They stated in August. The DON was asked if they smoking policy had been followed. They stated, No.

Based on observation and interview the facility failed to ensure: a. a interdisciplinary assessment was completed for use of side rails, b. a physician order was obtained for use of side rails , c. resident representatives were notified about the benefits and potential hazards associated with side rails, and d. side rails were care planned for one (#4) of one resident sampled for side rail use. The MDS coordinator identified 8 Resident used bed rails. Findings: A Bed Safety policy, undated, read in part, .If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative . The staff shall obtain consent for use of the side rails from the resident or residents legal representative prior to their use . Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified . Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with the side rails when using side rails for any reason, the staff shall take measures to reduce related risk . A Use of restraints policy, undated, read in part, .Restraints shall only be used for safety and well being of the resident .The definition of a restraint is based upon the functional status of the resident and not the device, If the resident can not remove a device in the same manner in which the staff applied it .Prior to placing a resident in restraints, there shall be a pre-restraining assessment .Restraints shall only be used ., other recurrent depressive disorders upon written/verbal order of a physician and after obtaining consents for the resident and/or resident representative . Resident #4 was admitted on [DATE] with diagnoses which included COPD, unspecified dementia and anxiety. A comprehensive assessment, dated 09/21/23, documented Resident #4's cognition was severly impaired. A Hospice Plan of Care document, dated 08/19/23 did not document the use of side rails. Resident #4's care plan, revised 03/04/24, did not document the use of side rails. A physician order summary, dated 04/24/24 did not document an order for side rails. On 04/24/24 at 8:43 a.m., Resident #4 was observed in bed with upper bed rails up on the Resident's right side and the bed was against wall on the left side. On 04/24/24 at 12:52 p.m., CNA #1 was asked about the half upper bed rails raised. CNA #1 stated the side rail was supposed to help resident to grab and hold to roll over. CNA #1 was asked if the side rail was care planned. CNA #1 reviewed the care plan and stated that the side rail was not in the care plan for repositioning. CNA #1 stated that they knew a bed rail could be considered a restraint. On 04/24/24 at 1:05 p.m., LPN #2 was asked to look at Resident # 4's bed. LPN #2 stated Resident #4 had a half bed rail raised on the upper right side up with the bed pushed against the wall on left side. LPN #2 stated Resident #4 transfers for meals with a 2 person lift assist. LPN #2 stated the bed rail was used for repositioning and should be care planned. LPN #2 was asked to review resident #4's care plan. They stated the bed rail was not in the care plan for repositioning. On 04/24/24 at 01:22 p.m., the DON was asked what the policy was for using bed rails. The DON stated they were not really supposed to use them because there were considered a restraint. The DON stated half rails could be used for repositioning and should be care planned if they are left up. The DON reviewed Resident #4's care plan and Hospice care plan. The DON stated the bed rail was not in the care plan or hospice care plan for repositioning or mobility care. The DON was asked to review the bed safety policy. The DON was asked what was the problem with the bed rail. The DON stated that there was no interdisciplinary assessment completed, family was not notified, there were no signed consents, and the bed rail should of been care planned for mobility and repositioning.

Based on record review and interview, the facility failed to ensure a second tuberculin skin test was read for two (#50 and #16) of five sampled residents reviewed for immunizations. The Administrator identified 51 residents who resided in the facility. Findings: An undated, Tuberculosis Screening policy, read in part .All employees and residents must comply without established tuberculosis screening procedures .If the TST method is used for HCW's who have not had a documented negative test result or M. tuberculosis during the preceding 12 months, the baseline TST result should be obtained by using the two-step method . 1. Resident #50 had diagnoses which included Alzheimer's disease and high blood pressure. Resident #50's clinical health record for immunizations documented Resident #50 received their second TB skin test on 03/26/24 but still had pending results. On 04/25/24 at 12:48 p.m., the IPC nurse was asked to review the immunizations and where were the results from the second TB test. They were not sure. The IPC nurse reviewed the MAR and the progress notes. The clinical health record did not document the second test had been resulted. 2. Resident #16 had diagnoses which included high blood pressure and anxiety. Resident #16's clinical health record for immunizations documented Resident #16 had received their second TB skin test on 11/30/23 but still had pending results. On 04/25/24 at 12:59 p.m., the IPC nurse was asked what the second TB test results were for Resident #16. They reviewed the immunizations record and stated It was not ever read.

Based on record review and interview, the facility failed to ensure residents were offered the pneumonia vaccination according to policy for one (#27) of five sampled residents reviewed for immunizations. The Administrator identified 51 residents resided in the facility. Findings: An undated, Pneumococcal Vaccine policy, read in part .Administration of the pneumococcal vaccination or revaccinations will be made in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations at the time of the vaccinations . Resident #27 had diagnoses which included, type two diabetes mellitus, cardiac pacemaker, and high blood pressure. Resident #27's clinical health record for immunizations documented the resident received their last pneumonia vaccination in 2018. On 04/25/24 at 12:45 p.m., the IPC nurse was asked if they follow up to evaluate whether the resident was due for a pneumonia shot. They stated they thought it was reevaluated after five years, but they had not followed up to see if the Resident #27 was eligible to receive another pneumonia vaccination.

Based on record review and interview, the facility failed to ensure residents were offered, educated, and signed a consent or declination form, for the pneumococcal vaccine within 30 days of admission, for four (#9, #10, #29, and #33) of six residents reviewed for compliance with influenza/pneumococcal vaccinations. The Resident Census and Conditions of Residents, dated 03/14/23, documented 50 residents resided in the facility. Findings: The facility's Pneumococcal Vaccine policy, read in parts, .All residents will be offered the pneumococcal vaccine to aid in preventing infections and pneumonia .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccination within 30 days of admission to the facility unless medically contraindicated or the resident refuses the vaccine for personal or religious reasons . 1. Resident #9 was admitted to the facility on [DATE]. Resident #9's medical record documented no date the resident had received a pneumococcal vaccine, before or since admission to the facility. The resident's medical record documented no proof the resident or resident's representative had been offered, educated on, and given the opportunity to consent to or decline the pneumococcal vaccine since admission to the facility. 2. Resident #10 was admitted to the facility on [DATE]. Resident #10's medical record documented no date the resident had received a pneumococcal vaccine, before or since admission to the facility. The resident's medical record documented no proof the resident or resident's representative had been offered, educated on, and given the opportunity to consent to or decline the pneumococcal vaccine since admission to the facility. 3. Resident #29 was admitted to the facility on [DATE]. Resident #29's medical record documented the resident was given the pneumococcal vaccine in the facility on 11/10/21. The resident's medical record did not contain a signed consent form for the pneumococcal vaccine. The resident's medical record documented the no proof the resident or resident's representative had been offered and educated on the pneumococcal vaccine within 30 days of admission or before the vaccine was administered. 4. Resident #33 was admitted to the facility on [DATE]. Resident #33's medical record documented no date the resident had received a pneumococcal vaccine, before or since admission to the facility. The resident's medical record documented no proof the resident or resident's representative had been offered, educated on, and given the opportunity to consent to or decline the pneumococcal vaccine since admission to the facility. On 03/15/23 at 11:53 a.m., the IP reported there was no documentation regarding the pneumococcal vaccine for residents #9, #10, or #33. The IP reported resident #29 had been given the pneumonia vaccine, on 11/10/21, but no consent form or proof of education was provided. The IP reported the pneumococcal vaccine had not been offered to residents routinely upon admission to the facility.

Based on record review and interview, the facility failed to ensure the COVID-19 vaccine had been offered, education provided, and declination signed by residents or resident representatives for three (#9, #32, and #49) of six residents reviewed for compliance with COVID-19 immunizations. The Resident Census and Conditions of Residents, dated 03/14/23, documented 50 residents resided in the facility. Findings: The facility's COVID-19 Vaccination policy, dated 08/25/22, read in parts, .All residents and employees will be offered the COVID-19 vaccine to encouraged and promote the benefits associated with immunizations against COVID-19 .Residents and employees will receive education regarding benefits and possible side effects of the vaccination .Appropriate entries must be documented in the resident's medical records indicating the date of receipt or refusal of the COVID-19 vaccination . 1. Resident #9 was admitted to the facility on [DATE]. Resident #9's medical record documented no education was provided to the resident or resident's representative for the COVID-19 vaccine, and no declination form had been signed. The resident's medical record documented no date the resident had received a COVID-19 vaccine before or since admission to the facility. 2. Resident #32 was admitted to the facility 11/22/22. Resident #32's medical record documented no education was provided to the resident or resident's representative for the COVID-19 vaccine, and no declination form had been signed. The resident's medical record documented no date the resident had received a COVID-19 vaccine before or since admission to the facility. 3. Resident # 49 was admitted to the facility on [DATE]. Resident #49's medical record documented no education was provided to the resident or resident's representative for the COVID-19 vaccine, and no declination form had been signed. The resident's medical record documented no date the resident had received a COVID-19 vaccine before or since admission to the facility. On 03/15/23 at 11:53 a.m., the IP reported residents #9, #32, and #49 had declined the COVID-19 vaccination. The IP reported no declination form had been signed for the COVID-19 vaccine by the residents or resident's representative and no documentation that education regarding the COVID-19 vaccine was provided. The IP reported the decline for the COVID-19 vaccine was verbal and had not been documented in the resident's medical records.

Based on record review and interview, the facility failed to ensure competency skills were completed prior to one CNA (#1) and two CMA's (#2, and #3) of three sampled direct care staff who provided care and provided medication administration. The Administrator identified 39 residents resided in the facility. Findings: On 04/20/22 at 12:58 p.m., employee files were reviewed. No competency skills checks were in the files for CNA #1, CMA #2, and #3. On 04/20/22 at 2:10 p.m., staff competency skills checklist for CNA #1, CMA #2 and #3 were requested. RN #1 stated that should be in their employee files. The Administrator stated, They are not in the files, we don't have them. On 04/20/22 at 2:20 p.m., CNA #1 was working in the memory care unit. CNA #1 was asked if she had a competency/skills checklist completed prior to providing resident care. She stated, No. CNA #1 was asked if she had been trained. She stated, Yes like one day. On 04/20/22 at 2:22 p.m., CMA #2 was working in the memory care unit. CMA #2 was asked if she had a competency/skills checklist prior to passing medications. She stated, No. On 04/20/22 at 2:47 p.m., RN #1 stated there was no facility policy for competency/skills checklist.

On 09/13/17 at 1:00 p.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to provide adequate supervision to prevent falls, and to identify and implement interventions to aid in the prevention of falls for one (#30) of four sampled residents who had experienced falls in the facility. Resident #30 had thirteen falls from January 2017 through August 2017 in which one resulted in a hip fracture, one in a rib fracture and one with a fracture to the right humerus. At 1:17 p.m., the OSDH (Oklahoma State Department of Health) verified the existence of the IJ situation. At 2:45 p.m., the administrator and the interim director of nurses (DON) were informed of the IJ situation and were asked to provide the surveyors with a plan of removal. At 5:29 p.m., the facility submitted an acceptable plan of removal. The plan of removal documented: .Staff performed the Fall Team Resident Assessment form and assessed cited resident . Care Plan for resident was updated with the following interventions: Bed was adjusted to appropriate height for 90* sitting, Grip/nonslip shockers were placed on her feet, 7 Day Bowel and Bladder Program instituted . Bright Blue paper sign in room to keep bed at lowest height, Bright Blue paper sign in room for gripper socks, Bowel and Bladder Program on bright blue paper for ADL (activities of daily living) Book, Report to Charge Nurse . Inservice to staff on duty re: Care Plan Interventions for cited resident, The 9/15/17 6a-6p & 6p-6a Charge nurse/or other staff LPN's will be instructed to be able to give inservice to oncoming staff (ALL Departments) and that these staff members WILL be instructed before rendering care to said resident . On 07/18/17 at 3:00 p.m., the IJ was removed back to the plan of removal time on the completion of the inservice on Friday September 15, 2017 at 6:00 p.m., All staff when interviewed were able to verify their knowledge and understanding of the inservices presented as a result of the IJ situation. The deficient practice remained at a level of actual harm at a pattern. Based on observation, record reviews and staff interviews, it was determined the facility failed to provide adequate supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for two (#30 and #62) of four sampled residents who had experienced falls in the facility. The facility identified 57 residents who were at risk for falls. Findings: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 12/29/17 at 11:00 a.m., documented the resident ambulated with a rolling walker, need stand by assist for safety and had fallen at home in the past. The note further documented the resident required staff assistance with transfers, ambulation if if needed to use the bathroom. A fall risk assessment, dated 12/30/16, documented the resident had a score of 13. A score greater than 10 represented a high fall risk. The assessment documented an action plan in which staff would be alerted of increased fall risk by yellow stars that were to be placed in her chart and on the door and above the bed. Staff were to implement falling star precautions and be ongoing. The assessment documented additional comments in which the resident had multiple falls at hoe before being admitted , as she overestimated her abilities at times and she does not alert staff when she does need help as she was independent of all activities of daily living (ADL). A nurse's note, dated 01/04/17, documented the resident's gait was unsteady with a rolling walker and needed one person assist with toileting and transfers. The note documented the resident was continent of bowel and bladder and was able to make her needs known. An admission assessment, dated 01/11/17, documented the resident's cognition was moderately impaired, she was independent with ADLs, was continent of her bowel and bladder, no limitations on range of motion, used a walker for mobility and had no falls. A care plan, dated 01/11/17 documented, Problem: I am at risk for injuries R/T (related to) falls due to falls when lived alone and unsteady balance. I can overestimate my abilities at times and forget to ask for assistance. Goal: I will maintain or improve my current level of ADL function over next 90 days. APPROACH: I perform all ADLs independently. Remind me to use my call light if I feel weak or dizzy. I have fallen at home in the past, I can be unsteady at times but can steady myself without assistance. I prefer my own room much of the time. I like that is quiet. I do come out to socialize and attend activities. I eat most meals in the dining room and order from menu. I usually get up around 6-7 am but I retire anywhere from 9:30 - 2:00 am This was the same schedule followed at home. I perform my own teeth care and peri care. I do ambulate independently but I need some assistance with transfers. I need assistance for whirlpool. I have tremors that can make it difficult for me to write and eat at times. Assist me as needed but I can become embarrassed by this so only give me minimal assistance. the doctor could not prescribe medication for them. Another care plan, dated 01/11/17, documented, I will be free of major injuries R/T falls and remain free of adverse side effects D/T (due to) use of daily antidepressant therapy over next 90 days. APPROACH: Educate me regarding side effects of antidepressant and if I feel weak or dizzy or if I need assistance with ambulation, I should call for a nurse. Here are some ideals that might help me and keep me from falling. Please make sure my bed is in the lowest position. Place all the items I need within reach such as the call light. TV remote water etc. Encourage me to call for assistance as needed. Ensure I have well-fitting slipper/shoes on or I have the socks with grippes dot on the bottom. Keep floor clear of clutter. Assist me with transfers or walking when needed. Encourage ROM with my routine ADLS. I am A&O X3 (alert and oriented to person, place and time). I am able to make wants and needs known, ensure I have my call light within reach so that I can call for help when need for ambulation and transferring. I am new to CCH (Cordell Christian Home). I lived at home before coming to live here. I did have falls while at home. I still have some pain from past falls. I can be unsteady at times. I am independent of all ADLs but do require some assistance whe transferring at times. I can sometimes overestimate my abilities and not call for help when I need it. Frequently remind me that if I am feeling weak or dizzy to call for assistance when ambulating. I take routine Paxil for depression, administer my medication per physician orders [REDACTED]. I have a cerebral aneurism with coil placed. A physicians progress note, dated 01/17/17, documented the resident appeared very stable except for memory loss with a falling history. The note documented she actually just fell on the floor as a result in ecchymosis of the left side of her body to include her chest and abdomen. She had a history of [REDACTED]. A nurse's note, dated 01/17/17, documented a new order for Prednisone for tremors. A nurse's note, dated 01/17/17 at 2:45 p.m., documented during a care plan meeting, she alerted the staff she fell at home before being admitted to the facility. She had frequent back pain she believed to be from her past falls at home. An incident report, dated 01/30/17 / 01/31/17, time unknown, documented, called to resident room by CNA (certified nurse aide), reports res (resident) has a large bruise on L (left) arm, upon assessment, res noted with baseball sized dark purple bruise with large knot on left outer elbow (cont) . Additional comments documented (name-deleted hospital) for x-rays of left arm L hip L ribs at 11:00 a.m. Sent to hospital. Res instructed to use call light and ask for staff assistance with ambulation. Verbalized understanding. A nurse's note, dated 01/31/17 at 7:40 a.m., documented, (cont) bruised area to L posterior ribs et small bruise to left (upper)outer buttocks. Res denies falling, states 'I hit the doorway when I went to the bathroom, but I don't think I fell .' c/o soreness to (L) posterior rib area, able to move/flex (L) arm s s/s (without signs or symptoms) pain. Denies pain to (L) hip when palpated. No external rotation noted to LLE (left lower extremety). Res instructed to use call light et ask for assist c amb (ambulation) Verbalized Understanding. A telephone order, dated 01/31/17, documented to obtain an x-ray of the left hip, left posterior ribs and left arm related to the bruising. The care plan for falls contained a handwritten update which documented, 01/30/17 documented lg (large) bruise noted on left arm, baseball sized with large knot on left outer elbow. Another handwritten notation, dated 01/31/17, documented, I was bruised on my left side and reported I bumped into door in room. X-Rays were done of Left hip, L posterior ribs and left arm. Another handwritten update, dated 02/151/7, documented, May send to ER (emergency room ) for eval (evaluation) and treatment for [REDACTED]. An incident report, dated 2/25/17 at 1545, documented, Res (resident) was in dining room talking to another res, leaned on rolling walker et (and) it rolled away from her. fell to floor, landing on R hip. Rolled to L (left) side, c/o pain rated 9/10 to R hip Additional comments and/or steps taken to prevent recurrence: Res states walker got away from me' Could not straighten leg, s (without) c/o (complaints of) pain. Left on L side until EMS (emergency medical services) arrived. A fall care plan contained a handwritten updated which documented, 02/25/17 had fall and Rt hip fx. She returned on PT/OT (physical therapy/occupational therapy), she received PT/OT 5x /wk and is progressing. She is WBAT (weight bearing as tolerated) and uses walker with assist and w/c (wheelchair) independently. An X-ray report, dated 02/25/17, documented, .Impression: acute rt intratrochantric femoral neck fracture with moderately increased coxa varus angulation. A fall care plan contained a handwritten update which documented, 03/03/17 returned on SNF (skilled nursing facility) services. An incident report, dated 03/19/17 at 6:40 a.m., documented, LPN (licensed practical nurse) called to room, res sitting on floor in front of recliner. asked res what happened and res stated I was trying to go to the bathroom and fell . res has 2 skin tears to R forearm, abrasion to R shoulder; L wrist pain .Additional comments and/or steps taken to prevent recurrence Discussed with res to turn light on for assistance and not to get up herself. A fall care plan which contained a handwritten update, documented, 03/19/17 fell and received X 2 ST (skin tear) to right forearm. An incident report, dated 03/31/17 at 12:30 p.m., documented, Res stated I fell this morning in my room. I was leaning over in the recliner and slid out of recliner to the floor. Put self back in recliner .Additional comments and/or steps to prevent recurrence: Personal alarm placed. A fall care plan which contained a handwritten note documented, she fell again 03/31/17 without injury. No new interventions. Another fall care plan with a handwritten notation documented, Fall without injury 03/31/17. A fall risk assessment, dated 04/11/17, documented her total score was 14 and to continue the care plan. A score of greater than 10 represented a high risk for falls. A quarterly assessment, dated 04/13/17, documented the residents cognition was intact, required supervision with mobility, limited assistance with ambulation in her room, transfers, ADLs and bathing. The assessment further documented she had limited range of motion on the lower extremities and has had 2 falls with injury. An incident report, dated 05/03/17 at 5:25 a.m., documented, Res found sitting on floor holding her elbow, Res stated I don't remember getting up, but I fell and my elbow hurts really bad. R (right) elbow appeared swollen c (with) deformity to inner portion of elbow. No other injuries were noted @ this time Additional comments and/or steps taken to prevent recurrence: Advised and counseled Res about using call light when she needs assistance to go to bathroom or to get up. Always wait for staff to get help. An X-ray report from hospital, dated 05/3/17, documented the resident had a possible nondisplaced fracture of the medial epicondyle of the right humerus; Total right elbow arthroplasty without radiographic evidence of hardware failure or loosening. A physician's orders [REDACTED].falling on the floor .Result in inability moving of R elbow; X-ray appear fracture of R elbow. DX (diagnosis) fracture of R humeri . A fall care plan with a handwritten update documented, X (times) 5 falls this quarter 05/05/17 fall resulting in right elbow fracture, she wore splint for some time, On RAP 2x/wk for ROM. She has been educated on using call light and waiting for assist. Attempted personal alarms, but one removes. Respond promptly to call lights and check frequently throughout shift. Another fall care plan with a handwritten update, documented, 5/5/17 Fall c (with) R elbow fx. A nurse's note, dated 05/05/17 at 10:30 a.m., documented, LE(late entry) Res returned from (name-deleted physician office) epicondyle implant (Rt). Res Rt hand c 2+ edema. c/o pain RUE (right upper extremety). Required 2 persons assist c transfers c gaitbelt. Res able make needs known. Splint et sling in place. An incident report, dated 05/26/17 at 1:00 p.m., documented, Res Found lying on the floor in front of her w/c. beside bed. Check For injuries, moves EXT (extremities) Denies pain. R elbow in splint D/T old Fx. R hand red and hair found on closet door where head hit (But resident denies) L(NAME) (level of consciousness) - Res impulsive get up unattended at x's state I walk by myself at home, 'I can do it' .Additional comments and/or steps to prevent recurrence: Personal Alarm placed on Resident. Instruct res to use call light. A fall care plan, dated 05/26/17, documented, lying in floor in front of her w/c in room, beside bed - No injuries noted. An incident report, dated 05/31/17 at 12:15 p.m, documented, Res reports she was trying to get to the toilet et missed the toilet (and) sat onto trash can, (no) injuries noted. ROM WNL for res. Assisted up (and) onto toilet .Additional comments and/or steps to prevent recurrence: Res instructed to have staff assist her c toileting. A fall care plan with a handwritten update documented, 05/31/17 documented Res reports trying to get to toilet (and) missed it (and) sat onto trash can. (no) injuries. An incident report, dated 6/29/17 at 6:00 a.m., documented, Res found by CNA in her bathroom laying the bathtub. Unable to state how she got there. Denies hitting her head. S.T. to R elbow noted. No other injuries found. skin Tear x 3 .Additional comments and/or steps to prevent recurrence: Q2hr (every two hours) checks by staff; self alarm in bed (and) w/c. Instructed on use call light, res voiced understanding. An incident report, dated 06/29/17 at 6:40 p.m., documented, Resident found on floor of room between bed (and) chair, c/o pain on left side and back near ribs - Red mark - 4in long. red mark 4 inches long c/o pain when touched. Bruised hardened area on elbow - several 2cm Bruises Above elbow .Additional comments and/or steps to prevent recurrence: Encourage resident to call for assistance when she needs to get up. Personal alarm for safety. A fall care plan with a handwritten update, documented, 06/29/17 transferred to (name-deleted hospital) after fall for eval (evaluation) and chest xray to left upper back and side left arm and elbow for complaints of pain after fall. Saw (name-deleted physician) on 6/29/17 for complaints of chest pain . A physician's orders [REDACTED]. A nurse's note, dated 07/01/17 at 12:00 p.m., documented, Res in Rm c door closed. Opened door et Res in w/c reading. Res has no recollection of falls. c/o lt (left) side pain 1+ pitting edema BLE (bilateral lower edema). Another fall care plan with a handwritten update, documented, 07/18/17, documented x 5 falls this quarter. On 5/5, one fell & fractured right elbow, she wore splint for period of time. She started RAP 2x/wk for ROM on 5/30. She does have multiple contusions of bilateral wrists and tremors. Started Inderal 100 mg BID (twice a day) 7/6 She continues to use w/c outside of room. She requires limited assist with transfers and mobility with walker. A quarterly assessment, dated 07/14/17, documented the residents cognition was severely impaired, had rejection of care 1-3 days; required limited assistance with transfers, ambulation, dressing, toilet use and bathing. The assessment documented limited range of motion on the lower extremities and used a walker and wheelchair for mobility, she was occasionally incontinent of bladder and continent of bowel. Her pain rated at a 10, she had in fall with no injury, one fall with minor injury and two falls with major injury. An incident report, dated 7/28/17 at 5:25 a.m., documented, Resident found on floor by bed by staff stated I don't know what happened. When asked if she hurt anywhere stated no When asked if res hit her head stated no .Additional comments and/or steps to prevent recurrence: Encourage resident to use call light wait for staff to help. Staff assist resident to Restroom during rounds. A care plan with a handwritten note documented, 07/31/17 PT (physical therapy) to eval Part B PT services 8/2/17 PT to eval (and) tx (treat) 3x/wk x 4 wks per Part B to improve mobility, transfer gait safety. An incident report, dated 8/10/17 1:20 p.m., documented, (name-deleted CNA) heard res yelling for help. Entered room (and) found Res on Floor between w/c (and) bed. Res resp (responded) 'I don't know what I was doing.' 1 abrasion spine, S/T RFA (right forearm) 2.1/ 2 x 3 1/2 AAO x 1 (awake alert oriented to person) .Additional comments and/or steps to prevent recurrence: Bed Alarm in place. Call light in reach (and) reminded of use. Remind resident to ask for help. An incident report,8/22/17 at 4:30 a.m., documented, heard noise, found res sitting on bottom on the floor next to bed with small, superficial abrasion to the L underarm .Additional comments and/or steps to prevent recurrence: place tag alarm on resident and remind her to call for help. The fall care plan did not contain any new interventions. An incident report, dated 8/28/17 at 9:00 p.m., documented, saw res while walking by. she was on her knees facing the bed. Hematoma both knees alert/oriented (to self mainly) .Additional Comments and/or steps to prevent recurrence: remind res to use call light when needing assistance. / placed tag alarm on res. The fall care plan did not contain any new interventions. On 09/15/17 at 12:12 p.m., the minimum data set coordinator (MDS) #1 and #2 were asked what interventions were placed for her. They stated apersonal alarm she kept taking it off, bowel and bladder program, reminded her to use her call light and frequent checks. They were asked if the care plan was updated after each fall with new interventions. MDS coordinator #1 stated she updated the careplan each quarter, she did not know that she needed to do after each fall. She further stated the care plan was not updated with new interventions and the root cause was probably related to going to the bathroom. On 09/15/17 at 1:25 p.m., CNA #3 was asked if any resident on hall B was on a bowel and bladder program. She stated no. They would check on them more often at least every two hours, make sure they got to the bathroom encourage them to call for help when needed and to use the call light. 2. Resident #62 was admitted to the facility's Special Care Unit with [DIAGNOSES REDACTED]. An admission assessment, dated 1/24/17, documented the resident's cognition was severely impaired, she was independent in bed mobility, transfers, walking and eating. The assessment further documented the resident required limited assistance for dressing, toileting, personal hygiene and bathing, was usually continent of bowel and bladder, wandered daily and had no falls. A fall risk assessment, dated 01/24/17, documented the score to be a 11. The total score of 10 or above represents a high risk. An incident report, dated 01/25/17 at 1:20 a.m. documented, Called to e-wing by aides who reported res to be in floor on buttocks. res very anxious. No s/s of injury. neuros started d/t res reported hitting head .alert; oriented to self; often confused and very anxious . The report documented the resident was sent to the local hospital. Additional comments and/or steps taken to prevent recurrence documented, aides notified to assist res in ambulation. An incident report, dated 02/03/17 at 6:20 p.m., documented, Res approached other resident standing (at) Nurses Station, pulled on her arm causing res to fall. No Injuries Alert to self only Res (up) amb (ambulating) by self - gait usually steady .Additional comments and/or steps taken to prevent recurrence: Will keep reminding res not to grab hands or arms to walk with them. Not to pull on them. A care plan with a handwritten notation, documented 02/03/17 pulled on another resident causing her to fall. An incident report, dated 02/18/17 at 10:45 a.m., documented, Res was ambulating about unit (and) walking between res chairs (and) lost balance, falling to floor (no) injury evident. Alert to self only .Additional comments and/or steps taken to prevent recurrence: Staff will cont (continue) to help res remain indep (independent) as possible in a safe environment still to enc (encourage) rest periods as she allows. A care plan with a handwritten notation documented on 2/18/17 fall without injuries An incident report dated 04/19/17 at 11:45 p.m., documented, CNA heard a door slam, went to check. Found resident sitting on the floor in front of bed. CN (charge nurse) to (check resident res .in room E-2, sitting on the floor in front of the bed. Checked for injuries. (none) noted .Additional comments and/or steps taken to prevent recurrence: Instr. (instruct) staff to keep Res in sight D/T unsteadiness (and) poor eye sight. Staff to keep door open. An incident report, dated 04/20/17 at 6:45 p.m., documented, Res got up out of chair, bal (balance) poor -fell - sm s/t (skin tear) to L hand. (no) other injuries noted .Additional comments and/or steps taken to prevent recurrence: Will monitor for steady gait and balance. Will re direct - 1 on 1 get Res involved res in activities. A care plan with a handwritten notation, dated 05/13/17, documented, fell to knees x 2 (no) injuries. An incident report, dated 05/13/17 at 7:55 a.m., documented, RN (registered nurse) stated res became unsteady towards water fountain (and) res grabbed hold of wall (and) looked up yelled, '(name-deleted resident) (and) then dropped to floor on knees. Res assisted (up) x 2 (and) assisted to room weak Res dropped to floor on knee again. Res assisted (up) x 2 person (and) assisted to bed. On observation when we touched res would holler out. Res has caloss to both of foot tender to touch .Additional comments and or steps taken to prevent recurrence: Will leave note for transport call appt for podiatrist if possible. A care plan with a handwritten notation, dated 05/14/17, documented, On knees c forehead against door, hematoma to back of head, neuro's done. An incident report, dated 05/16/17 at 9:00 a.m., documented, Res tripped over another residents foot. fell (and) hit the table with her chin causing a laceration. s/t to R side neck s/t to R elbow. Bruise x 2 L knee .Additional comments and or steps taken to prevent recurrence: have physician review meds. Still to provide 1:1 when restless in place. A care plan with a handwritten notation, dated 05/16/17, documented, Tripped over another residents foot. fell (and) hit table c her chin causing a laceration. Dressing chin s/t R side of neck (and) s/t to R elbow. A Final report for (Resident #62) documented, 5/19/17, (Resident #62) was in the (name deleted psychiatric care center) r/t increased behaviors from 03/29/17 to 04/18/17. She was existing seeking, easily agitated at times, briskly paced halls and disrobing in the common areas while others were present. (Resident #62) was not sleeping well and went to the point of exhaustion. She would only sleep for minutes at a time. She was not easily redirected at times. She often said, 'I don't want to miss out on anything.' (Resident #62) has been drowsy at times since returning to CCH. While at (name-deleted psychiatric care center) (name-deflated physician) did med (medication) adjustments. On 5/4/17, (Name-deleted pharmacy consultant) reviewed meds. (Name-deleted physician) and her family has been kept informed of falls. Staff encourages rest periods during the day but often unsuccessful. She requires 1:1 at times esp (especially) on days she is drowsy and restless. She has a history of falls. Unable to determine a pattern r/t falls. She is impulsive and gets up unattended. She continues to reside on the Special Care Unit r/t poor cognition. She does exhibit adequate hearing by answering when other talk. She does see (name-deleted physician) for the callous on her lt foot (bottom side). Her next visit is 05/23/17 with (name-deleted podiatrist) The incident 5-14-17 neuro checks wnl for res. Unable to recall fall. Speech unrelated to my simple direct questions no change in cognition. Staff assist x1 while walking. Unable to assess her vision adequately she keeps her eyes closed at times but will make eye contact when she feels up to it. Staff will ensure the door is open when resident is in the room to ensure staff ability to visualize (Resident #62). 1:1 will continue with staff at the times she not redirectable and being impulsive by getting up unassisted. The incident of 5-16-17 she was attempting to walk in small space and tripped over another residents foot. She hit chin on table and went to ER at (name-deleted hospital) for eval she received 3 sutures. Neuro checks wnl for resident. No significant changes in overall cognition. She is up with assist x1 for walking. The CT scan report results dated 5-16-17 indicates no acute intracranial process and posterior scalp hematoma. The sutures to chin are without any s/s infection. I spoke with (name-deleted physician) 5-19-17. Dr. will review med regime. N/O (new order) for lab and Ua to be obtained. To eval for use of the soft shell protective head gear to aid in reducing force to head when falls occur. Staff will continue with the 1:1 intervention during restless and impulsive. An incident report, dated 06/03/17 at 10:00 a.m., documented, I was using housekeeping cart to clean up a food mess in Ewing lobby while res was pacing all over unit and res tripped over the corner of cart and landed on knees .Additional comments and/or steps taken to prevent recurrence: Will keep pathway clear and try to keep resident sitting as much as possible by providing activity/snack. A care plan with a handwritten notation, dated 06/03/17, documented, Res. pacing about unit (and) tripped over housekeeping cart and landed on knees. (no) injuries noted. An incident report, dated 06/10/17 at 5:30 p.m., documented, Res in D.R. (dining room) tripped over other resident's foot pedals on his w/c. (No) injuries noted. Additional comments and/or steps taken to prevent recurrence documented, Will have w/c res. to move his w/c out of amb. (ambulatory) res. way. A care plan with a handwritten notation, dated 06/10/17, documented, In DR (and) tripped over another res. foot pedals on w/c (no) injuries. An incident report dated 06/12/17 at 08:50 a.m., documented, Res stood up from a chair and turned to follow staff down the hall. Stumbled and fell backward. Staff unable to catch her. Sat on buttocks and then laid backwards, hitting the back of head on floor. Neuros were initiated and an ice pack was applied. Additional comments: Res resides on chu, is @ increased risk for fall d/t disease process of dementia that wanders, staff will cont. to keep resident safe. Offer SBA when unsteady. A care plan with a handwritten notation, dated 06/12/17, documented, Res stood (up) from chair (and) turned to follow staff (and) stumbled (and) fell backwards (and) sat on buttocks (and) then laid backwards hitting back of head on floor. Raised area back of head. Ice pack applied. Neuro checks initiated. An incident report, dated 06/30/17 at 11:50 a.m., documented Res sat on bottom in lobby. (No) redness or injury evident. ROM WNL for res, assisted x 2, about unit per usual routine .alert to self .Additional comments and/or steps taken to prevent recurrence: Res resides on ., is (at} (increased) risk for fall d/t (due to) disease process, staff will cont to work to keep res safe (and) maintain optimal level of independence. An incident report, dated 07/06/17 at 6:00 p.m., documented, Res tripped over the leg of another residents w/c - fell to floor on R side (no) injuries noted (at) this time .Additional comments and/or steps taken to prevent recurrence: Will have w/c resident park chair against the wall out of amb Residents way. An incident report, dated 07/07/17 at 8:10 a.m., documented, In dining room (at) breakfast. Res. ambulating about room-stopped (and) started walking backward. Caught her heel on another residents toe and fell on her buttocks Additional comments and/or steps taken to prevent recurrence: Staff will assist to redirect when undesirable decision by . A fall risk assessment, dated 07/27/17, documented the score to be a 17. The total score of 10 or above represents a high risk. An incident report, dated 08/01/17 at 11:05 a.m., documented, Resident went to sit in chair in sun room and missed the chair and sat on the floor . Additional comments and/or steps taken to prevent recurrence: Res reminded to be More aware of surrounding. An incident report, dated 08/14/17 at 10:30 a.m., documented, CN called to room, res sitting on floor beside a chair. staff member stated I just walked into room (and)res went to sit in chair (and) missed it landing on bottom ROM performed BLE (and)BUE s difficulty Res assisted (up) x 2 person (and) started walking out door .Additional comments and/or steps taken to prevent recurrence: Will check Res optometrist appt (and) placed folding chair in closet. An incident report, dated 09/04/17 at 4:00 a.m., documented, Called to unit by aides that reported res came out of room and was bleeding moderately from forehead. assessment revealed puncture wound that may require stitches. alert to self, short-term impairment, verbal stimuli response inappropriate .via ambulance to (name-deleted hospital) .additional comments and/or steps taken to prevent recurrence; bed alarm. Transfer to ER via ambulance. An untitled paper, documented, Final report 9-8-17 on 9-4-17 on (Resident #62). She fell on [DATE] around 4am. Transferred to ER at (name-deleted hospital) for further eval r/t wound/laceration to forehead which was bleeding profusely per n